14
Inspections
19
Deficiencies
2
Actual Harm or Above
5
Occurrences
April 1, 2026
Last Inspection
S/S D/E/F Potential for harmS/S G Actual harm

The most recent inspection of COTTONWOOD REHABILITATION AND HEALTHCARE CENTER on record is dated April 1, 2026. Across 14 published inspections, state surveyors cited 19 deficiencies, 2 of which reached actual harm or immediate jeopardy.

Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.

Provider Information

Status
Active
Facility Type
SNF (Medicare Only)
Administrator
Bradley, Christy Bernice
Owner
COTTONWOOD REHABILITATION AND HEALTHCARE CENTER LLC
Phone
(970) 516-1404
Payor Source
Medicare, Private Pay
City
DURANGO
ZIP
81301-7940

Inspections & Citations

14 inspections · 19 deficiencies
4/1/2026Complaint Survey · ID 22CC80-H11 deficiency
0000INITIAL COMMENTSSurveyor note
Findings
A complaint survey, prompted by #CO2673355 was conducted on 4/1/26. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0684Quality of Care
Findings
Based on record review and interviews, the facility failed to provide services to ensure the residents highest practical physical wellbeing for two (#2 and #3) of four residents reviewed out of four sample residents. Specifically, the facility failed to ensure Resident #2 and Resident #3 had a physician's order to consume alcoholic beverages. Findings include:I. Facility policy and procedure The Alcoholic Beverages Policy, revised February 2023 was provided by the director of clinical services on 4/1/26 at 1:19 p.m. The policy read,“The purpose of this procedure is to establish uniform guidelines concerning the administration of alcoholic beverages. “A physician's order must be received before any alcoholic beverage may be administered to a resident. “Should such an order be received, the nurse supervisor receiving the order must contact the pharmacist to determine if any of the residents' current medications would interact with alcohol. “Should there be a medication that would interact with the alcohol, the nurse manager must inform the physician of such medications.“Record and follow the physician's instructions.”The Physician Orders Related to Activities policy, revised June 2018, was provided by the director of clinical services on 4/1/26 at 1:19 p.m. The policy read, “The facility obtains activities related to physician orders in a timely manner. “The activity director/coordinator reviews the physician’s orders upon admission during the activity assessment period, and within ‘progress’ or ‘change of condition’ reviews for the following areas which may impact activities such as: Consumption of alcohol (if alcohol was served or requested by a resident).”II. Resident #2A. Resident statusResident #2, age 71, was admitted on 8/3/23. According to the March 2026 computerized physician orders (CPO), diagnoses included multiple sclerosis, hypertension, osteoarthritis and depression. The 2/5/26 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 13 out of 15. He required maximum assistance with activities of daily living (ADL). B. Resident interview Resident #2 was interviewed on 4/1/26 at 10:30 a.m. Resident #2 said he attended happy hour at the facility and he drank alcoholic beverages on occasion when offered. He said residents had the right to make their own decisions to consume alcohol or have non-alcoholic beverages. C. Record reviewReview of Resident #2’s confidentiality, privacy and activities form, dated 9/25/24, revealed Resident #2 circled yes and gave permission to the facility staff to allow alcoholic beverages to be served to him during the facility’s Happy Hour activity if the physician agreed. The form documented a maximum of two alcoholic drinks would be allowed, per the physician’s order. Review of Resident #2’s comprehensive care plan, initiated 3/10/25, revealed there was no care plan focus for Resident #2’s alcohol consumption. Review of Resident #2’s March 2026 CPO revealed no physician’s order that indicated Resident #2 was able to consume alcohol. III. Resident #3 A. Resident statusResident #3, age 77, was admitted on 11/30/25. According to the March 2026 CPO, diagnoses included chronic respiratory failure, hypertension, dementia, mild with anxiety disorder and depression. The 1/26/26 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS score of 11 out of 15. She required substantial maximum assistance with ADLs. B. Resident interviewResident #3 was interviewed on 4/1/26 at 11:35 a.m. Resident #3 said she attended happy hour weekly and enjoyed going to have alcoholic beverages and to socialize with others. She said not all residents had alcoholic beverages, but she preferred to. C. Record reviewReview of Resident #3’s confidentiality, privacy and activities form, dated 9/25/24, revealed Resident #3 circled yes and gave permission to the facility staff to allow alcoholic beverages to be served to her during the facility’s Happy Hour activity if the physician agreed. A maximum of two alcoholic drinks would be allowed, per the physician’s order. The psychosocial care plan, initiated 3/11/25 and revised 3/24/26, revealed Resident #3 had a history of alcohol abuse and dependency and the resident was in remission from alcoholism. The care plan revealed Resident #3 was at risk of an impaired psychiatric mood related to the diagnosis of depression, history of alcohol dependency and anxiety. Review of Resident #3’s March 2026 CPO revealed no physician’s order that indicated Resident #3 was able to consume alcoholic beverages. IV. Staff interviews The activities director (AD) was interviewed on 4/1/26 at 11:00 a.m. The AD said the facility’s happy hour activity took place every Thursday. She said alcoholic beverages and non-alcoholic beverages were served to the residents. The AD said residents were offered whatever they preferred to drink. She said a variety of alcoholic drinks were served, with a maximum of two drinks for each resident. The AD said upon admission to the facility, residents were asked about their preference to consume alcoholic beverages or not. She said the social services director (SSD) assisted residents to complete the alcoholic beverages preference form and the information was shared with activities if a resident was not allowed to consume alcohol. The AD said she did not have a list of residents who could or could not have alcohol. She said it was up to the residents to decide if they wanted alcohol or not. The interim SSD was interviewed on 4/1/26 at 12:02 p.m. The interim SSD said an evaluation for the consumption of alcoholic beverages was completed with residents as part of the admission packet when they were admitted to the facility. He said a care plan was completed if a resident had a history of alcohol abuse and the information was shared with the activities director and management. The interim SSD said residents had the right to consume alcohol. He said the physician was made aware if a resident had a history of alcohol abuse, in case the alcohol could interfere with certain medications or in case staff needed to be monitoring residents for any alcoholic withdrawal concerns. The interim SSD said the facility did not track residents’ intake of alcoholic beverages because consumption happened one time a week at happy hour and not on a daily basis. Registered nurse (RN) #1 was interviewed on 4/1/26 at 12:45 p.m. RN #1 said the physician gave orders when a resident wanted to consume alcoholic beverages. The director of clinical service nurse was interviewed on 4/1/26 at 12:15p.m. The director of clinical services said residents should have a physician's order to consume alcoholic beverages. She said the physician’s order should include parameters for the amount of alcohol and risks with any medications the resident took. She said she was not part of the evaluations for residents to have alcohol, but she said had started an audit to identify which residents consumed alcoholic beverages (during the survey). She said she would look at the residents’ physician’s orders and would discuss it in the interdisciplinary team (IDT )meeting. The interim nursing home administrator (NHA) was interviewed on 4/1/26 at 12:30p.m. The interim NHA said there was no documentation revealing education was completed on the effects of consuming alcoholic beverages for Resident #2 and Resident #3. The medical director (MD) was interviewed on 4/1/26 at 4:15 p.m. The MD said he would prefer for no residents to consume alcoholic beverages, but as a physician, he respected the autonomy of the residents’ choice to consume alcohol if they chose to do so. He said when the resident had red flags or big issues, such as they were a fall risk, had dementia or was a known alcoholic, he would not give orders for those residents to consume alcoholic beverages. He said the facility had a physician’s order set in the facility’s electronic charting system which allowed nursing staff to add the physician’s order to consume alcohol into a resident’s electronic medical record (EMR), when appropriate. He said it was up to the facility to alert him when a physician’s order was needed for the resident. He said he had discussed with residents before why drinking alcohol was a bad decision but he said he had not discussed this with any current residents at the facility that he could recall. He said he relied on the director of nursing (DON) to notify him with any resident alcohol consumption concerns.
Plan of correction · submitted by the facility
Corrective action:On 4-20-2026 resident #2 orders were reviewed to ensure there was a physician’s order to consume alcoholic beverages. On 4-20-2026 a physician order was obtained for resident #3 to consume alcohol beverages. Others Affected:An audit was completed on 4-1-2026 to ensure all residents that consume alcoholic beverages had a physician's order to consume alcoholic beverages. 10 residents were found to be affected by this deficient practice. All 10 residents affected by this deficient practice obtained physician's order to consume alcoholic beverages. Systematic change:Upon admission Activity Director or designee will interview resident and or representative to complete the “Admission Alcohol Preference Questionnaire” to determine alcohol consumption preference. This document will consist of Yes or NO I wish to receive alcoholic beverage during happy hour, resident/representative signature and date. Bottom section filled out by facility representative of document will contain yes or no answers for PHYSICIAN PERMISION, PHYSICIAN ORDER COMPLETED IN POINTCLICKCARE, CARE PLAN COMPLETED FOR PREFERENCE ON ALCOHOL, Facility representative signature and date of completion. Monitoring Plan:Administrator or designee will complete audit form that contains: resident name, date of admission, alcohol preference to receive alcohol, if yes, was physician notified to obtain order and date care plan was updated. This audit will be completed one time a week for 4 weeks and then monthly for 2 months or until substantial compliance is met. Audit will be reviewed monthly at QAPI times 3 months or until substantial compliance is met.
4/1/2026Licensure Complaint Survey · ID 22CC83-H11 deficiency
0000Initial CommentsSurveyor note
Findings
A survey prompted by #CO2714685 was completed on 4/1/26. One deficiency was cited.
Plan of correction
The state did not require a plan of correction for this citation.
0701Resident Care - Overall Care of the Residents
Findings
Based on record review and interviews, the facility failed to provide services to ensure the residents highest practical physical wellbeing for two (#2 and #3) of four residents reviewed out of four sample residents. Specifically, the facility failed to ensure Resident #2 and Resident #3 had a physician's order to consume alcoholic beverages. Findings include:I. Facility policy and procedure The Alcoholic Beverages Policy, revised February 2023 was provided by the director of clinical services on 4/1/26 at 1:19 p.m. The policy read,“The purpose of this procedure is to establish uniform guidelines concerning the administration of alcoholic beverages. “A physician's order must be received before any alcoholic beverage may be administered to a resident. “Should such an order be received, the nurse supervisor receiving the order must contact the pharmacist to determine if any of the residents' current medications would interact with alcohol. “Should there be a medication that would interact with the alcohol, the nurse manager must inform the physician of such medications.“Record and follow the physician's instructions.”The Physician Orders Related to Activities policy, revised June 2018, was provided by the director of clinical services on 4/1/26 at 1:19 p.m. The policy read, “The facility obtains activities related to physician orders in a timely manner. “The activity director/coordinator reviews the physician’s orders upon admission during the activity assessment period, and within ‘progress’ or ‘change of condition’ reviews for the following areas which may impact activities such as: Consumption of alcohol (if alcohol was served or requested by a resident).”II. Resident #2A. Resident statusResident #2, age 71, was admitted on 8/3/23. According to the March 2026 computerized physician orders (CPO), diagnoses included multiple sclerosis, hypertension, osteoarthritis and depression. The 2/5/26 comprehensive assessment revealed the resident was cognitively intact. He required maximum assistance with activities of daily living (ADL). B. Resident interview Resident #2 was interviewed on 4/1/26 at 10:30 a.m. Resident #2 said he attended happy hour at the facility and he drank alcoholic beverages on occasion when offered. He said residents had the right to make their own decisions to consume alcohol or have non-alcoholic beverages. C. Record reviewReview of Resident #2’s confidentiality, privacy and activities form, dated 9/25/24, revealed Resident #2 circled yes and gave permission to the facility staff to allow alcoholic beverages to be served to him during the facility’s Happy Hour activity if the physician agreed. The form documented a maximum of two alcoholic drinks would be allowed, per the physician’s order. Review of Resident #2’s comprehensive care plan, initiated 3/10/25, revealed there was no care plan focus for Resident #2’s alcohol consumption. Review of Resident #2’s March 2026 CPO revealed no physician’s order that indicated Resident #2 was able to consume alcohol. III. Resident #3 A. Resident statusResident #3, age 77, was admitted on 11/30/25. According to the March 2026 CPO, diagnoses included chronic respiratory failure, hypertension, dementia, mild with anxiety disorder and depression. The 1/26/26 comprehensive assessment revealed the resident was moderately cognitively impaired. She required substantial maximum assistance with ADLs. B. Resident interviewResident #3 was interviewed on 4/1/26 at 11:35 a.m. Resident #3 said she attended happy hour weekly and enjoyed going to have alcoholic beverages and to socialize with others. She said not all residents had alcoholic beverages, but she preferred to. C. Record reviewReview of Resident #3’s confidentiality, privacy and activities form, dated 9/25/24, revealed Resident #3 circled yes and gave permission to the facility staff to allow alcoholic beverages to be served to her during the facility’s Happy Hour activity if the physician agreed. A maximum of two alcoholic drinks would be allowed, per the physician’s order. The psychosocial care plan, initiated 3/11/25 and revised 3/24/26, revealed Resident #3 had a history of alcohol abuse and dependency and the resident was in remission from alcoholism. The care plan revealed Resident #3 was at risk of an impaired psychiatric mood related to the diagnosis of depression, history of alcohol dependency and anxiety. Review of Resident #3’s March 2026 CPO revealed no physician’s order that indicated Resident #3 was able to consume alcoholic beverages. IV. Staff interviews The activity director (AD) was interviewed on 4/1/26 at 11:00 a.m. The AD said the facility’s happy hour activity took place every Thursday. She said alcoholic beverages and non-alcoholic beverages were served to the residents. The AD said residents were offered whatever they preferred to drink. She said a variety of alcoholic drinks were served, with a maximum of two drinks for each resident. The AD said upon admission to the facility, residents were asked about their preference to consume alcoholic beverages or not. She said the social services director (SSD) assisted residents to complete the alcoholic beverages preference form and the information was shared with activities if a resident was not allowed to consume alcohol. The AD said she did not have a list of residents who could or could not have alcohol. She said it was up to the residents to decide if they wanted alcohol or not. The interim SSD was interviewed on 4/1/26 at 12:02 p.m. The interim SSD said an evaluation for the consumption of alcoholic beverages was completed with residents as part of the admission packet when they were admitted to the facility. He said a care plan was completed if a resident had a history of alcohol abuse and the information was shared with the activities director and management. The interim SSD said residents had the right to consume alcohol. He said the physician was made aware if a resident had a history of alcohol abuse, in case the alcohol could interfere with certain medications or in case staff needed to be monitoring residents for any alcoholic withdrawal concerns. The interim SSD said the facility did not track residents’ intake of alcoholic beverages because consumption happened one time a week at happy hour and not on a daily basis. Registered nurse (RN) #1 was interviewed on 4/1/26 at 12:45 p.m. RN #1 said the physician gave orders when a resident wanted to consume alcoholic beverages. The director of clinical service nurse was interviewed on 4/1/26 at 12:15p.m. The director of clinical services said residents should have a physician's order to consume alcoholic beverages. She said the physician’s order should include parameters for the amount of alcohol and risks with any medications the resident took. She said she was not part of the evaluations for residents to have alcohol, but she said had started an audit to identify which residents consumed alcoholic beverages (during the survey). She said she would look at the residents’ physician’s orders and would discuss it in the interdisciplinary team (IDT )meeting. The interim nursing home administrator (NHA) was interviewed on 4/1/26 at 12:30p.m. The interim NHA said there was no documentation revealing education was completed on the effects of consuming alcoholic beverages for Resident #2 and Resident #3. The medical director (MD) was interviewed on 4/1/26 at 4:15 p.m. The MD said he would prefer for no residents to consume alcoholic beverages, but as a physician, he respected the autonomy of the residents’ choice to consume alcohol if they chose to do so. He said when the resident had red flags or big issues, such as they were a fall risk, had dementia or was a known alcoholic, he would not give orders for those residents to consume alcoholic beverages. He said the facility had a physician’s order set in the facility’s electronic charting system which allowed nursing staff to add the physician’s order to consume alcohol into a resident’s electronic medical record (EMR), when appropriate. He said it was up to the facility to alert him when a physician’s order was needed for the resident. He said he had discussed with residents before why drinking alcohol was a bad decision but he said he had not discussed this with any current residents at the facility that he could recall. He said he relied on the director of nursing (DON) to notify him with any resident alcohol consumption concerns.
Plan of correction · submitted by the facility
Corrective action:On 4-20-2026 resident #2 orders were reviewed to ensure there was a physician’s order to consume alcoholic beverages. On 4-20-2026 a physician order was obtained for resident #3 to consume alcohol beverages. Others Affected:An audit was completed on 4-1-2026 to ensure all residents that consume alcoholic beverages had a physician's order to consume alcoholic beverages. 10 residents were found to be affected by this deficient practice. All 10 residents affected by this deficient practice obtained physician's order to consume alcoholic beverages. Systematic change:Upon admission Activity Director or designee will interview resident and or representative to complete the “Admission Alcohol Preference Questionnaire” to determine alcohol consumption preference. This document will consist of Yes or NO I wish to receive alcoholic beverage during happy hour, resident/representative signature and date. Bottom section filled out by facility representative of document will contain yes or no answers for PHYSICIAN PERMISION, PHYSICIAN ORDER COMPLETED IN POINTCLICKCARE, CARE PLAN COMPLETED FOR PREFERENCE ON ALCOHOL, Facility representative signature and date of completion. Monitoring Plan:Administrator or designee will complete audit form that contains: resident name, date of admission, alcohol preference to receive alcohol, if yes, was physician notified to obtain order and date care plan was updated. This audit will be completed one time a week for 4 weeks and then monthly for 2 months or until substantial compliance is met. Audit will be reviewed monthly at QAPI times 3 months or until substantial compliance is met.
5/15/2025Complaint Survey · ID 8YP611No deficiencies
0000INITIAL COMMENTSSurveyor note
Findings
A complaint survey, prompted by #CO39963 was conducted on 5/13/25 to 5/15/25. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
1/22/2025Revisit: Recertification Survey · ID LOUT22No deficiencies
0000INITIAL COMMENTSSurveyor note
Findings
A document revisit was completed with all deficiencies being corrected with the exception of any waived deficiency or deficiencies. All waived deficiencies will be corrected at a later date as per the approved waiver. A plan of correction is not required.
Plan of correction
The state did not require a plan of correction for this citation.
9999FINAL OBSERVATIONSSurveyor note
Findings
The state listed this citation without publishing narrative text.
Plan of correction
The state did not require a plan of correction for this citation.
1/6/2025Revisit: Recertification Survey · ID LOUT12No deficiencies
0000Initial CommentsSurveyor note
Findings
A revisit survey was completed on 1/6/25 for all previous deficiencies cited on 11/21/24. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
12/11/2024Recertification Survey · ID LOUT216 deficiencies
0000INITIAL COMMENTSSurveyor note
Findings
The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag # K 000) are informational only and represent the facility's general characteristics. The facility is a 37,050-square-foot facility consisting of 40 resident rooms and supporting services. It is a one-story, slab-on-grade, without a basement, Type II (111) construction. It is classified as fully protected by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system. The facility is licensed for 40 beds and operated as a non-secured facility at the time of this survey; the census on the day of the survey was 35 residents. This Life Safety Code survey was conducted on December 11, 2024, for compliance with NFPA 101 Life Safety Code, 2012, Chapter 19, Existing Healthcare Occupancies; NFPA 99 Health Care Facilities Code, 2012 edition; and referenced publications.
Plan of correction
The state did not require a plan of correction for this citation.
0321Hazardous Areas - EnclosureS/S F
Findings
Through observation during the survey, it was determined that the facility failed to maintain hazardous areas in accordance with NFPA 101. This was evidenced by:1) The maintenance office deemed hazardous needs door closure2) The janitor closet main needs to reinstall the door closure 3) The kitchen mechanical room needs fire sealant around ceiling penetrations4) The furnace mechanical room needs the ceiling repaired, smoke-tight NFPA 101 19.3.2.1.2* Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4. NFPA 101 19.3.2.1.3 The doors shall be self-closing or automatic-closing. NFPA 101 4.6.12 Maintenance, Inspection, and Testing. 4.6.12.1 Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. 4.6.12.2 No existing life safety feature shall be removed or reduced where such feature is a requirement for new construction. 4.6.12.3* Existing life safety features obvious to the public, if not required by the Code, shall be either maintained or removed. 4.6.12.4 Any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature requiring periodic testing, inspection, or operation to ensure its maintenance shall be tested, inspected, or operated as specified elsewhere in this Code or as directed by the authority having jurisdiction. 4.6.12.5 Maintenance, inspection, and testing shall be performed under the supervision of a responsible person who shall ensure that testing, inspection, and maintenance are made at specified intervals in accordance with applicable NFPA standards or as directed by the authority having jurisdiction. This deficiency could affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the facility maintenance director during the exit conference.
Plan of correction · submitted by the facility
Tag 0321NFPA 101 19.3.2.1.2*Where the sprinkler option of 19.3.2.1 is used, the areas shall be separated from other spaces by smoke partitions in accordance with Section 8.4. NFPA 101 19.3.2.1.3The doors shall be self-closing or automatic-closing. NFPA 101 4.6.12 Maintenance, Inspection, and Testing. 4.6.12.1Whenever or wherever any device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or any other feature is required for compliance with the provisions of this Code, such device, equipment, system, condition, arrangement, level of protection, fire-resistive construction, or other feature shall thereafter be continuously maintained. Maintenance shall be provided in accordance with applicable NFPA requirements or requirements developed as part of a performance-based design, or as directed by the authority having jurisdiction. Corrective Action1) The maintenance office deemed hazardous and self closing hinges ordered and installed on 12/23/2024. Door tested and recorded to be closing with positive latch. 2) self closer on the janitor closet main ordered on 12/16/2024 and will be reinstalled when it arrives. Self closing spring hinges installed on 12/16/2024 to ensure door function until appropriate door closer arrives. 3) The kitchen mechanical room has been repaired with proper fire sealant where water supply and combustion air vent penetrate ceiling. 4) The furnace mechanical room ceiling has been repaired to ensure room is smoke-tight so that the fire suppression, and smoke detector function properly. Identifications of others. This deficient practice could affect occupants, including residents, staff, and visitors within the entire facility. Systematic ChangeAreas within the facility deemed hazardous will be inspected and documented monthly to ensure proper function of self-closing doors and all related hardware. Fire barriers and smoke barriers will be inspected and documented monthly to ensure that Appropriate rooms are smoke/fire tight. MonitoringEvery month Maintenance director or other appropriate staff will inspect all hazardous areas to ensure doors are self-closing and properly latching. This will be documented for each area. All findings will be covered during Monthly QAPI meeting. Newly installed hardware will be inspected and documented weekly for the first 3 months to ensure equipment is functioning properly, all findings will be reviewed in monthly QAPI meeting. Every month fire/smoke barriers will be inspected, and findings will be documented. all findings will be reviewed during monthly QAPI meeting. Newly repaired areas will be inspected weekly for the first 3 months to ensure repairs are in good condition. All findings will be reviewed monthly
0353Sprinkler System - Maintenance and TestingS/S D
Findings
Through document review and observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13. This was evidenced by1) The hydraulic information plate is incorrect and needs to reflect the proper design criteria from the drawings. It also lacks a general information sign. NFPA 101, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 25, 5.2 Inspection. 5.2.6* Hydraulic Design Information Sign. The hydraulic design information sign for hydraulically designed systems shall be inspected quarterly to verify that it is attached securely to the sprinkler riser and is legible. 5.2.8* Information Sign. The information sign shall be inspected annually to verify that it is securely attached and is legible. NFPA 13, 24.6 General Information Sign. 24.6.1 The installing contractor shall provide a general information sign used to determine system design basis and information relevant to the inspection, testing, and maintenance requirements required by NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 24.6.1.1 Such general information shall be provided with a permanently marked weatherproof metal or rigid plastic sign secured with corrosion-resistant wire, chain, or other acceptable means. 24.6.1.2 Such signs shall be placed at each system control riser, antifreeze loop, and auxiliary system control valve. 24.6.2 The sign shall include the following information:(1) Name and location of the facility protected(2) Occupancy classification(3) Commodity classification(4) Presence of high-piled and/or rack storage(5) Maximum height of storage planned(6) Aisle width planned(7) Encapsulation of pallet loads(8) Presence of solid shelving(9) Flow test data(10) Presence of flammable/combustible liquids(11) Presence of hazardous materials(12) Presence of other special storage(13) Location of auxiliary drains and low point drains on dry-pipe and preaction systems(14) Original results of main drain flow test(15) Name of installing contractor or designer(16) Indication of presence and location of antifreeze or other auxiliary systems
Plan of correction · submitted by the facility
Tag 0353NFPA 101, 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. NFPA 13, 24.6 General Information Sign. 24.6.1 The installing contractor shall provide a general information sign used to determine system design basis and information relevant to the inspection, testing, and maintenance requirements required by NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Corrective ActionCooper fire arrived at cottonwood RHC facility on 12/16/2024 to assess appropriate signage needed, and to ensure that signage is accurate and up to date. General information sign containing the fallowing: (1) Name and location of the facility protected(2) Occupancy classification(3) Commodity classification(4) Presence of high-piled and/or rack storage(5) Maximum height of storage planned(6) Aisle width planned(7) Encapsulation of pallet loads(8) Presence of solid shelving(9) Flow test data(10) Presence of flammable/combustible liquids(11) Presence of hazardous materials(12) Presence of other special storage(13) Location of auxiliary drains and low point drains on dry-pipe and preaction systems(14) Original results of main drain flow test(15) Name of installing contractor or designer(16) Indication of presence and location of antifreeze or other auxiliary systemsHas been requested from Cooper fire and will be installed upon arrival. Identifications of others. All residents have potential for harm from this deficient practice. Systematic ChangeSignage will be checked and documented during monthly visual sprinkler room inspections. MonitoringMonthly signage Inspection results will be reviewed monthly in QAPI to ensure proper placement and appropriate signs with accurate information.
0521HVACS/S F
Findings
Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 80, and 105. This was evidenced by:1) Fire Dampers (4-6 years)(101 8.5.5.4.1 & 80 19.4): Not ProvidedNFPA 101 8.5.5.4.1 Air-conditioning, heating, ventilating ductwork, and related equipment, including smoke dampers and combination fire and smoke dampers, shall be installed in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, and NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. NFPA 80 19.4* Periodic Inspection and Testing. 19.4.1 Each damper shall be tested and inspected 1 year after installation. 19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. NFPA 105 6.5 Periodic inspection and testing. 6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences. 6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. This deficiency can potentially affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the facility maintenance director during the exit conference.
Plan of correction · submitted by the facility
Tag 0521NFPA 101 8.5.5.4.1 Air-conditioning, heating, ventilating ductwork, and related equipment, including smoke dampers and combination fire and smoke dampers, shall be installed in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilating Systems, and NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. NFPA 80 19.4* Periodic Inspection and Testing. 19.4.1 Each damper shall be tested and inspected 1 year after installation. 19.4.1.1 The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shall be every 6 years. Corrective ActionVents inspected for fire dampers. All dampers discovered have been visually inspected for proper function and compliance. replacement fusible links ordered 12/30/2024 for testing. All dampers will be function tested by 1/16/2024. Identifications of othersThis deficient practice can potentially affect occupants, including residents, staff, and visitors within the entire facility. Systematic ChangeDamper inspections and Testing completed and documented. Periodic inspection and testing now added to Tels to ensure inspections are completed. In accordance with NFPA 101. MonitoringDamper inspection will be reviewed monthly in QAPI to ensure completion and to determine when next inspection is due.
0711Evacuation and Relocation PlanS/S F
Findings
Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) Fire Safety Plan (101 19.7.2.2): This plan was not provided per NFPA 101 requirements, and the evacuation maps do not show smoke compartment walls. NFPA 101 19.7.1 Evacuation and Relocation Plan and Fire Drills. 19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. NFPA 101 19.7.2.2 Fire Safety Plan. A written health care occupancy fire safety plan shall provide for all of the following:(1)Use of alarms(2)Transmission of alarms to fire department(3)Emergency phone call to fire department(4)Response to alarms(5)Isolation of fire(6)Evacuation of immediate area(7)Evacuation of smoke compartment(8)Preparation of floors and building for evacuation(9)Extinguishment of fireNFPA 101 This deficiency can potentially affect occupants, including residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.
Plan of correction · submitted by the facility
Tag 0711NFPA 101 19.7.1 Evacuation and Relocation Plan and Fire Drills. 19.7.1.1 The administration of every health care occupancy shall have, in effect and available to all supervisory personnel, written copies of a plan for the protection of all persons in the event of fire, for their evacuation to areas of refuge, and for their evacuation from the building when necessary. Corrective ActionCottonwoods evacuation maps have been updated to show the 4 smoke compartments, and walls/doors that separate them in addition to pre existing evacuation routs. The fire plan has been simplified and updated to reflect these maps. Fire safety plan now elaborates on alarm activation means (automatic and manual activation). How and when to activate alarms. How our alarm system transmits signal to the fire department. As well as who is responsible for calling the fire department after alarm is activated. The plan also elaborates on all staff responsibility after fire is identified, and/or when alarm is activated. This includes: isolating the fire by closing doors and windows. evacuation of staff, residents, and visitors in the immediate area. When it is appropriate and steps to safely attempt to extinguish the fire. Evacuating the smoke compartment, (i.e., how to transport residents, give directions, and where is a safe location to evacuate to. Staff will be educated on these changes during all staff meeting on January 16th 2025, all new hires will be educated on this upon hire and full staff annual. Identifications of othersThis deficient practice can potentially affect occupants, including residents, staff, and visitors within the entire facility. Systematic ChangeFire plan will be updated, and staff notified of any changes to reflect best practices upon recommendations from qualified professionals. Plan will be reviewed quarterly to ensure they are up to date and signs are placed appropriately with appropriate information identified on the map. MonitoringMaps and fire plan will be audited on/ before monthly QAPI meeting for the first 3 months the quarterly after that. Findings will be covered During monthly QAPI meeting.
0741Smoking RegulationsS/S E
Findings
Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) Smoking (101 19.7.4): There are designated areas; however, during the survey, it was seen that staff are not using the designated areas with approved trash and cigarette receptacles. We need to make this area designated and compliant or have staff smoke in approved areas. NFPA 101 19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:(1)Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.(2)In healthcare occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.(3)Smoking by patients classified as not responsible shall be prohibited.(4)The requirement of 19.7.4(3) shall not apply where the patient is under direct supervision.(5)Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.(6)Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. This deficiency could affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the facility maintenance director during the exit conference.
Plan of correction · submitted by the facility
Tag 0741NFPA 101 19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions:(1)Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking.(2)In healthcare occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required.(3)Smoking by patients classified as not responsible shall be prohibited.(4)The requirement of 19.7.4(3) shall not apply where the patient is under direct supervision.(5)Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted.(6)Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. Corrective ActionStaff educated on appropriate smoking location and dedicated smoking location regulations. All staff education will be provided on 1/16/2025 for all current staff. All new staff will be educated upon hire, and smoking regulations will be covered annually during all staff Inservice. Identifications of othersThis deficient practice could affect occupants, including residents, staff, and visitors within the entire facility. Systematic ChangeAll staff will be given and sign a copy of the facility smoking policy that clearly states safe location and regulations on smoking. Any staff found smoking out side of the designated smoking location will receive a progressive disciplinary warning starting with a verbal warning and education, and after 3 violations ending in possible termination of employment. MonitoringDuring monthly QAPI meeting all signed smoking policies will be reviewed. To ensure all staff have received appropriate education.
0914Electrical Systems - Maintenance and TestingS/S F
Findings
Through document review during the survey, it was determined that the facility failed to maintain the electrical systems in accordance with NFPA 99. This was evidenced by:1) Receptacle Testing (99 6.3.4.1): The record does not meet NFPA 99 requirementsNFPA 996.3.4.2 Record Keeping. 6.3.4.2.1* General. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modifications. 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. This deficiency could affect occupants, including residents, staff, and visitors within the entire facility. The deficient item was discussed with the maintenance team at the exit conference.
Plan of correction · submitted by the facility
Tag 0914NFPA 996.3.4.2 Record Keeping. 6.3.4.2.1* General. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modifications. 6.3.4.2.1.2 At a minimum, the record shall contain the date, the rooms or areas tested, and an indication of which items have met, or have failed to meet, the performance requirements of this chapter. Corrective ActionNew testing form created. This form covers GFCI testing (pass/fail), polarization (pass/fail), and receptacle retention (specific measurement/ pass fail). Identifications of othersThis deficient practice could affect occupants, including residents, staff, and visitors within the entire facility. Systematic Changeany time retention testing of outlets is completed specific retention will be measured and recorded then marked as pass or fail based on the findings. MonitoringReceptacle Retention will be tested and recorded as needed and annually. Task and appropriate documentation Added to tels. This document will be reviewed monthly During QAPI meeting and recorded on an audit form.
9999FINAL OBSERVATIONSSurveyor note
Findings
Christmas decorations: destructive testing. We tested multiple decorations and found that 1 green garland was not being treated properly. This garland was removed before the survey ended.
Plan of correction
The state did not require a plan of correction for this citation.
11/21/2024Recertification Survey · ID LOUT112 deficiencies
0000Initial CommentsSurveyor note2 building records
Findings · record 1 of 2
A recertification survey was conducted from 11/18/24 to 11/21/24. Two deficiencies were cited.
Findings · record 2 of 2
An Emergency Preparedness survey was conducted from 11/18/24 to 11/21/24. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0740Behavioral Health ServicesS/S D
Findings
Based on record review and interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for one (#14) of three residents reviewed for behavioral and emotional status out of 22 sample residents. Specifically, the facility failed to coordinate timely necessary behavioral, mental and emotional health care and services for Resident #14. Findings include: I. Resident #14 A. Resident status Resident #14, age 65, was admitted on 11/3/23. According to the November 2024 computerized physician orders (CPO), diagnoses included Arnold-Chiari syndrome with hydrocephalus (a condition where the lower part of the brain protrudes into the spinal canal causing a blockage in the flow of cerebrospinal fluid and leading to a buildup of fluid in the brain), anxiety disorder, depression, insomnia, other complicated headache syndrome, cognitive communication deficit, unspecified dementia, severe, with mood disturbance and malignant neoplasm of prostate. The 9/17/24 minimum data set (MDS) assessment revealed the resident's cognition was severely impaired with a brief interview for mental status (BIMS) score of four out of 15. Verbal behavioral symptoms directed towards others were present during the assessment. He used a wheelchair for mobility and required partial moderate assistance with toileting hygiene, substantial/maximal assist with bathing and partial/moderate assist with transfers. He was prescribed antianxiety and antidepressant medications. B. Record review A review of the comprehensive care plan, initiated on 11/14/23 and revised on 11/20/24, revealed Resident #14 had a history of depression and insomnia and was taking two antidepressant medications (Trazodone and Lexapro) due to sleep disturbances, withdrawal from activities and refusals of care. He received Ativan for anxiety as evidenced by restlessness and leg movements, pacing, increases in complaints, agitation, obsession about clothing and temperature changes, false accusations against staff, and playing with a suprapubic urinary catheter. Resident #14 was prescribed and administered an antipsychotic medication (Seroquel) related to auditory hallucinations, increased agitation and anxiety. Interventions included referral to a psychologist/psychiatrist as needed. Review of Resident #14's behavior care plan, initiated on 5/16/24 and revised on 11/18/24, revealed the resident had behaviors related to his dementia diagnosis and often made false allegations and statements. The resident yelled and cussed at staff, residents and imaginary individuals and often had auditory hallucinations. He was withdrawn from group activities and stayed in his room most of the day. He had depression at times that caused him to have difficulty sleeping as evidenced by sleep disturbances and restless leg movements. Interventions included administering medications per the physician's order, approaching the resident in a calm manner to avoid frustration and behavior escalation, attempting to redirect the resident when he was exhibiting behaviors, monitoring and documenting episodes of inappropriate behaviors, monitoring the resident's behavior episodes and attempting to determine the underlying cause of the behavior, including considering location, time of day, persons involved and situations, observing and reporting any changes in mental status caused by situational stressors and offering psychologist/psychiatrist services as needed. Review of Resident #14's November 2024 CPO revealed the following physician's orders:Trazodone HCl oral tablet 50 milligrams (mg). Give 25 mg by mouth at bedtime for insomnia and depression, ordered 11/23/23. Cymbalta oral capsule delayed release particles 20 mg (Duloxetine HCl). Give one capsule by mouth one time a day for depression, ordered 11/4/23 and discontinued on 10/31/24. Escitalopram Oxalate (Lexapro tablet 20mg). Give one tablet by mouth one time a day for depression, ordered 11/1/24. Ativan (Lorazepam) oral tablet 1 mg. Give one tablet by mouth at bedtime related to generalized anxiety, ordered 5/7/24. Quetiapine Fumarate Oral Tablet 25 mg. Give one tablet by mouth three times a day for unspecified dementia, severe, with mood disturbance, ordered 11/14/24. A nurse progress note dated 4/7/24 documented Resident #14 had been angry that he was not served breakfast immediately when entering the dining room. The resident was reminded that the cooking staff did not arrive to work until 6:00 a.m., therefore they were unable to serve him at 5:00 a.m..The resident was yelling at his neighbor to 'shut-up', because his neighbor was whistling songs while getting ready for the day. A nurse progress note dated 4/9/24 documented the interdisciplinary team (IDT) met to review resident's psychotropic medication usage. The resident had no adverse side effects to the medications and no changes were made to the current medications per the power of attorney's (POA) and the resident's request. A risk versus benefit form was completed and the IDT would continue to review quarterly or PRN (as needed). A nurse progress note dated 4/16/24 documented Resident #14 had repeatedly set his call light off while laying in bed. When asked upon entering each time, what the nurse could do to assist him, he said his neighbor slammed the bathroom door, his sheet was coming off or he did not call. Upon the nurse entering his room the last time, the resident had thrown a dish from the kitchen on the floor and it shattered. Resident #14 had changed his shirt at least six times this morning (4/16/24). A nurse progress note dated 5/9/24 documented Resident #14 was upset that his neighbor shut his bathroom door loudly. The resident attempted twice to throw ice water into his neighbor's room and was very angry and difficult to redirect. A nurse progress note dated 5/13/24 documented Resident #14 said he was going to throw water at another resident's face. He was asked what made him so upset and he reported his neighbor was in the bathroom, slammed the doors and woke him up. The CNA (certified nurse aide) informed the resident it was his neighbor's shower and he was not creating excess noise on purpose. The resident said he was still going to throw water in his face. The CNA then asked the resident to give them 20 minutes, which he agreed to. No more threats had been made since and he was now in a pleasant mood. A nurse progress note dated 7/24/24 documented the IDT met to review Resident #14's psychotropic medication usage. The resident had had no adverse side effects to the medications and no changes were being made to the resident's current medications. The IDT would continue to review quarterly at the psychotropic committee meeting or PRN and plan GDRs (gradual dose reduction) as appropriate. Resident #14 and his POA requested that no changes be made to his medications because the medications were working for the resident. -The progress note did not indicate the facility offered a psychologist or psychiatrist consultation to the resident to help with the resident's behaviors. A nurse progress note dated 10/6/24 documented the staff was to monitor the resident for the following behaviors related to the use of Ativan as evidenced by an increase in complaints, obsession about clothing and temperature changes, false accusations against staff, playing with his catheter and refusals of care.-The progress note failed to identify interventions that were to be used with the resident to help the resident with the distressing behaviors. A progress note documented by the DON on 10/23/24 DON revealed Resident #14 pressed his call light five times in one minute. The resident was complaining his ears were ringing and he was not able to hear. He was given some eardrops but persisted in fixating on the concern and pressed his call light repeatedly for the same reason. He was requesting to have the physician come in and look in his ears. The note documented the resident had his television (TV) volume extremely loud and, though he claimed he could not hear, he was able to understand everything the DON and the CNAs were saying to him. The DON suggested he turn his TV volume down which could potentially help with his complaint of not being able to hear but the resident refused. Redirection continued without success and the DON notified the physician of the resident's request to look in his ears. A nurse progress note dated 10/24/24 documented Resident # 14 was agitated during the shift and asked to use the bathroom four times in 30 minutes. Staff would assist him to the bathroom every time, for him to sit down, stand right back up and say he was done. The resident was fixating on certain other residents being in the dining room and refusing to eat because they were in there. The resident had to be redirected to the dining room five times during the shift, after being placed at a table per his request, then stating 'that resident is down here' and turning around and leaving the dining room. The resident was difficult to redirect. A nurse progress note dated 10/28/24 documented the resident was yelling out at neighbors and staff to stop slamming the doors. Staff were mindful about closing the doors softly and he continued to yell when doors around him were shut as quietly as possible. Resident #14 was assured everyone was trying to keep the environment quiet, he was given fresh water and his medications at his preferred time. He continued to yell out after any sounds were made in the hall or neighboring rooms until he fell asleep. A nurse progress note dated 10/30/24 documented the resident was yelling loudly about people slamming doors. The nurse watched the resident's neighbor's door be shut with no slamming. The resident had continually used his call light when he was upset about loud noises and cold coffee. A nurse progress note dated 11/1/24 documented Resident #14 was repeatedly screaming 'be quiet' at the top of his lungs, as well as putting his call light on. The nurse informed the resident they would be as quiet as they could and he verbalized understanding. A nurse progress note dated 11/12/24 documented the resident had been yelling over any noise throughout the night. He yelled at another resident to shut up who was talking in the hallway on the way back to their room. Resident #14 was offered food and drink, efforts to keep his environment quiet and reassurance that no one was being noisy on purpose. The resident voiced his understanding, however the resident continued to yell at neighboring residents and staff from his room. A progress note documented by the DON on 11/14/24 documented Resident #14 had been extremely agitated, more so than his normal. He was yelling at his next door neighbor even though the resident was not in his room next door. Resident #14 had pushed his call light three times in five minutes and was yelling and agitated. He then pressed his call light another two times and when the CNA entered the room, he was yelling that the lady next door kept slamming the door, however, there was no lady next door. The physician was notified. A progress note documented by the DON on 11/15/24 documented the DON called the resident's family member to let her know the physician ordered Seroquel for the resident and to obtain consent for the medication. The family member gave consent for the medication. A nurse progress note dated 11/15/24 documented the resident was agitated, yelling, and cursing during the shift and refused a catheter change. The note documented the resident had begun taking Seroquel and was offered a quiet environment, food and drink and lotion was applied to his abdomen as requested for itchiness. A nurse progress note dated 11/19/24 documented the resident was yelling profanities from his room regarding another resident slamming her door, however, there were no residents slamming their doors. A nurse progress note dated 11/20/24 documented Resident #14 was again yelling and screaming about a resident slamming her door. There were no noises heard by staff who were outside his door being mindful of providing a quiet environment for the resident. The nurse apologized and told the resident the staff did not hear any loud noises or door slamming, but they would be more cautious of making noise. Resident #14 indicated the unoccupied room next to him was where the noise was coming from. A progress note documented by the social services director (SSD) on 11/21/24 (during the survey) documented a physician's order for a referral to behavioral psychiatric services for Resident #14 had been obtained. The resident's POA was contacted and agreed with the referral. The SSD attempted to schedule an appointment with a behavioral health services provider.-The progress note failed to indicate if the SSD was able to schedule a behavioral health services appointment.-Review of the progress notes from 4/7/24 through 11/21/24 revealed there was no documentation to indicate the facility assessed the underlying causes and potential triggers for Resident #14's expressions of distress.-There was no documentation in the resident's electronic medical record (EMR) to indicate the facility offered a psychologist or psychiatrist consultation for Resident #14 in order to assist the resident with his distressing behaviors until 11/21/24, despite several months of documentation related to the resident's behaviors (see progress notes above). II. Staff interviews Registered nurse (RN) #2 and CNA #1 were interviewed together on 11/18/24 at 2:01 p.m. RN #2 and CNA #1 said Resident #14 had exhibited his agitation and aggressive verbal behaviors towards staff and other residents for the past several months. RN #2 said Resident #14's behaviors were disturbing to other residents who were on the unit for skilled rehabilitation services and were going back to the community. RN #2 and CNA #1 said Resident #14 was not offered and had not received any psychological or psychiatric health care consultation or services. RN#1 was interviewed on 11/21/24 at 8:45 a.m. RN #1 said Resident #14's behaviors were consistent in the past few weeks and very disturbing to him and other residents. She said his behaviors were not specifically directed. She said the staff offered non-pharmacological interventions such as distractions, TV shows/sports, activities and offered to take the resident outside. She said the resident was not receiving any mental health services for his behaviors. The DON was interviewed on 11/21/24 at 11:10 a.m. The DON said Resident #14's behaviors had escalated within the last few weeks and she said the resident "did not feel good in his own skin." She said she communicated with the resident's POA, as well as his physician, regarding recent psychotropic medications changes. She said the physician wanted to try medications first. She said the facility did not consider a behavioral health consultation for the resident during the most recent psychotropic medications review with the medical director and the pharmacist. The DON said she would reach out to the resident's POA for an approval for a mental health consultation for the resident.
Plan of correction · submitted by the facility
F740- Behavioral health services. Each resident must receive, and the facility must provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Behavioral health encompasses a resident’s whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders. It is the practice of the facility to treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of state and federal law. Corrective Action On 11/21/2024, SSD (social service director) obtained consent from resident #14’s POA (power of attorney) to refer resident #14 to behavioral health services with Axis Mental Health. The receptionist at Axis Mental Health stated that the Senior Reach Team would be more appropriate. SSD called the Senior Reach team on 11/21 and left a voice mail. On 12/2 Axis Senior Reach Team returned the call for the appointment request and stated that the receptionist with Axis Mental Health should have set up the appointment, and that she would have the receptionist call the facility to schedule. On 12/6 SSD again reached out to Axis Mental Health to schedule the appointment and the receptionist stated that she would reach out to the Senior Reach Team to schedule an appointment and call back on 12/9 with the day and time. 12/10/2024 Received call back from Axis Mental Health, an appointment for resident #14 has been set up for 12/20/2024 @ 2pm. Identifications of othersSSD will audit all residents with patterned behaviors to ensure their recommended behavioral health care needs and/or services have been addressed by 12/15/2024. Any concerns identified will be corrected by 12/20/2024. SSD to audit all behavioral health care plans so ensure all recommendations and interventions are currently being or have been followed by 12/15/2024. Any concerns identified will be corrected by 12/20/2024. Systematic ChangeNHA (nursing home administrator)/designee will in-service SSD by 12/15/2024 on assessing, identifying, and addressing behavioral health care and behavioral health services needs of residents and ensuring recommendations are followed. MonitoringStarting 12/20/2024 SSD/designee will monitor with each new behavior and/or new/change in psychotropic medication, that the residents behavioral, mental, and emotional care needs are being met and that interventions are in place and being followed. Monitoring results will be documented on an audit form. Starting 12/20/2024 the NHA/designee will audit weekly during At Risk Review residents on a new or have a change in psychotropic medications, new admissions with behaviors and current residents with behaviors to ensure their behavioral, mental, and emotional care has been addressed and that interventions are in place and being followed. Monitoring results will be documented on an audit form. The NHA/designee and SSD/designee will track and trend the results of the audits and report their findings to the QAPI committee monthly. The QAPI committee will evaluate the effectiveness of the plan based on trends identified and implement additional interventions as needed to ensure compliance monthly for 3 months and then reassess the need for continued monitoring based on compliance.
0882Infection Preventionist Qualifications/RoleS/S F
Findings
Based on interviews and record review, the facility failed to employ an infection preventionist (IP) who had completed specialized training in infection prevention and control which had the potential to affect all residents residing in the facility at the time of the survey. Specifically, the facility failed to have a qualified IP involved with the facility's infection prevention and control program. Findings include: I. Facility policy and procedure The Infection Preventionist policy, revised September 2022, was provided by the nursing home administrator (NHA) on 11/21/24 at 8:25 a.m. The policy read in pertinent part, "The IP is professionally trained in nursing, medical technology, microbiology, epidemiology, or other related field with at least the following professional training:-A nurse must have earned a certificate/diploma in nursing; and,-A medical technologist must have earned at least an associate's degree in medical technology or clinical laboratory science. "The IP is employed on site and at least part time; and,-The IP is scheduled with enough time to properly assess, develop, implement, monitor, and manage the infection control program, address the training requirements, and participate in required committees." II. Record review A request was made for the IP's infection control certificate on 11/20/24 at 2:30 p.m. The director of nursing (DON) was unable to locate the IP certificate of completion. III. Staff interviews The DON was interviewed on 11/20/24 at 2:10 p.m. The DON said she had worked at the facility as a full time DON. She said she completed the required education in 2024 to obtain the infection control certificate but was unable to locate the certificate of completion. The DON said she worked in the facility as a full time DON but also functioned as the facility IP. The DON said she collected infection statistics but had not analyzed the information to ensure the infection control program was effective. The DON said she was unaware of the requirement for the facility to have a qualified infection preventionist that worked as an IP at least half time. The DON said the facility will review the requirement for the IP position and discuss the requirement with the NHA.
Plan of correction · submitted by the facility
F882 Infection preventionistThe facility must designate one or more individual(s) as the infection preventionist(s) (IP)(s) who are responsible for the facility’s IPCP. The IP must:§483.80(b)(1) Have primary professional training in nursing, medical technology, microbiology, epidemiology, or other related field;§483.80(b)(2) Be qualified by education, training, experience, or certification. It is the practice of the facility to treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of state and federal law. Corrective ActionPrevious IP (infection preventionist) present at the time of survey is no longer employed with Cottonwood RHC. Previous IP (infection preventionist) had completed 15 modules pertaining to IP (infection preventionist) but failed to attempt final exam for IP (infection preventionist) certification. New qualified IP (infection preventionist) hired with completed Co Train infection preventionist training as of 12/08/24. Proof of completion was provided and filed. Identifications of othersAll residents have the potential to be affected by this deficient practice. Systematic ChangeStarting 12/8/2024 all current or new IP (infection preventionists), will be required to obtain their IP (infection preventionist) training certificate within 14 days of hire. IP (infection preventionist) training and certification will be reviewed upon any position/ status changes of Current IP (infection preventionist) by NHAMonitoringStarting 12/8/2024, NHA/designee will confirm monthly that the designated IP (infection preventionist) certificate is current. The NHA/designee will track and trend the results of the audits and report their findings to the QAPI committee monthly. The QAPI committee will evaluate the effectiveness of the plan based on trends identified and implement additional interventions as needed to ensure compliance monthly for 3 months and then reassess the need for continued monitoring based on compliance.
1/30/2024Focused Infection Control, Other-Fed Survey · ID QA9M111 deficiency
0884Reporting - National Health Safety NetworkS/S F
Findings
Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention's (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation. The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 01/22/2024 and 01/28/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.
Plan of correction
The state did not require a plan of correction for this citation.
8/31/2023Revisit: Recertification Survey · ID NTJQ22No deficiencies
0000INITIAL COMMENTSSurveyor note
Findings
A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.
Plan of correction
The state did not require a plan of correction for this citation.
8/30/2023Revisit: State Licensure Survey · ID EBHJ12No deficiencies
0000Initial CommentsSurveyor note
Findings
A revisit survey was completed on 8/29/23 for all previous deficiencies cited on 8/30/23. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
8/30/2023Revisit: Recertification Survey · ID NTJQ12No deficiencies
0000Initial CommentsSurveyor note
Findings
A revisit survey was completed on 8/29/23 and 8/30/23 for all previous deficiencies cited on 7/12/23. The facility is in compliance with all regulations surveyed.
Plan of correction
The state did not require a plan of correction for this citation.
8/9/2023Recertification Survey · ID NTJQ212 deficiencies
0000INITIAL COMMENTSSurveyor note
Findings
The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments, (ID Prefix Tag # K 000), are informational only and a representation of the facility's general characteristics. The facility is a 37,050 square foot facility consisting of 40 resident rooms and supporting services. It is a one story, slab on grade, without a basement, of Type II (111) construction. It is classified as fully protected by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system. The facility is licensed for 40 beds and operated as a non-secured facility at the time of this survey; the census on the day of the survey was 35 residents. This Life Safety Code survey was conducted on August 9, 2023 for compliance to NFPA 101 Life Safety Code, 2012, Chapter 19, Existing Healthcare Occupancies; NFPA 99 Health Care Facilities Code, 2012 edition; and referenced publications.
Plan of correction
The state did not require a plan of correction for this citation.
0363Corridor - DoorsS/S E
Findings
Rooms A08, B01& B Soiled Linen Room - doors to corridor do not latch upon closure. Based on staff interviews, record review and observations during the facility survey on January 20, 2020, it was determined that the facility failed to meet the life safety protection requirements of the Life Safety Code (NFPA 101) and Standard for Fire Doors and Other Opening Protectives (NFPA 80) by not maintaining corridor doors. This was evidenced by: 1)Rooms A08, B01 and B Soiled Linen - doors do not close and securely latch providing for a suitable means of keeping the door closed. NFPA 101- 19.3.6.3.5This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within two of the six smoke compartments. Deficient items were discussed with the Maintenance Director during the survey and again with the Maintenance Director and Administrator during the exit conference on August 08, 2023.
Plan of correction · submitted by the facility
K 363 Corridor – DoorsIt is the practice of the facility to maintain positive latch and closure of doors in Accordance with the 2012 edition of the NFPA 101, life safety code. Corrective ActionThe doors to resident room A08, resident room B01 and B Soiled Linen Room have been corrected to positively latch upon closure as of 8/14/2023. Identification of othersNo further issues were identified during survey. Systematic ChangeThe NHA/designee will in-service the Maintenance Director on Life Safety Code by 08/16/2023. MonitoringStarting the week of 08/21/2023 the Maintenance Director/designee will audit 10 resident rooms weekly, and 5 common and storage doors weekly. The Maintenance Director/designee will track and trend the results of these audits and report findings to the QAPI committee monthly. The QAPI committee will evaluate the effectiveness of the plan based on the trends identified and implement additional interventions as needed to ensure compliance for 3 months then reassess the need for continued monitoring based on compliance
0511Utilities - Gas and ElectricS/S D
Findings
Gas fired appliance in kitchen with casters had no restraintsBased on observation and staff interview during the course of the survey it was determined the facility failed to maintain the building services for gas equipment in accordance with NFPA 101, 19.5, 19.5.1.1, 9.1.1, including NFPA 54, National Fuel Gas Code. The following evidenced this: 1) Gas fired appliance in kitchen with casters had no restraints 9.6.1.2 Restraint. Movement of appliances with casters shall be limited by a restraining device installed in accordance with the connector and appliance manufacturer's installation instructions. This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within one of the six smoke compartments. Deficient items were discussed with the Maintenance Director during the survey and again with the Maintenance Director and Administrator during the exit conference on August 08, 2023.
Plan of correction · submitted by the facility
K 511- Utilities Gas and ElectricIt is the practice of the facility to maintain the building services for gas equipment in Accordance with the 2012 edition of the NFPA 101, life safety code. Corrective ActionThe restraint was replaced and installed in accordance with the connector and appliance manufacturers instructions on 08/9/2023 Identification of othersNo further issues were identified during survey. Systematic ChangeThe NHA/designee will in-service the Maintenance Director on Life Safety Code by 08/16/2023. MonitoringStarting the week of 08/21/2023 the Maintenance Director/designee will audit gas oven and fryer Weekly to ensure all safety standards are met and in compliance with the 2012 edition of the NFPA 101, life safety code The Maintenance Director/designee will track and trend the results of these audits and report findings to the QAPI committee monthly. The QAPI committee will evaluate the effectiveness of the plan based on the trends identified and implement additional interventions as needed to ensure compliance for 3 months then reassess the need for continued monitoring based on compliance
7/12/2023State Licensure Survey · ID EBHJ112 deficiencies
0000Initial CommentsSurveyor note
Findings
A licensure survey was completed on 7/9/23 to 7/12/23. Two deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0705Resident Care - Behavioral Health Care
Findings
Based on observation, records review and interviews, the facility failed to adequately monitor the resident for unnecessary psychotropic medications needed to provide effective and person-centered care for three (#15, #89 and #26) of five residents reviewed for use of psychotropic medication out of 18 sample residents. Record review revealed that Resident #15 had exit-seeking behaviors. The facility failed to obtain consent prior to increasing the administration of antipsychotic medication (Seroquel) and failed to ensure the antipsychotic medication administered was given to treat the resident's medical symptoms and not used for discipline or convenience. Additionally, the facility failed to implement effective person-centered behavior management interventions to prevent occasional wandering and exit-seeking behaviors. The resident was initially administered Seroquel 25 milligrams (mg) without any behaviors present and documented which was increased to 50 mg two times a day after displaying aggressive behaviors toward a nurse who woke the resident from his afternoon nap, triggering Resident #15's aggression. Resident #15 became verbally and physically aggressive towards staff after being provoked, at which time Resident #15 was given an antipsychotic medication Seroquel. The facility failed to ensure Resident #15's antipsychotic medication was not used for discipline or staff convenience. In addition, the facility failed to: -Ensure staff identified triggers for Resident #26's depression and anxiety episodes; -Develop a resident-centered plans of care for generalized anxiety disorder for Resident #26;-Develop a resident-centered plans of care for depressive episodes for Resident #89 and #26;-Ensure staff monitored and documented Resident #89 and Resident #26's response to antidepressant medication and its effectiveness;-Ensure staff monitored and documented adverse reactions to antianxiety and antidepressant therapy Resident #89 and #26;-Ensure provided non-pharmacological interventions were implemented with anxiety and depression for Resident #89 and #26; and, -Obtain informed consent from resident/representative for psychotropic medications Resident #89 and #26. Findings includeI. Facility policyThe Psychotropic Medication Use policy, dated July 2022, was requested received on 7/11/23 from the nursing home administrator (NHA), which read in pertinent part:"A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior."Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: antipsychotics, antidepressants, antianxiety, and hypnotics. "Residents are involved in the medication management process. Management includes; indications for use, dose, duration, adequate monitoring for efficacy and preventing, identifying, and responding to adverse consequences. "Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record."Use of psychotropic medications are not increased when efforts to decrease antipsychotic medications are being implemented."Non pharmacological approaches are used to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible."Residents receiving psychotropic medications are monitored for adverse consequences including: anticholinergic effects, cardiovascular effects, metabolic effects, psychological effects."II. Resident #15A. Professional reference The Saunders Nursing Drug Handbook, 2021, Quetiapine (Seroquel), read in part; "Elderly with dementia related psychosis are at increased risk for death. Uses: Treatment of schizophrenia. Treatment of acute manic episodes associated with bipolar disorder ... Off-label: psychosis/agitation related to Alzheimer's dementia." B. Resident status Resident #15, age 95, was admitted on 1/7/22. According to July 2023 computerized physician orders (CPO), diagnoses included chronic atrial fibrillation, cardiomyopathy, adult failure to thrive, pain, and unspecified dementia, severe, with other behavioral disturbance. The 5/9/23 significant change in status facility assessment revealed the resident's cognition was severely impaired with a brief interview for mental status (BIMS) score of three out of 15. No hallucinations, delusions, rejection of care or wandering behaviors were documented. He required limited assistance with bed mobility, dressing and personal hygiene, supervision with transfers, eating and toilet use. Medications included an anticoagulant and antibiotic. There were no physical restraints or alarms used. The 6/20/23 facility assessment revealed wandering occurred in one to three days during the assessment period. He required supervision with bed mobility, transfers, eating and personal hygiene, and extensive assistance with dressing and toilet use. Medications included an antipsychotic, anticoagulant and antibiotic. No physical restraints and no alarms were noted. C. Resident observations On 7/9/23 at 3:32 p.m. Resident #15 was observed asleep in his room. On 7/10/23 at 10:00 a.m. Resident #15 was observed in the television (TV) room. He was sleeping in his wheelchair. On 7/11/23 at 10:00 a.m. the resident was observed in the dining room at a table, with other residents playing a bingo game. Resident #15 had his game board in front of him and was not paying attention to the numbers called. He was not able to place a checker on a called number on the game board. The activities staff and other residents were assisting the resident through the game. On 7/11/23 at 2:00 p.m. Resident #15 was observed in his room, sleeping in his wheelchair. D. Record review 1. Care plan The comprehensive care plan revealed the following:-"Resident is at risk for elopement r/t (related to) exit seeking behavior (dated 5/22/23). Interventions included: Calmly redirect and divert resident's attention. Distract resident when wandering/insistent on leaving facility by offering pleasant diversions, structured activities, food, conversation, television, books. Set up meeting with family/guardian to determine if resident may need a more appropriate facility if elopement attempts continue.-"I am at risk for falls r/t (related to) cognition and not knowing my own abilities, dementia, abnormal gait, weakness, difficulty walking, unsteady on feet (dated 4/11/23). Interventions included: Activity Program/Group Program. Apply bed cane for positioning. Bed against the wall. Call before you fall sign, for visual reminder. Low bed. Maintain needed items within reach.-"Resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) cognitive impairment, dementia, depression, fluctuating ADLs, generalized weakness, history of falls, impaired mobility, poor balance (dated 4/11/23). Interventions included: Allow time for resident to express feelings of frustration regarding the need for assistance in ADL tasks." -The resident's centered care plan did not address the use of psychotropic medication Seroquel (Quetiapine Fumarate). 2. Physician orders Quetiapine Fumarate oral tablet 25 mg, give 1(one) tablet by mouth one time a day related to unspecified dementia, severe, with other behavioral disturbance. Start date 5/23/23. D/C (discontinued) date 5/26/23. Quetiapine Fumarate oral tablet 25 mg, give 1(one) tablet by mouth two times a day related to unspecified dementia, severe, with other behavioral disturbance. Start date 5/26/23. D/C date 6/3/23. Seroquel oral tablet 50 mg (Quetiapine Fumarate), give 1 (one) tablet by mouth two times a day related to unspecified dementia, severe, with other behavioral disturbance. Start date 6/4/23.3. Physician notesOn 4/5/23 the resident's physician documented: "94 year old male with dementia with behaviors. Pt (patient) with recent decline and adult failure to thrive. Have titrated off and stopped Seroquel."On 6/8/23 the resident's physician documented: "Recent GDR (gradual dose reduction) failed and pt (patient) had to be restarted on Seroquel due to agitation and exit seeking. Pt (patient) has improved and more focused without exit seeking."-The physician's note did not reveal the resident was sleepy and lethargic. (see staff interviews)The chemical/physical restraint and antidepressant review committee document in the resident's medical record was dated 1/25/23. (see staff interviews) E. Nursing notes On 3/16/23 at 6:47 p.m., a nurse documented: "Resident attempted to leave facility three times today. Twice out East door and once out North. Redirected by staff. Daughter aware." On 5/22/23 a director of nursing documented: "Spoke with (physician's name) regarding resident's increased behaviors and exit seeking. Per (physician's name), resident may resume Quetiapine 25mg by mouth daily. Order updated to reflect changes." -There was no documentation in the medical record related to resident's exit seeking or any behaviors from 3/16/23 until 5/25/23 (see below), three days after the psychotropic medication Seroquel was started. On 5/25/23 at 5:20 a.m., a nurse documented: "Resident was found by RN (registered nurse) on A wing wheeling out the main door to facility. RN caught him before he made it to the second door. Resident stated he was going to work and was redirected by RN telling him he needed coffee first." On 6/3/23 at 2:40 p.m., a nurse documented: "Resident was heading towards the front doors stating that he needed to get out of here and go home. This nurse was able to redirect the resident back to his room. The resident came back to the nurses' station 15-20 minutes later stating that he needed to leave and go home. This nurse was able to redirect the resident to the kitchen for a snack and a cup of coffee." On 6/3/23 at 4:11 p.m., a nurse documented: "This nurse went in to the residents room to give the resident his evening medication. The resident was asleep and this nurse woke him up gently. The resident woke up and swung at this nurse grazing this nurse's chin causing the resident to get two skin tears on his right hand. The resident continued to wing his arms stating that this nurse was trying to fight him. This nurse was able to deescalate the resident and allow this nurse to place two Band-Aids on the resident's top of hand. Resident refused his medication from this nurse. This nurse asked the resident to get up and please have dinner. The resident went down to dinner. This nurse asked the CMA (certified medical assistant) to give medication to the resident. The resident's responsible party is out of town. The resident's second contact is also out of town. Staff will notify when the responsible parties are back in town. This nurse notified the DON (director of nursing), administrator, and (physician's name). This CMA was able to administer medication after encouraging and reassuring resident that no one was trying to trick him." On 6/3/23 at 5:45 p.m., a nurse documented: "(physician's name) increased the resident Quetiapine to 50 mg PO (orally) BID (two times a day). This nurse notified the resident daughter (name) of the changes in medication. On 6/10/23 at 2:27 p.m., a nurse documented: "Res (resident) went out the east door by kitchen, door alarm sounded, res (resident) was able to make it out the door. Housekeeping assisted res (resident) around the building and back into facility through the front entrance with redirection. Res (resident) in his room currently in recliner, continue to check on resident frequently." F. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 7/11/23 at 9:45 a.m. She said the staff was monitoring the resident every 15 minutes and documented each time on a paper sheet. Every shift the document was turned in to the DON. She said this intervention was initiated by the new director of nursing approximately a month ago. CNA #2 was interviewed on 7/11/23 at 10:05 a.m. She said that in the past couple of months the resident was looking for the facility exit doors four times. She said the resident told the staff he wanted to go home or needed to go to work. She said only one time the resident became aggressive with a nurse who woke him up and tried to give him his medications (Seroquel). She said Resident #15 was very lethargic most of the time, needed more assistance with all activities of daily living. Certified nurse aide (CNA) #1 was interviewed on 7/11/23 at 10:10 a.m. She said she worked with the resident frequently. She said the resident was very sleepy all the time. The social service director (SSD) was interviewed on 7/11/23 at 10:50 a.m. She said she was new to her position. She said she was not aware the resident's care plan did not include the antipsychotic medication Seroquel. She said she added the medication to the resident's care plan "today."She said she was unable to find any of the psychotropic medications review notes for Resident #15 and the review dated 1/25/23 was the last one in his medical record. The director of nursing (DON) was interviewed on 7/11/23 at 11:15 a.m. She said she was a new DON in the facility, "for about a month." She said there was no care plan for staff monitoring the resident every 15 minutes and there was no care plan for the use of Seroquel. She said the staff who attended the psychotropic committee meeting was not aware the resident was off of Seroquel since March (2023). She said there was no documentation in the resident's medical record to justify initiating the psychotropic medication Seroquel therapy in May (2023). She said at the time Seroquel was started the resident was treated with an antibiotic for urinary tract infection which could trigger an increase in wandering behavior. III. Resident #89A. Resident statusResident #89, age 88, was admitted to the facility on 4/14/23. According to the July 2023 computerized physician orders (CPO) diagnoses included congestive heart failure, falls, depression, respiratory failure and cataracts. The 4/20/23 facility assessment document the resident had moderate cognitive impairment as evidenced by a brief interview for mental status (BIMS) with a score of 10 out of 15. She required one-person assistance for all activities of daily living (ADLs) and had supervision for bed mobility, transfers, walking in the room, locomotion on and off the unit, toilet use, eating and personal hygiene. She required limited assistance for dressing. B. Record reviewAccording to the July 2023 medication administration record (MAR) the resident received duloxetine for depression that was ordered on 4/14/23.-The resident's care plan, initiated on 4/20/23, indicated the resident did not have a care plan for care of the resident's depression. -A review of the computerized physician orders (CPO) revealed the facility failed to identify, offer and document effectiveness of non-pharmacological interventions for the resident's depression. The July 2023 MAR was reviewed and revealed the facility failed to effectively monitor the resident for side effects of antidepressant therapy. The physician order directed the nurse to monitor for side effects: drowsiness, blurred vision, dizziness, fatigue, trouble sleeping, dry mouth, hallucination and other unusual changes in mood or behavior every shift. Specifically, if monitoring was performed and none of side effects were observed, the nurse was directed to chart "Y"; if monitoring was performed and side effects were observed the nurse was directed to chart "N" and then select chart code "other/see nurses notes and progress notes" for findings. On 7/1/23, 7/3/23 and 7/8/23 the nurse documented "N" and information about the side effects the resident experienced and what interventions were taken was not found in the resident's medical record.-The facility failed to identify sources or triggers that manifested the resident's depression and then monitor for effectiveness of antidepressant treatment. C. Resident observation and interviewOn 7/9/23 at 3:45 p.m., the resident was observed lying in her bed. She said she was tired. She said her mood was not the best. The resident said she knew she had medication for depression and did not remember the name of the medication. She said she did not know why she felt depressed and said maybe it was from her recent illness. D. Staff interviewRegistered nurse (RN) #1 was interviewed on 7/10/23 at 11:15 a.m. She said the resident took antidepressant medication. She said she was aware the resident took antidepressant medication but was unaware of resident specific needs for the resident's depression. RN #1 said she had not observed the resident acting depressed. IV. Resident #26A. Resident status Resident #26, age 85, was admitted on 6/12/23. According to the July 2023 CPO, diagnoses included depression and anxiety. The 6/24/23 facility assessment revealed the resident had a moderate cognitive impairment with a BIMS score of seven out of 15. The resident required limited to extensive assistance for most ADLs. The resident received antianxiety and antidepressant medication. No behaviors were indicated. B. Record reviewA review of the July 2023 medication administration record (MAR) revealed the resident was administered Duloxetine for depression and Buspirone for anxiety that was ordered on 6/12/23.-The care plan, initiated 6/12/23, revealed the facility failed to establish a plan of care for the resident's depression and anxiety. -A review of the resident's record revealed the facility failed to obtain a consent for antianxiety medication and the antidepressant medication consent was unsigned by facility staff or the physician.-The facility failed to identify, offer and document effectiveness of non-pharmacological interventions for the resident's depression and anxiety.-A review of the CPO revealed the facility failed to effectively monitor the resident for side effects from antidepressant and antianxiety medication. The MAR revealed the nurse entered a check mark to indicate monitoring, a check mark was entered every shift every day, but there was no indication what the check mark represented. -A review of the CPO revealed the facility failed to identify triggers for anxiety and to monitor the effectiveness of medication management. C. Resident observation and interviewOn 7/9/23 at 3:10 p.m., the resident was observed sitting in her room. She said that she frequently felt she had high anxiety related to her health status, felt alone, her stay at the facility and wished to go home. She said she was unaware that she took medication for anxiety and said that if she was ordered medication, it did not help. D. Staff interviewRN #1 was interviewed on 7/10/23 at 11:15 a.m. She said the resident was prescribed an antidepressant and antianxiety medication. She said the resident was aware the resident took antianxiety and antidepressant medications but was unaware what specifically the resident needed to manage her depression and anxiety. RN #1 said she had not observed the resident depressed or anxious. The RN said when a nurse monitors medication side effects or effectiveness of medications, the monitoring was documented on the resident's MAR.V. Administrative interviewThe director of nursing (DON) was interviewed on 7/11/23 at 10:15 a.m. The DON said when a resident was admitted to the facility the interdisciplinary team developed the resident's care plan. She said the residents' care plan should have included care needs and management specific to the resident's depression and anxiety. The DON said a resident taking antipsychotic medication should be monitored for side effects and effectiveness, like a change in resident behavior or mood or adverse outcomes of the medication. The DON was unable to locate care plans specific to managing the residents' depression and anxiety. She said the residents' care plans should have included care needs and management specific to the resident's depression. The DON was interviewed again on 7/12/23 at 10:15 a.m. She said monitoring results were helpful for the physician to determine effectiveness of medication therapy. The DON said that when a resident was admitted, the interdisciplinary team (IDT) determined what monitoring was necessary and then nursing would obtain physician orders for monitoring. The DON said she would review how monitoring orders were entered to make future monitoring complete and effective. The director of nursing (DON) was interviewed on 7/12/23 at 10:15 a.m. She said monitoring results were helpful for the physician to determine effectiveness of medication therapy. The DON said that when a resident was admitted, the interdisciplinary team (IDT) determined what monitoring was necessary and then nursing would obtain physician orders for monitoring. The DON said she would review how monitoring orders were entered to make future monitoring complete and effective.
Plan of correction · submitted by the facility
S705 Behavioral Health Care Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of state and federal law. It is the practice of the facility to treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Corrective Action: Resident # 15 discharged from the facility on 7/24/2023 Resident # 89 expired on 7/13/2023 Resident # 26’s care plan was updated with individualized, including non-pharmacological, interventions for the anxiety and antidepressant medications on 7/31/2023. Resident #26’s Behavior tracking was initiated on 8/1/2023 Resident #26’s consent form signed on 8/1/2023 Identification of Others: DON/designee to audit residents with psychotropic medications to ensure consents are signed and appropriate GDR or RB done by 8/2/2023 and corrections made by 8/7/2023 SSD/designee to audit all resident’s care plans with psychotropic medication to ensure each psychotropic medication has individualized, including non-pharmacological, interventions and approaches for behaviors associated with the medication by 8/2/2023, any issues/concerns identified will be corrected by 8/7/2023 DON/designee to audit all resident’s care plans with psychotropic medication to ensure behavior monitoring is in place to assess for adverse reactions and effectiveness by 8/2/2023, issues/concerns will be corrected by 8/7/2023 Systemic Change: NHA/designee to in-service SSD on Behavior Management Program, education to include personalized, including non-pharmacological interventions, for residents receiving psychotropic medications by 8/2/2023 DON/designee to in-service all staff on reporting behaviors to the nurse by 8/10/2023 or prior to next shift worked DON/designee to in-service nurses on behavior tracking/monitoring/documentation for adverse reactions and effectiveness for residents on psychotropic medications. Education to include reporting adverse reactions/behaviors/effectiveness to the DON and Med Director by 8/10/2023 or prior to next shift worked Monitoring: SSD/designee to audit weekly x 12 weeks all new residents with psychotropic medications and 5 current residents with psychotropic medications to ensure an individualized care plan for behaviors associated with the medication is in place and include non-pharmacological and personalized interventions and approaches. DON/designee will audit weekly x 12 weeks, all new residents on a psychotropic medication and 5 current residents with psychotropic medications, to ensure behavior tracking, including adverse reactions and effectiveness of psychotropic medication, is being documented, a signed consent form for psychotropic medication and a GDR and/or RB completed. The DON/designee and SSD/designee will track and trend the results of the audits and report their findings to the QAPI committee monthly. The QAPI committee will evaluate the effectiveness of the plan based on trends identified and implement additional interventions as needed to ensure compliance monthly for 3 months and then reassess the need for continued monitoring based on compliance.
0709Resident Care - Weight Changes
Findings
Based on observations, record review and interviews, the facility failed to implement appropriate nutritional interventions for one (#1) of three residents reviewed for nutrition out of 18 sample residents to maintain acceptable parameters of nutritional status. Resident #1 had diagnoses of Parkinson's disease, protein calorie malnutrition, dysphagia (swallowing difficulty) and dementia, which made her at nutritional risk. She required supervision assistance at meals, which through observations was not provided. The facility failed to implement nutrition interventions when the resident sustained a severe weight loss. Due to the facility's failures, Resident #1 sustained a weight loss of 15.1% (16.8 lbs) from 2/9/23 through 7/6/23, which was considered severe. Findings include: I. Facility policy and procedure The Nutrition at Risk policy, not dated, was provided by the nursing home administrator (NHA) on 7/12/23 at approximately 2:00 p.m. The policy read in pertinent part, "Residents with significant weight loss will be submitted to the interdisciplinary nutrition at risk (NAR) committee comprising of the food services, nursing, rehab services, social services, activity and administrator following confirmation by re-weighing. The NAR committee will meet to discuss the resident assessment findings, develop a new MDS (minimum data set) if indicated and plan of care to correct undesirable weight change. Physician will be notified of the plan of care and recommendations. Family members will be encourage to participate and/or will be notified of the recommendations. If despite appropriate interventions by the NAR committee and the staff, the resident is not receiving sufficient nutritional support to meet his/her metabolic needs, physician will be notified." II. Resident #1 Resident #1, age 86, was admitted on 11/12/22. According to July 2023 computerized physician orders (CPO), diagnoses included Parkinson's disease, cerebral infarction, unspecified protein calorie malnutrition, aphasia (loss of ability to understand or express speech), dysphasia, dementia and anxiety. The 6/16/23 facility assessment revealed severely impaired vision and severely impaired cognition with a brief interview for mental status (BIMS) score three out of 15. She required limited assistance with bed mobility, extensive assistance with transfers, dressing, toilet use and personal hygiene and supervision with eating. Section K (Swallowing Disorders) revealed no difficulty with swallowing, her weight was 96 pounds and no weight loss of 5% or more in the last month or loss of 10% or more in the last six months was documented. She received a mechanically altered diet. Medications received included an antianxiety and anticoagulant. -Section K was incorrectly coded for the resident's weight loss. At the time of the assessment look back period, the resident lost 13.8% weight in three months. III. Resident interview and observations The resident was interviewed on 7/9/23 at 3:41 p.m. She said she did not like the food and had no appetite. The resident was observed on 7/9/23 at 5:10 p.m. in the dining room. She did not eat her supper meal. She was observed drinking a nutritional supplement. The resident was observed on 7/10/23 at 12:20 p.m. in the dining room. There were no staff assisting the resident with her meal. The resident said she had a couple bites of her food. The resident was drinking a nutritional supplement. The resident was observed on 7/11/23 at 5:15 p.m. in the dining room. She did not eat her supper meal. She was drinking a nutritional supplement. The resident was observed on 7/12/23 at 12:10 p.m. There was no staff assisting the resident with her lunch meal and she did not eat any of her food.-The resident was not provided any additional meal options when she did not eat her meal and was only provided a nutritional supplement. IV. Representative interview The representative was interviewed on 7/10/23 at 3:00 p.m. She said she was very disappointed when she learned her mother lost 15 pounds of her weight in a couple months. She said the facility should implement assistance with meals and encourage her mother to eat. She said no staff asked her about her mother's favorite food that she preferred to eat. She said she asked her mother's physician about a hospice care referral so she could get more staff assistance. V. Record review A. Care plan and weights The comprehensive care plan revealed the following:-I am at risk for altered nutritional status r/t (related to): frequently consumes less than 75% meals, low body mass index, refusal of meals, vision problems, dysphagia, malnutrition, potential for dehydration. Regular diet/mechanically soft texture (dated 4/9/23). Interventions included: Administer medication and/or vitamin/mineral supplement per physician order. Encourage/provide intake of fluids throughout the day; if not contraindicated. Monitor meal percentage intake for changes in eating habits. Provide adaptive equipment (likes food in separate bowls as desired, mechanical soft texture) as needed to maintain/promote independence with eating. Provide feeding/dining assistance as needed. If refuses meal offer shake as desired, don't force feed, family will bring in food and snacks at times (dated 6/29/23). Provide nutritional supplement(s) as ordered by physician-Boost. Weekly weights (dated 6/14/23).-I have an ADL (activities of daily living) self-care performance deficit r/t (related to) anxiety, cognitive impairment, fluctuating ADLs, generalized weakness, history of falls, pain, Parkinson's (dated 4/9/23). Interventions included: Eating: Independent to oversight with eating; offer assistance with meal set-up if needed (dated 5/22/23). The resident's weights were: On 1/7/23 the resident weighed 109.6 lbsOn 2/9/23 the resident weighed 111 lbsOn 3/24/23 resident's weight was 110 lbsOn 4/2/23 the resident weighed 109 lbsOn 5/1/23 the resident weighed 102.2 lbs (8% weight loss in three months)On 6/6/23 the resident weighed 94.8 lbs (14% weight loss in three months)On 7/6/23 the resident's weight was 94.2 lbs B. Interdisciplinary notes On 5/15/23 a registered dietitian (RD) documented: "Resident f/u (follow up). Diet: mechanical soft consuming 25-50% on average. Boost (nutritional supplement) BID (two times a day) taking well. Weights:105.9# (12/30/22) 109.8# (1/7/23) 111# (2/9/23) 110# (3/24/23) 109.6# (4/2/23) 102.2# (5/1/23) BMI:16.5 underweight. Weight loss likely related to previous COVID infection and meal intakes have declined slightly. Resident weight is below RWR (recommended weight range)- 117-143#. Noted all meds (medications). No skin issues noted. Braden-17. Fluid needs: 1393ml/day and resident taking 1610ml/day. No new labs to eval. Continue supplements. Continue to offer snacks. Encourage good meal intakes as resident will accept. Monitor po (oral) intakes, tolerance, labs as available, skin, weights, and care plan. Will follow."-There were no nutritional interventions added when the resident sustained 6.8 lbs weight loss, which was 6.3% (severe). The RD note was written 14 days after the weight loss occurred. The resident weight was not more frequently monitored with her sustaining a significant weight loss. On 6/6/23 a registered dietitian (RD) documented: "Resident f/u (follow up). Diet: mechanical soft consuming 25-50% on average. Boost (nutritional supplement) BID (two times a day) taking well with an occasional refusal. Weights: 105.9# (12/30/22) 109.8# (1/7/23) 111# (2/9/23) 110# (3/24/23) 109.6# (4/2/23) 102.2# (5/1/23) 90.3# (6/4/23) Staff getting another body weight today to make sure this is accurate. Meal intakes remain stable at this time. BMI: 14.6 underweight. Resident weight is below RWR - 117-143#. Noted all meds. No skin issues noted. Braden-17. Fluid needs: 1393ml/day and resident taking 1520ml/day. No new labs to eval. Continue supplements. Continue to offer snacks. Please obtain current body weight to confirm accurate weight. Encourage good meal intakes as resident will accept. Monitor po intakes, tolerance, labs as available, skin, weights, and care plan. Will follow." On 6/7/23 the RD documented: "Noted current weight of 94.8# (6/6/23) Noted 90.3# was inaccurate. Resident eating breakfast at time of visit and reports appetite 'ok.' Consider increasing boost to TID (three times a day) in between meals. Continue to offer snacks. Encourage good meal intakes. Monitor po (oral) intakes, tolerance, labs as available, skin, weights, and care plan. Will follow.-Even though the weight was 94.8 lbs and not 90.3 lbs as indicated by the RD documentation, the resident still lost an additional 7.4 lbs since her last weight, which was 7.24% in one month (severe). Over two months, she lost 14.2 lbs. On 6/10/23 a nurse documented: "Resident's appetite is poor, encouraged resident to eat, supplements offered, resident declined to drink them. Different foods offered to resident, she continues to have poor appetite, Resident's daughters in to visit and discussed resident not wanting to sit and be assisted. Staff will continue to encourage resident to eat and accept assistance. On 6/29/23 the dietary manager (DM) documented: "Hospice referral in progress. Family wants comfort measures only. Family states that (Resident) may skip meals if she wishes." On 6/29/23 the DM documented: "Meal intake 47%, continue with providing Boost, add ice cream to mighty shake with every meal." On 7/5/23 the RD documented: "Resident now admitted to hospice. Diet: mechanical soft consuming 50% on average. Noted that resident is permitted to skip meals as she likes. Boost BID (two times a day) taking well with an occasional refusal. Weights: 95.2# (6/4/23) 95.2# (6/27/23) Meal intakes remain stable at this time. BMI: 15.4 underweight. Resident weight is below RWR - 117-143#. Noted all meds. No skin issues noted. Fluid needs: 1393ml/day and resident taking 1840 ml/day. No new labs to eval. Continue supplements. Continue to offer snacks. Encourage good meal intakes as resident will accept. Monitor po (oral) intakes, tolerance, labs as available, skin, weights, and care plan. Will follow."-Prior to the resident being admitted to hospice care, she had sustained a severe weight loss with limited interventions put in place to address it. C. Physician note On 6/8/23 the physician documented: "Pt (patient) continues to lose weight with adult failure to thrive. D/W (discussed with) Pt's (patient's) daughter today and they request comfort measures only for end of life care and no aggressive medical interventions." VI. Staff interviews The director of nursing (DON) was interviewed on 7/10/23 at 2:48 p.m. She said she has been in her position in this facility for three weeks. She said she was aware of Resident #1's weight loss through Nutrition at Risk Review Meetings with the interdisciplinary team (IDT). She said the IDT recommended increasing the Boost supplement to three times a day. She said staff assistance with meals was not considered as the resident was independent. -However, the Boost supplement was not increased and per the facility assessment the resident minimally required supervision at meals. Certified nurse aide (CNA) #2 was interviewed on 7/11/23 at 10:07 a.m. She said she was not aware Resident #1 required staff assistance during meals. She said she did not see nursing staff helping Resident #1 with meals in the dining room. The resident was seated alone at her table and most of the time she was drinking her supplement. The DM was interviewed on 7/12/23 at 10:28 a.m. He said he was new to this position. He said he did not complete residents' nutritional assessments or food preferences. He said if a newly admitted resident had some kind of diet restrictions, the admitting nurse would send a request to the kitchen. He said he was aware of Resident #1's weight loss and meal refusals. He said he served the resident a milk shake with each meal. He said the dietary aides were recording each resident's meal intakes and took them to the nursing staff. The RD was interviewed on 7/12/23 at 2:45 p.m. She said she did not consider any other protein supplement for the resident as the resident was drinking the prescribed Boost most of the time. She said she was not aware the resident did not receive staff assistance with meals. She said she did not request from the physician any lab work to check on the resident's Albumin (Prealbumin) as she knew it would be low. She said she tried to be in the facility two times a month. She said she did not observe Resident #1 during meals and calculated her meal intakes based on staff recordings. She said she did not provide any education to the dietary staff on how to appropriately document meal intakes.
Plan of correction · submitted by the facility
S709 Weight Changes Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of state and federal law. It is the practice of the facility to treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident’s individuality. The facility must protect and promote the rights of the resident. Corrective Action: Resident #1 expired on 7/28/2023 MDS date 6/26/2023 for resident #1 was corrected and re-submitted on 7/31/2023 Identification of Others: DON/designee to audit all current residents’ weights to ensure a weekly/monthly (as appropriate) weight has been done and no significant change in weight has been noted that has not been addressed with appropriate interventions by 8/2/2023, any issues/concerns identified will be corrected by 8/7/2023 DM/designee to audit all current residents dining care plans to ensure likes/dislikes/texture/adaptive equipment needs are current by 8/2/2023, any issues/concerns identified will be corrected by 8/7/2023 Systemic Changes: DON/designee to re-educate clinical staff on the weight management system, obtaining weights, assistance with meals, meal setup, monitoring weight loss, % of meal consumed and resident preferences by 8/10/2023 or prior to next shift worked NHA/designee to in-service Dining Manager on the weight management system, obtaining resident food preferences likes/dislikes, texture and needed adaptive equipment, updating the dining care plan upon admission, re-admission, qrtly and with significant changes in health by 8/2/2023 NHA/designee to re-educate the IDT on the weight management system by 8/10/2023 or prior to next shift worked IDT members will review the weight variance report weekly during the At Risk IDT meeting starting 8/2/2023 to ensure all interventions are in place to mitigate weight loss. RD to educate on Directed In-service, received approval of the requested RD from Chad Fear on 8/8/2023. Directed in-services are scheduled for 8/14/2023 and 8/16/2023. Monitoring: DON/designee to audit each new admission and 10 current residents every week x 4 weeks, then 2 x monthly x 1 month then 1 x monthly x 1 month to ensure scheduled weights were obtained DON/designee to audit weekly x 12 weeks during At Risk meeting residents triggering for 3% or greater weight loss and ensure interventions are in place, and that the resident/resident representative, RD and MD have been notified of weight loss and interventions in place. DM/designee will audit weekly x 12 weeks all new admissions, all current residents triggering for weight loss, all residents due for qrtly, annual and/or significant changes in health to ensure care plans contain likes/dislikes/texture/adaptive equipment needs The DON/designee and DM/designee will track and trend the results of the audits and report their findings to the QAPI committee monthly. The QAPI committee will evaluate the effectiveness of the plan based on trends identified and implement additional interventions as needed to ensure compliance monthly for 3 months and then reassess the need for continued monitoring based on compliance.
7/12/2023Complaint, Recertification Survey · ID NTJQ114 deficiencies
0000Initial CommentsSurveyor note2 building records
Findings · record 1 of 2
A recertification survey was conducted from 7/9/23 to 7/12/23. Four deficiencies were cited.
Findings · record 2 of 2
An Emergency Preparedness survey was conducted from 7/9/23 to 7/12/23. No deficiencies were cited.
Plan of correction
The state did not require a plan of correction for this citation.
0660Discharge Planning ProcessS/S E
Findings
Based on record review and interviews, the facility failed to develop and implement a discharge planning process that focused on the resident's discharge goals for three (#93, #36 and #138) of four residents out of 20 sample residents. Specifically, the facility failed to for Resident #93, #36 and #138:-Develop and complete a discharge plan of care;-Obtain physician orders for discharge; -Educate and document for discharge instructions; and, -Reconcile medications prescribed for discharge. Findings includeI. Facility policy and procedureThe Discharge Process policy was requested on 7/12/23 from the nursing home administrator (NHA). The NHA provided the Discharge Protocol, undated, on 7/12/23 and it documented in pertinent part:"Three days prior/as soon as notice is given for discharge the following to be initiated.-Discharge Plan of Care;-Social service to fist open;-Nursing, Therapy, MDS, and/or designee will complete their designated sections;-All areas should be completed thoroughly prior to the day of discharge."At the time of discharge:-The in-progress Discharge Plan of Care of Care Evaluation is to have each section completed prior to the resident departing the facility;-The facility to provide the order summary report. The order summary report will include the next time the order is to be administered (handwritten next to each physician order);-Facility Representative to Review/Discuss Reconciliation of Pre and Post discharged medications." II..Resident #93 A. Resident status Resident #93, over the age of 65, was admitted on 6/14/23 and discharged home on 7/3/23. According to the July 2023 computerized physician orders (CPO), diagnoses included femur (hip) fracture, muscle weakness, pulmonary embolism, abnormalities of gait and mobility and heart disease. The 6/15/23 minimum data set (MDS) assessment document the resident had no cognitive impairment as evidenced by a brief interview for mental status (BIMS) with a score of 15 out of 15. He required one-person assistance for all activities of daily living (ADLs) with supervision for dressing, eating, personal hygiene and limited assistance for bed mobility and transfers. B. Record reviewA review of the July 2023 CPO revealed the facility failed to obtain a physician discharge orders.-The resident's discharge care plan, dated 6/30/23, revealed the care plan was not complete. The discharge care plan was not completed by the therapy department and failed to include information regarding the resident's current abilities, therapy goals, and summary of therapy treatment during the admission. The discharge summary, dated 7/3/23, read the nurse who completed the discharge provided the resident with 46 tablets of five milligram oxycodone. -The record did not include a physician's order to discharge the resident with the opioid medication. The record review failed to indicate the resident or his family member received information on when the next dose of each medication could be administered. III. Resident #36A. Resident status Resident #36, age 83, was admitted to the facility on 5/24/23 and discharged home on 5/30/23. According to the May 2023 CPO diagnoses included stroke, respiratory failure, muscle weakness, abnormalities of the gait, metabolic encephalopathy (brain injury) and inflammation of the inside lining of the heart. The 5/30/23 MDS assessment documented the resident had a moderate cognitive impairment as evidenced by a brief interview for mental status BIMS with a score of 11 out of 15. He required one-person assistance for all ADLs and had supervision for bed mobility, locomotion on and off the unit, dressing, eating, personal hygiene and limited assistance for transfers and toileting. The resident participated in goal setting, he expected to transfer to another facility and did not include his family or guardian. B. Record review-A review of the July 2023 CPO revealed the facility obtained a physician's order to discharge the resident home with discharge instructions and medications. -A review of the resident's record indicated the facility failed to initiate and complete a discharge care plan, discharge summary and failed to provide discharge teaching for the resident. IV. Resident #138 A. Resident status Resident #138, age 87, was admitted on 5/11/23 and discharged home on 6/2/23. According to the June 2023 CPO, diagnoses included respiratory infection, respiratory failure, gait abnormalities, adult failure to thrive, dementia, shortness of breath and urinary tract infection. The 5/14/23 MDS assessment documented the resident had a moderate cognitive impairment as evidenced by a BIMS with a score of nine out of 15. She required one-person assistance for all ADLs with supervision for dressing, eating, personal hygiene and limited assistance for bed mobility and transfers. The resident participated in goal setting, that she expected to transfer to another facility and did not include her family or guardian. B. Record review-A review of the July 2023 CPO revealed the facility obtained a physician order to discharge to another facility with instructions and medication.-The resident's discharge care plan, dated 6/2/23, indicated the care plan was not complete. The discharge care plan was not completed by the therapy department and failed to include information regarding the resident's current abilities, therapy goals, and summary of therapy treatment during the admission. The discharge summary dated 6/2/23, read the nurse who completed the discharge reviewed and provided medications. -The record review failed to reveal the resident, family member or accepting facility received information on when the next dose of each medication could be administered. V. Staff interviewsRegistered nurse (RN) #2 was interviewed on 7/12/23 at 10:15 a.m. She said when she discharged a resident she was responsible to print the resident's Discharge Plan of Care, review the discharge instructions with the resident and or family member, provide and review medications and document the information on the discharge summary assessment form in the resident's record. She said every resident who was discharged received the controlled prescription medications and other prescription medications were returned to the pharmacy. She said she used nursing judgment when she decided which and how many controlled substance medications she provided to the resident. She said she would give only a few days of narcotic medication, not 30 tablets. The RN said if the resident did not have a discharge order from the physician she would contact a co-worker or the director of nursing (DON) for assistance. The social worker aide (SWA) was interviewed on 7/12/23 at 9:50 a.m. She said the facility had a discharge protocol. She said she coordinated each discharge with the therapy department to determine a discharge date and initiated the Discharge Plan of Care. She said every discipline was responsible to complete the applicable section with resident specific information. She said she did not use the physician discharge order to arrange post discharge care and equipment but referred to the face to face assessment completed by the physician. The SWA said she arranged home health care for every resident because it was a state regulation but she was unsure which regulation. The DON was interviewed on 7/12/23 at 11:15 a.m. She said each nurse discharged a resident to verify the physician had provided a discharge order and to contact the physician if the order was not written. The DON said the physician's order would contain direction to the nurse regarding what medications and amounts should be provided to the resident when discharged and it should not be decided by nursing judgment.
Plan of correction · submitted by the facility
F660 Discharge Care Planning Process Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of state and federal law. It is the practice of the facility to ensure each resident has a complete discharge plan, with all instructions, including medication dosages and next dose time, and is given to the residents/resident representatives/receiving facility at the time of discharge. Corrective Action: Discharge Plan of Care Reviews was completed and sent to resident #93 on 8/2/2023Discharge Plan of Care Review was completed and sent to resident # 36 on 8/2/2023Discharge Plan of Care Review was completed and sent to resident # 138 on 8/2/2023 Identification of Others: SSD/designee will audit all resident care plans by 8/2/2023 to ensure a discharge care plan is in place, including the following information: where the resident plans to live, plans to discharge back into the community, family vs. resident wishes, post discharge needs, outside services/referrals being made. Any concerns/issues will be corrected by 8/7/2023. Systemic Changes: NHA/designee to re-educate the IDT on Discharge Care Plan Conference’s- including timing, participation by residents/resident representatives, attendance by appropriate members of the IDT, and complete care conference notes. Education to be done by 8/2/2023 or prior to next shift worked NHA/designee to re-educate IDT team on completing the Discharge Plan of Care Review prior to the date of discharge, summary to include: discharge details, destination, PCP, F/U appointments, home health needs and home health agency if applicable, DME needed and company name providing, medication list with dosage and next dose due written next to each medication, dietary needs, clinical diagnosis’s, clinical education done, overview of rehab current abilities, therapy goals, summary of therapy treatment during stay, clinical recap of resident stay and physician discharge order. Education to be done by 8/2/2023 or prior to next shift worked DON/designee to re-educate licensed nurses on the discharge process. To include: completing the Discharge Plan of Care Review, to include: recap of clinical stay, education done with resident/resident representative, printing medication list with next scheduled dose time, obtaining signed copies of all paper work for health record and giving a copy of all paperwork to resident/resident representative/receiving facility and obtaining the Physician’s Order for Discharge. Education to be done by 8/10/2203 or prior to next shift workedMonitoring:NHA/designee to audit 1 business day prior to every discharge that the Discharge Plan of Care Review has been completed by: Social Services, Dining Services, Therapy Services and Nursing Services with complete information and instructions, to start 8/3/2023 and continue x 12 weeks. DON/designee to audit 1 business day prior to discharge that a “physician’s order for discharge with discharge location and medication instructions has been completed. Starting 8/3/2023 x 12 weeks DON/designee to audit 1 business day post discharge that Discharge Plan of Care Review and medication list with next scheduled dose time was completed, a discharge progress note was entered by nursing stating that the Discharge Plan of Care Review and medication list was reviewed with resident/resident representative/receiving facility and facility retained signed copies. Audit to start 8/3/2023 x 12 weeks The NHA/DON/designee will track and trend the results of the audits and report their findings to the QAPI committee monthly. The QAPI committee will evaluate the effectiveness of the plan based on trends identified and imp0lement additional interventions as needed to ensure compliance monthly for 3 months and then reassess the need for continued monitoring based on compliance.
0692Nutrition/Hydration Status MaintenanceS/S G
Findings
Based on observations, record review and interviews, the facility failed to implement appropriate nutritional interventions for one (#1) of three residents reviewed for nutrition out of 20 sample residents to maintain acceptable parameters of nutritional status. Resident #1 had diagnoses of Parkinson's disease, protein calorie malnutrition, dysphagia (swallowing difficulty) and dementia, which made her at nutritional risk. She required supervision assistance at meals, which through observations was not provided. The facility failed to implement nutrition interventions when the resident sustained a severe weight loss. Due to the facility's failures, Resident #1 sustained a weight loss of 15.1% (16.8 lbs) from 2/9/23 through 7/6/23, which was considered severe. Findings include: I. Facility policy and procedure The Nutrition at Risk policy, not dated, was provided by the nursing home administrator (NHA) on 7/12/23 at approximately 2:00 p.m. The policy read in pertinent part, "Residents with significant weight loss will be submitted to the interdisciplinary nutrition at risk (NAR) committee comprising of the food services, nursing, rehab services, social services, activity and administrator following confirmation by re-weighing. The NAR committee will meet to discuss the resident assessment findings, develop a new MDS (minimum data set) if indicated and plan of care to correct undesirable weight change. Physician will be notified of the plan of care and recommendations. Family members will be encourage to participate and/or will be notified of the recommendations. If despite appropriate interventions by the NAR committee and the staff, the resident is not receiving sufficient nutritional support to meet his/her metabolic needs, physician will be notified." II. Resident #1 Resident #1, age 86, was admitted on 11/12/22. According to July 2023 computerized physician orders (CPO), diagnoses included Parkinson's disease, cerebral infarction, unspecified protein calorie malnutrition, aphasia (loss of ability to understand or express speech), dysphasia, dementia and anxiety. The 6/16/23 minimum data set (MDS) assessment revealed severely impaired vision and severely impaired cognition with a brief interview for mental status (BIMS) score three out of 15. She required limited assistance with bed mobility, extensive assistance with transfers, dressing, toilet use and personal hygiene and supervision with eating. Section K (Swallowing Disorders) revealed no difficulty with swallowing, her weight was 96 pounds and no weight loss of 5% or more in the last month or loss of 10% or more in the last six months was documented. She received a mechanically altered diet. Medications received included an antianxiety and anticoagulant. -Section K was incorrectly coded for the resident's weight loss. At the time of the assessment look back period, the resident lost 13.8% weight in three months. III. Resident interview and observations The resident was interviewed on 7/9/23 at 3:41 p.m. She said she did not like the food and had no appetite. The resident was observed on 7/9/23 at 5:10 p.m. in the dining room. She did not eat her supper meal. She was observed drinking a nutritional supplement. The resident was observed on 7/10/23 at 12:20 p.m. in the dining room. There were no staff assisting the resident with her meal. The resident said she had a couple bites of her food. The resident was drinking a nutritional supplement. The resident was observed on 7/11/23 at 5:15 p.m. in the dining room. She did not eat her supper meal. She was drinking a nutritional supplement. The resident was observed on 7/12/23 at 12:10 p.m. There was no staff assisting the resident with her lunch meal and she did not eat any of her food.-The resident was not provided any additional meal options when she did not eat her meal and was only provided a nutritional supplement. IV. Representative interview The representative was interviewed on 7/10/23 at 3:00 p.m. She said she was very disappointed when she learned her mother lost 15 pounds of her weight in a couple months. She said the facility should implement assistance with meals and encourage her mother to eat. She said no staff asked her about her mother's favorite food that she preferred to eat. She said she asked her mother's physician about a hospice care referral so she could get more staff assistance. V. Record review A. Care plan and weights The comprehensive care plan revealed the following:-I am at risk for altered nutritional status r/t (related to): frequently consumes less than 75% meals, low body mass index, refusal of meals, vision problems, dysphagia, malnutrition, potential for dehydration. Regular diet/mechanically soft texture (dated 4/9/23). Interventions included: Administer medication and/or vitamin/mineral supplement per physician order. Encourage/provide intake of fluids throughout the day; if not contraindicated. Monitor meal percentage intake for changes in eating habits. Provide adaptive equipment (likes food in separate bowls as desired, mechanical soft texture) as needed to maintain/promote independence with eating. Provide feeding/dining assistance as needed. If refuses meal offer shake as desired, don't force feed, family will bring in food and snacks at times (dated 6/29/23). Provide nutritional supplement(s) as ordered by physician-Boost. Weekly weights (dated 6/14/23).-I have an ADL (activities of daily living) self-care performance deficit r/t (related to) anxiety, cognitive impairment, fluctuating ADLs, generalized weakness, history of falls, pain, Parkinson's (dated 4/9/23). Interventions included: Eating: Independent to oversight with eating; offer assistance with meal set-up if needed (dated 5/22/23). The resident's weights were: On 1/7/23 the resident weighed 109.6 lbsOn 2/9/23 the resident weighed 111 lbsOn 3/24/23 resident's weight was 110 lbsOn 4/2/23 the resident weighed 109 lbsOn 5/1/23 the resident weighed 102.2 lbs (8% weight loss in three months)On 6/6/23 the resident weighed 94.8 lbs (14% weight loss in three months)On 7/6/23 the resident's weight was 94.2 lbs B. Interdisciplinary notes On 5/15/23 a registered dietitian (RD) documented: "Resident f/u (follow up). Diet: mechanical soft consuming 25-50% on average. Boost (nutritional supplement) BID (two times a day) taking well. Weights:105.9# (12/30/22) 109.8# (1/7/23) 111# (2/9/23) 110# (3/24/23) 109.6# (4/2/23) 102.2# (5/1/23) BMI:16.5 underweight. Weight loss likely related to previous COVID infection and meal intakes have declined slightly. Resident weight is below RWR (recommended weight range)- 117-143#. Noted all meds (medications). No skin issues noted. Braden-17. Fluid needs: 1393ml/day and resident taking 1610ml/day. No new labs to eval. Continue supplements. Continue to offer snacks. Encourage good meal intakes as resident will accept. Monitor po (oral) intakes, tolerance, labs as available, skin, weights, and care plan. Will follow."-There were no nutritional interventions added when the resident sustained 6.8 lbs weight loss, which was 6.3% (severe). The RD note was written 14 days after the weight loss occurred. The resident weight was not more frequently monitored with her sustaining a significant weight loss. On 6/6/23 a registered dietitian (RD) documented: "Resident f/u (follow up). Diet: mechanical soft consuming 25-50% on average. Boost (nutritional supplement) BID (two times a day) taking well with an occasional refusal. Weights: 105.9# (12/30/22) 109.8# (1/7/23) 111# (2/9/23) 110# (3/24/23) 109.6# (4/2/23) 102.2# (5/1/23) 90.3# (6/4/23) Staff getting another body weight today to make sure this is accurate. Meal intakes remain stable at this time. BMI: 14.6 underweight. Resident weight is below RWR - 117-143#. Noted all meds. No skin issues noted. Braden-17. Fluid needs: 1393ml/day and resident taking 1520ml/day. No new labs to eval. Continue supplements. Continue to offer snacks. Please obtain current body weight to confirm accurate weight. Encourage good meal intakes as resident will accept. Monitor po intakes, tolerance, labs as available, skin, weights, and care plan. Will follow." On 6/7/23 the RD documented: "Noted current weight of 94.8# (6/6/23) Noted 90.3# was inaccurate. Resident eating breakfast at time of visit and reports appetite 'ok.' Consider increasing boost to TID (three times a day) in between meals. Continue to offer snacks. Encourage good meal intakes. Monitor po (oral) intakes, tolerance, labs as available, skin, weights, and care plan. Will follow.-Even though the weight was 94.8 lbs and not 90.3 lbs as indicated by the RD documentation, the resident still lost an additional 7.4 lbs since her last weight, which was 7.24% in one month (severe). Over two months, she lost 14.2 lbs. On 6/10/23 a nurse documented: "Resident's appetite is poor, encouraged resident to eat, supplements offered, resident declined to drink them. Different foods offered to resident, she continues to have poor appetite, Resident's daughters in to visit and discussed resident not wanting to sit and be assisted. Staff will continue to encourage resident to eat and accept assistance. On 6/29/23 the dietary manager (DM) documented: "Hospice referral in progress. Family wants comfort measures only. Family states that (Resident) may skip meals if she wishes." On 6/29/23 the DM documented: "Meal intake 47%, continue with providing Boost, add ice cream to mighty shake with every meal." On 7/5/23 the RD documented: "Resident now admitted to hospice. Diet: mechanical soft consuming 50% on average. Noted that resident is permitted to skip meals as she likes. Boost BID (two times a day) taking well with an occasional refusal. Weights: 95.2# (6/4/23) 95.2# (6/27/23) Meal intakes remain stable at this time. BMI: 15.4 underweight. Resident weight is below RWR - 117-143#. Noted all meds. No skin issues noted. Fluid needs: 1393ml/day and resident taking 1840 ml/day. No new labs to eval. Continue supplements. Continue to offer snacks. Encourage good meal intakes as resident will accept. Monitor po (oral) intakes, tolerance, labs as available, skin, weights, and care plan. Will follow."-Prior to the resident being admitted to hospice care, she had sustained a severe weight loss with limited interventions put in place to address it. C. Physician note On 6/8/23 the physician documented: "Pt (patient) continues to lose weight with adult failure to thrive. D/W (discussed with) Pt's (patient's) daughter today and they request comfort measures only for end of life care and no aggressive medical interventions." VI. Staff interviews The director of nursing (DON) was interviewed on 7/10/23 at 2:48 p.m. She said she has been in her position in this facility for three weeks. She said she was aware of Resident #1's weight loss through Nutrition at Risk Review Meetings with the interdisciplinary team (IDT). She said the IDT recommended increasing the Boost supplement to three times a day. She said staff assistance with meals was not considered as the resident was independent. -However, the Boost supplement was not increased and per the MDS assessment the resident minimally required supervision at meals. Certified nurse aide (CNA) #2 was interviewed on 7/11/23 at 10:07 a.m. She said she was not aware Resident #1 required staff assistance during meals. She said she did not see nursing staff helping Resident #1 with meals in the dining room. The resident was seated alone at her table and most of the time she was drinking her supplement. The DM was interviewed on 7/12/23 at 10:28 a.m. He said he was new to this position. He said he did not complete residents' nutritional assessments or food preferences. He said if a newly admitted resident had some kind of diet restrictions, the admitting nurse would send a request to the kitchen. He said he was aware of Resident #1's weight loss and meal refusals. He said he served the resident a milk shake with each meal. He said the dietary aides were recording each resident's meal intakes and took them to the nursing staff. The RD was interviewed on 7/12/23 at 2:45 p.m. She said she did not consider any other protein supplement for the resident as the resident was drinking the prescribed Boost most of the time. She said she was not aware the resident did not receive staff assistance with meals. She said she did not request from the physician any lab work to check on the resident's Albumin (Prealbumin) as she knew it would be low. She said she tried to be in the facility two times a month. She said she did not observe Resident #1 during meals and calculated her meal intakes based on staff recordings. She said she did not provide any education to the dietary staff on how to appropriately document meal intakes.
Plan of correction · submitted by the facility
F692 Nutrition/Hydration Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of state and federal law. It is the practice of the facility to treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life, recognizing each resident’s individuality. The facility must protect and promote the rights of the resident. Corrective Action: Resident #1 expired on 7/28/2023 MDS date 6/26/2023 for resident #1 was corrected and re-submitted on 7/31/2023 Identification of Others: DON/designee to audit all current residents’ weights to ensure a weekly/monthly (as appropriate) weight has been done and no significant change in weight has been noted that has not been addressed with appropriate interventions by 8/2/2023, any issues/concerns identified will be corrected by 8/7/2023 DM/designee to audit all current residents dining care plans to ensure likes/dislikes/texture/adaptive equipment needs are current by 8/2/2023, any issues/concerns identified will be corrected by 8/7/2023 Systemic Changes: DON/designee to re-educate clinical staff on the weight management system, obtaining weights, assistance with meals, meal setup, monitoring weight loss, % of meal consumed and resident preferences by 8/10/2023 or prior to next shift worked NHA/designee to in-service Dining Manager on the weight management system, obtaining resident food preferences likes/dislikes, texture and needed adaptive equipment, updating the dining care plan upon admission, re-admission, qrtly and with significant changes in health by 8/2/2023 NHA/designee to re-educate the IDT on the weight management system by 8/10/2023 or prior to next shift worked IDT members will review the weight variance report weekly during the At Risk IDT meeting starting 8/2/2023 to ensure all interventions are in place to mitigate weight loss. RD to educate on Directed In-service, received approval of the requested RD from Chad Fear on 8/8/2023. Directed in-services are scheduled for 8/14/2023 and 8/16/2023. Monitoring: DON/designee to audit each new admission and 10 current residents every week x 4 weeks, then 2 x monthly x 1 month then 1 x monthly x 1 month to ensure scheduled weights were obtained DON/designee to audit weekly x 12 weeks during At Risk meeting residents triggering for 3% or greater weight loss and ensure interventions are in place, and that the resident/resident representative, RD and MD have been notified of weight loss and interventions in place. DM/designee will audit weekly x 12 weeks all new admissions, all current residents triggering for weight loss, all residents due for qrtly, annual and/or significant changes in health to ensure care plans contain likes/dislikes/texture/adaptive equipment needs The DON/designee and DM/designee will track and trend the results of the audits and report their findings to the QAPI committee monthly. The QAPI committee will evaluate the effectiveness of the plan based on trends identified and implement additional interventions as needed to ensure compliance monthly for 3 months and then reassess the need for continued monitoring based on compliance.
0758Free from Unnec Psychotropic Meds/PRN UseS/S G
Findings
Based on observation, records review and interviews, the facility failed to adequately monitor the resident for unnecessary psychotropic medications needed to provide effective and person-centered care for three (#15, #89 and #26) of five residents reviewed for use of psychotropic medication out of 18 sample residents. Record review revealed that Resident #15 had exit-seeking behaviors. The facility failed to obtain consent prior to increasing the administration of antipsychotic medication (Seroquel) and failed to ensure the antipsychotic medication administered was given to treat the resident's medical symptoms and not used for discipline or convenience. Additionally, the facility failed to implement effective person-centered behavior management interventions to prevent occasional wandering and exit-seeking behaviors. The resident was initially administered Seroquel 25 milligrams (mg) without any behaviors present and documented which was increased to 50 mg two times a day after displaying aggressive behaviors toward a nurse who woke the resident from his afternoon nap, triggering Resident #15's aggression. Resident #15 became verbally and physically aggressive towards staff after being provoked, at which time Resident #15 was given an antipsychotic medication Seroquel. The facility failed to ensure Resident #15's antipsychotic medication was not used for discipline or staff convenience. In addition, the facility failed to: -Ensure staff identified triggers for Resident #26's depression and anxiety episodes; -Develop a resident-centered plans of care for generalized anxiety disorder for Resident #26;-Develop a resident-centered plans of care for depressive episodes for Resident #89 and #26;-Ensure staff monitored and documented Resident #89 and Resident #26's response to antidepressant medication and its effectiveness;-Ensure staff monitored and documented adverse reactions to antianxiety and antidepressant therapy Resident #89 and #26;-Ensure provided non-pharmacological interventions were implemented with anxiety and depression for Resident #89 and #26; and, -Obtain informed consent from resident/representative for psychotropic medications Resident #89 and #26. Findings includeI. Facility policyThe Psychotropic Medication Use policy, dated July 2022, was requested received on 7/11/23 from the nursing home administrator (NHA), which read in pertinent part:"A psychotropic medication is any medication that affects brain activity associated with mental processes and behavior."Drugs in the following categories are considered psychotropic medications and are subject to prescribing, monitoring, and review requirements specific to psychotropic medications: antipsychotics, antidepressants, antianxiety, and hypnotics. "Residents are involved in the medication management process. Management includes; indications for use, dose, duration, adequate monitoring for efficacy and preventing, identifying, and responding to adverse consequences. "Residents who have not used psychotropic medications are not prescribed or given these medications unless the medication is determined to be necessary to treat a specific condition that is diagnosed and documented in the medical record."Use of psychotropic medications are not increased when efforts to decrease antipsychotic medications are being implemented."Non pharmacological approaches are used to minimize the need for medications, permit the lowest possible dose, and allow for discontinuation of medications when possible."Residents receiving psychotropic medications are monitored for adverse consequences including: anticholinergic effects, cardiovascular effects, metabolic effects, psychological effects."II. Resident #15A. Professional reference The Saunders Nursing Drug Handbook, 2021, Quetiapine (Seroquel), read in part; "Elderly with dementia related psychosis are at increased risk for death. Uses: Treatment of schizophrenia. Treatment of acute manic episodes associated with bipolar disorder ... Off-label: psychosis/agitation related to Alzheimer's dementia." B. Resident status Resident #15, age 95, was admitted on 1/7/22. According to July 2023 computerized physician orders (CPO), diagnoses included chronic atrial fibrillation, cardiomyopathy, adult failure to thrive, pain, and unspecified dementia, severe, with other behavioral disturbance. The 5/9/23 significant change in status minimum data set assessment (MDS) revealed the resident's cognition was severely impaired with a brief interview for mental status (BIMS) score of three out of 15. No hallucinations, delusions, rejection of care or wandering behaviors were documented. He required limited assistance with bed mobility, dressing and personal hygiene, supervision with transfers, eating and toilet use. Medications included an anticoagulant and antibiotic. There were no physical restraints or alarms used. The 6/20/23 MDS assessment revealed wandering occurred in one to three days during the assessment period. He required supervision with bed mobility, transfers, eating and personal hygiene, and extensive assistance with dressing and toilet use. Medications included an antipsychotic, anticoagulant and antibiotic. No physical restraints and no alarms were noted. C. Resident observations On 7/9/23 at 3:32 p.m. Resident #15 was observed asleep in his room. On 7/10/23 at 10:00 a.m. Resident #15 was observed in the television (TV) room. He was sleeping in his wheelchair. On 7/11/23 at 10:00 a.m. the resident was observed in the dining room at a table, with other residents playing a bingo game. Resident #15 had his game board in front of him and was not paying attention to the numbers called. He was not able to place a checker on a called number on the game board. The activities staff and other residents were assisting the resident through the game. On 7/11/23 at 2:00 p.m. Resident #15 was observed in his room, sleeping in his wheelchair. D. Record review 1. Care plan The comprehensive care plan revealed the following:-"Resident is at risk for elopement r/t (related to) exit seeking behavior (dated 5/22/23). Interventions included: Calmly redirect and divert resident's attention. Distract resident when wandering/insistent on leaving facility by offering pleasant diversions, structured activities, food, conversation, television, books. Set up meeting with family/guardian to determine if resident may need a more appropriate facility if elopement attempts continue.-"I am at risk for falls r/t (related to) cognition and not knowing my own abilities, dementia, abnormal gait, weakness, difficulty walking, unsteady on feet (dated 4/11/23). Interventions included: Activity Program/Group Program. Apply bed cane for positioning. Bed against the wall. Call before you fall sign, for visual reminder. Low bed. Maintain needed items within reach.-"Resident has an ADL (activities of daily living) self-care performance deficit r/t (related to) cognitive impairment, dementia, depression, fluctuating ADLs, generalized weakness, history of falls, impaired mobility, poor balance (dated 4/11/23). Interventions included: Allow time for resident to express feelings of frustration regarding the need for assistance in ADL tasks." -The resident's centered care plan did not address the use of psychotropic medication Seroquel (Quetiapine Fumarate). 2. Physician orders Quetiapine Fumarate oral tablet 25 mg, give 1(one) tablet by mouth one time a day related to unspecified dementia, severe, with other behavioral disturbance. Start date 5/23/23. D/C (discontinued) date 5/26/23. Quetiapine Fumarate oral tablet 25 mg, give 1(one) tablet by mouth two times a day related to unspecified dementia, severe, with other behavioral disturbance. Start date 5/26/23. D/C date 6/3/23. Seroquel oral tablet 50 mg (Quetiapine Fumarate), give 1 (one) tablet by mouth two times a day related to unspecified dementia, severe, with other behavioral disturbance. Start date 6/4/23.3. Physician notesOn 4/5/23 the resident's physician documented: "94 year old male with dementia with behaviors. Pt (patient) with recent decline and adult failure to thrive. Have titrated off and stopped Seroquel."On 6/8/23 the resident's physician documented: "Recent GDR (gradual dose reduction) failed and pt (patient) had to be restarted on Seroquel due to agitation and exit seeking. Pt (patient) has improved and more focused without exit seeking."-The physician's note did not reveal the resident was sleepy and lethargic. (see staff interviews)The chemical/physical restraint and antidepressant review committee document in the resident's medical record was dated 1/25/23. (see staff interviews) E. Nursing notes On 3/16/23 at 6:47 p.m., a nurse documented: "Resident attempted to leave facility three times today. Twice out East door and once out North. Redirected by staff. Daughter aware." On 5/22/23 a director of nursing documented: "Spoke with (physician's name) regarding resident's increased behaviors and exit seeking. Per (physician's name), resident may resume Quetiapine 25mg by mouth daily. Order updated to reflect changes." -There was no documentation in the medical record related to resident's exit seeking or any behaviors from 3/16/23 until 5/25/23 (see below), three days after the psychotropic medication Seroquel was started. On 5/25/23 at 5:20 a.m., a nurse documented: "Resident was found by RN (registered nurse) on A wing wheeling out the main door to facility. RN caught him before he made it to the second door. Resident stated he was going to work and was redirected by RN telling him he needed coffee first." On 6/3/23 at 2:40 p.m., a nurse documented: "Resident was heading towards the front doors stating that he needed to get out of here and go home. This nurse was able to redirect the resident back to his room. The resident came back to the nurses' station 15-20 minutes later stating that he needed to leave and go home. This nurse was able to redirect the resident to the kitchen for a snack and a cup of coffee." On 6/3/23 at 4:11 p.m., a nurse documented: "This nurse went in to the residents room to give the resident his evening medication. The resident was asleep and this nurse woke him up gently. The resident woke up and swung at this nurse grazing this nurse's chin causing the resident to get two skin tears on his right hand. The resident continued to wing his arms stating that this nurse was trying to fight him. This nurse was able to deescalate the resident and allow this nurse to place two Band-Aids on the resident's top of hand. Resident refused his medication from this nurse. This nurse asked the resident to get up and please have dinner. The resident went down to dinner. This nurse asked the CMA (certified medical assistant) to give medication to the resident. The resident's responsible party is out of town. The resident's second contact is also out of town. Staff will notify when the responsible parties are back in town. This nurse notified the DON (director of nursing), administrator, and (physician's name). This CMA was able to administer medication after encouraging and reassuring resident that no one was trying to trick him." On 6/3/23 at 5:45 p.m., a nurse documented: "(physician's name) increased the resident Quetiapine to 50 mg PO (orally) BID (two times a day). This nurse notified the resident daughter (name) of the changes in medication. On 6/10/23 at 2:27 p.m., a nurse documented: "Res (resident) went out the east door by kitchen, door alarm sounded, res (resident) was able to make it out the door. Housekeeping assisted res (resident) around the building and back into facility through the front entrance with redirection. Res (resident) in his room currently in recliner, continue to check on resident frequently." F. Staff interviews Licensed practical nurse (LPN) #2 was interviewed on 7/11/23 at 9:45 a.m. She said the staff was monitoring the resident every 15 minutes and documented each time on a paper sheet. Every shift the document was turned in to the DON. She said this intervention was initiated by the new director of nursing approximately a month ago. CNA #2 was interviewed on 7/11/23 at 10:05 a.m. She said that in the past couple of months the resident was looking for the facility exit doors four times. She said the resident told the staff he wanted to go home or needed to go to work. She said only one time the resident became aggressive with a nurse who woke him up and tried to give him his medications (Seroquel). She said Resident #15 was very lethargic most of the time, needed more assistance with all activities of daily living. Certified nurse aide (CNA) #1 was interviewed on 7/11/23 at 10:10 a.m. She said she worked with the resident frequently. She said the resident was very sleepy all the time. The social service director (SSD) was interviewed on 7/11/23 at 10:50 a.m. She said she was new to her position. She said she was not aware the resident's care plan did not include the antipsychotic medication Seroquel. She said she added the medication to the resident's care plan "today."She said she was unable to find any of the psychotropic medications review notes for Resident #15 and the review dated 1/25/23 was the last one in his medical record. The director of nursing (DON) was interviewed on 7/11/23 at 11:15 a.m. She said she was a new DON in the facility, "for about a month." She said there was no care plan for staff monitoring the resident every 15 minutes and there was no care plan for the use of Seroquel. She said the staff who attended the psychotropic committee meeting was not aware the resident was off of Seroquel since March (2023). She said there was no documentation in the resident's medical record to justify initiating the psychotropic medication Seroquel therapy in May (2023). She said at the time Seroquel was started the resident was treated with an antibiotic for urinary tract infection which could trigger an increase in wandering behavior. III. Resident #89A. Resident statusResident #89, age 88, was admitted to the facility on 4/14/23. According to the July 2023 computerized physician orders (CPO) diagnoses included congestive heart failure, falls, depression, respiratory failure and cataracts. The 4/20/23 minimum data set (MDS) assessment document the resident had moderate cognitive impairment as evidenced by a brief interview for mental status (BIMS) with a score of 10 out of 15. She required one-person assistance for all activities of daily living (ADLs) and had supervision for bed mobility, transfers, walking in the room, locomotion on and off the unit, toilet use, eating and personal hygiene. She required limited assistance for dressing. B. Record reviewAccording to the July 2023 medication administration record (MAR) the resident received duloxetine for depression that was ordered on 4/14/23.-The resident's care plan, initiated on 4/20/23, indicated the resident did not have a care plan for care of the resident's depression. -A review of the computerized physician orders (CPO) revealed the facility failed to identify, offer and document effectiveness of non-pharmacological interventions for the resident's depression. The July 2023 MAR was reviewed and revealed the facility failed to effectively monitor the resident for side effects of antidepressant therapy. The physician order directed the nurse to monitor for side effects: drowsiness, blurred vision, dizziness, fatigue, trouble sleeping, dry mouth, hallucination and other unusual changes in mood or behavior every shift. Specifically, if monitoring was performed and none of side effects were observed, the nurse was directed to chart "Y"; if monitoring was performed and side effects were observed the nurse was directed to chart "N" and then select chart code "other/see nurses notes and progress notes" for findings. On7/1/23, 7/3/23 and 7/8/23 the nurse documented "N" and information about the side effects the resident experienced and what interventions were taken was not found in the resident's medical record.-The facility failed to identify sources or triggers that manifested the resident's depression and then monitor for effectiveness of antidepressant treatment. C. Resident observation and interviewOn 7/9/23 at 3:45 p.m., the resident was observed lying in her bed. She said she was tired. She said her mood was not the best. The resident said she knew she had medication for depression and did not remember the name of the medication. She said she did not know why she felt depressed and said maybe it was from her recent illness. D. Staff interviewRegistered nurse (RN) #1 was interviewed on 7/10/23 at 11:15 a.m. She said the resident took antidepressant medication. She said she was aware the resident took antidepressant medication but was unaware of resident specific needs for the resident's depression. RN #1 said she had not observed the resident acting depressed. IV. Resident #26A. Resident status Resident #26, age 85, was admitted on 6/12/23. According to the July 2023 CPO, diagnoses included depression and anxiety. The 6/24/23 MDS assessment revealed the resident had a moderate cognitive impairment with a BIMS score of seven out of 15. The resident required limited to extensive assistance for most ADLs. The resident received antianxiety and antidepressant medication. No behaviors were indicated. B. Record reviewA review of the July 2023 medication administration record (MAR) revealed the resident was administered Duloxetine for depression and Buspirone for anxiety that was ordered on 6/12/23.-The care plan, initiated 6/12/23, revealed the facility failed to establish a plan of care for the resident's depression and anxiety. -A review of the resident's record revealed the facility failed to obtain a consent for antianxiety medication and the antidepressant medication consent was unsigned by facility staff or the physician.-The facility failed to identify, offer and document effectiveness of non-pharmacological interventions for the resident's depression and anxiety.-A review of the CPO revealed the facility failed to effectively monitor the resident for side effects from antidepressant and antianxiety medication. The MAR revealed the nurse entered a check mark to indicate monitoring, a check mark was entered every shift every day, but there was no indication what the check mark represented. -A review of the CPO revealed the facility failed to identify triggers for anxiety and to monitor the effectiveness of medication management. C. Resident observation and interviewOn 7/9/23 at 3:10 p.m., the resident was observed sitting in her room. She said that she frequently felt she had high anxiety related to her health status, felt alone, her stay at the facility and wished to go home. She said she was unaware that she took medication for anxiety and said that if she was ordered medication, it did not help. D. Staff interviewRN #1 was interviewed on 7/10/23 at 11:15 a.m. She said the resident was prescribed an antidepressant and antianxiety medication. She said the resident was aware the resident took antianxiety and antidepressant medications but was unaware what specifically the resident needed to manage her depression and anxiety. RN #1 said she had not observed the resident depressed or anxious. The RN said when a nurse monitors medication side effects or effectiveness of medications, the monitoring was documented on the resident's MAR.V. Administrative interviewThe director of nursing (DON) was interviewed on 7/11/23 at 10:15 a.m. The DON said when a resident was admitted to the facility the interdisciplinary team developed the resident's care plan. She said the residents' care plan should have included care needs and management specific to the resident's depression and anxiety. The DON said a resident taking antipsychotic medication should be monitored for side effects and effectiveness, like a change in resident behavior or mood or adverse outcomes of the medication. The DON was unable to locate care plans specific to managing the residents' depression and anxiety. She said the residents' care plans should have included care needs and management specific to the resident's depression. The DON was interviewed again on 7/12/23 at 10:15 a.m. She said monitoring results were helpful for the physician to determine effectiveness of medication therapy. The DON said that when a resident was admitted, the interdisciplinary team (IDT) determined what monitoring was necessary and then nursing would obtain physician orders for monitoring. The DON said she would review how monitoring orders were entered to make future monitoring complete and effective. The director of nursing (DON) was interviewed on 7/12/23 at 10:15 a.m. She said monitoring results were helpful for the physician to determine effectiveness of medication therapy. The DON said that when a resident was admitted, the interdisciplinary team (IDT) determined what monitoring was necessary and then nursing would obtain physician orders for monitoring. The DON said she would review how monitoring orders were entered to make future monitoring complete and effective.
Plan of correction · submitted by the facility
F758Free From Unnecessary Psychotropic Meds/PRN Use Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of state and federal law. It is the practice of the facility to treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his/her quality of life recognizing each resident's individuality. The facility must protect and promote the rights of the resident. Corrective Action: Resident # 15 discharged from the facility on 7/24/2023 Resident # 89 expired on 7/13/2023 Resident # 26’s care plan was updated with individualized, including non-pharmacological, interventions for the anxiety and antidepressant medications on 7/31/2023. Resident #26’s Behavior tracking was initiated on 8/1/2023 Resident #26’s consent form signed on 8/1/2023 Identification of Others: DON/designee to audit residents with psychotropic medications to ensure consents are signed and appropriate GDR or RB done by 8/2/2023 and corrections made by 8/7/2023 SSD/designee to audit all resident’s care plans with psychotropic medication to ensure each psychotropic medication has individualized, including non-pharmacological, interventions and approaches for behaviors associated with the medication by 8/2/2023, any issues/concerns identified will be corrected by 8/7/2023 DON/designee to audit all resident’s care plans with psychotropic medication to ensure behavior monitoring is in place to assess for adverse reactions and effectiveness by 8/2/2023, issues/concerns will be corrected by 8/7/2023 Systemic Change: NHA/designee to in-service SSD on Behavior Management Program, education to include personalized, including non-pharmacological interventions, for residents receiving psychotropic medications by 8/2/2023 DON/designee to in-service all staff on reporting behaviors to the nurse by 8/10/2023 or prior to next shift worked DON/designee to in-service nurses on behavior tracking/monitoring/documentation for adverse reactions and effectiveness for residents on psychotropic medications. Education to include reporting adverse reactions/behaviors/effectiveness to the DON and Med Director by 8/10/2023 or prior to next shift worked Monitoring: SSD/designee to audit weekly x 12 weeks all new residents with psychotropic medications and 5 current residents with psychotropic medications to ensure an individualized care plan for behaviors associated with the medication is in place and include non-pharmacological and personalized interventions and approaches. DON/designee will audit weekly x 12 weeks, all new residents on a psychotropic medication and 5 current residents with psychotropic medications, to ensure behavior tracking, including adverse reactions and effectiveness of psychotropic medication, is being documented, a signed consent form for psychotropic medication and a GDR and/or RB completed. The DON/designee and SSD/designee will track and trend the results of the audits and report their findings to the QAPI committee monthly. The QAPI committee will evaluate the effectiveness of the plan based on trends identified and implement additional interventions as needed to ensure compliance monthly for 3 months and then reassess the need for continued monitoring based on compliance.
0761Label/Store Drugs and BiologicalsS/S E
Findings
Based on record review, observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards for one of two medication storage rooms and one of two medication carts. Specifically, the facility failed to label biological supplies and to lock the medication cart when unattended. Findings include:I. Facility policy The Administration of Medication policy, undated, was requested and received on 7/10/23 from the nursing home administrator (NHA). The policy documented in pertinent part: "Never leave medication care open and unattended."The Medication Labeling and Storage policy, undated, was requested and received on 7/10/23 from the NHA. The policy documented in pertinent part:"If the facility has discontinued, outdated or deteriorated medication or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items;"Each resident's medications are assigned to an individual cubicle, drawer, or other holding area to prevent the possibility of mixing medication of several residents; "Multidose vials that have been opened or accessed are dated and discarded within 28 days unless the manufacturer specifies a shorter or longer date for the open vial." II. Hall B medication cartOn 7/9/23 at 12:25 p.m., the medication cart was unlocked and unattended. Additionally, medications labeled with resident names were observed on top of the medication cart. The unsecure items were: four boxes of opened eye drops, one box of eye antibiotic drops box opened, two boxes of opened nasal spray and two medication cups that contained miscellaneous tablet medications. Two residents were sitting in wheelchairs adjacent to the medication cart and visitors were in the adjacent lounge area. Licensed practical nurse (LPN) #1 was interviewed on 7/9/23 at 12:27 p.m., when she returned to the medication cart. She said she was called into a resident's room and left the cart unlocked. She said the medication cart was to be locked and clear of medications whenever it was left unattended. III. Hall A medication room On 7/11/23 at 9:55 a.m., the medication room was observed with registered nurse (RN) #1. RN #1 verified a multidose vial of tubersol was stored in the supply room refrigerator. and it was opened and undated. RN #1 was interviewed immediately after the observation and said the tuberculin was used for testing residents when they were admitted to the facility to see if they had any exposure to tuberculosis. She said the night shift staff were responsible for identifying and removing expired items from the supply. The RN said the open vials must be dated with an expiration date 30 days after it was opened. The RN replaced the vial in the refrigerator and said she would need the tuberculin for admissions later that day. The director of nursing (DON) was interviewed on 7/11/23 at 10:15 a.m. She said when a nurse opened a multidose vial the nurse was responsible for dating the vial when opened. She said the multidose vial would expire 28 days after it was opened. The DON said the RN should not have replaced the undated tuberculin back in the refrigerator for use later that day and she removed the undated vial immediately.
Plan of correction · submitted by the facility
F761 Label/Store Drugs & Biologicals Preparation and/or execution of this plan of correction does not constitute admission or agreement by the provider of the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared and/or executed solely because it is required by the provisions of state and federal law. It is the practice of the facility to store medication in a secured and safe manner. Corrective Action: The vial of TB solution was discarded by the DON on 7/11/2023The DON educated RN #1 on 7/11/2023 on labeling/dating of TB solutionThe DON educated LPN #1 on 7/9/2023 on leaving medications on top of the medication cart and the medication cart being unlocked. Identification of Others: All medication storage areas have the potential to be affected by this. Systemic Changes: DON/designee will re-educate nurses and CMA’s on medication labeling, dating and storage by 8/10/223 or prior to next shift worked Monitoring: DON/designee will perform an audit of all medication storage areas 2 x weekly x 4 weeks, then 2 x monthly x 1 month, then 1 x monthly x 1 month for correct labeling, dating and storage of medications. The DON/designee will track and trend the results of the audits and report their findings to the QAPI committee monthly. The QAPI committee will evaluate the effectiveness of the plan based on trends identified and implement additional interventions as needed to ensure compliance monthly for 3 months and then reassess the need for continued monitoring based on compliance.

Reportable Occurrences

5 records
8/7/2025Misappropriation of Property · ID 2502E994003Reported on time: Yes
Occurrence summary
SUMMARY OF FINDINGS:On 8/7/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported a misappropriation of property event. Reportedly, client (B) alleged someone used her credit card to make unauthorized charges back in July 2025. The family assisted the client in closing the account. During the course of the investigation, the healthcare entity conducted interviews. No alleged assailant was identified. The bank conducted an investigation into potential fraud. No other clients reported concerns about theft. The facility could not substantiate an allegation of fraud or financial exploitation. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 9/29/2025 · released to the public 10/6/2025.
2/3/2025Physical Abuse · ID 2502E994002Reported on time: Yes
Occurrence summary
SUMMARY OF FINDINGS: On 2/3/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a physical abuse event. Female client (B) alleged male client (A) struck her on the shoulder as he passed by causing her pain. During the course of the investigation, the healthcare entity kept the clients separated, conducted an assessment and interviews and started safety checks. No visible injury was observed yet she continued to report her shoulder really hurt. Client (A) reported a different version about the event saying he utilized her shoulder to help move around her; however, he confirmed she reported pain with the touch. No one witnessed the interaction. Due to conflicting statements, the facility was unable to determine if the act was intentional or not. Client (B) discharged home two days later and safety monitoring remained in place for client (A). The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 4/4/2025 · released to the public 4/11/2025.
5/23/2024Brain Injury · ID 2402E994001Reported on time: Yes
Occurrence summary
SUMMARY OF FINDINGS: On 5/23/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a brain injury event. During the course of the investigation, the healthcare entity reported client (A) fell in the bathroom where he struck his head. He had complaints of pain and was transferred to the hospital for further evaluation. Diagnostic test results showed a brain bleed. He was transferred into hospice services where he passed away the following day. When reviewing the event, the facility determined he did not call for staff assistance and self ambulated to the bathroom where he fell with injury. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.
Publication
Sent to facility 3/4/2025 · released to the public 3/11/2025.
8/22/2023Diverted Drugs · ID 2302E994004Reported on time: Yes
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 8/22/23, while a nurse manager reviewed an incident involving medications, count discrepancies were discovered with one nurses’ practice (nurse 2). Also during shift change this morning and when conducting medication counts today, the oncoming nurse (1) noted several .5 mg Lorazepam tablets were unaccounted for. Nurse (2 – off-going nurse) could not account for the discrepancy. The facility filed a report of alleged drug diversion involving nurse (2). Management reviewed information from critical safety analysis reports (CSAR), pharmacy delivery sheets, and medication administration records. Management reported the following medications were identified as missing: 11.5 tablets of .5 mg Lorazepam, 28 tablets of 5 mg Oxycodone, three tablets of 50 mg Tramadol, one tablet of 5ml Hydrocodone, and 60 tablets of 5 mg Oxycodone. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police. Management suspended the nurse (2). Review of CSAR logs showed nurse (2) misdated medication entries with times not matching their work schedule or assigned cart/hallway. The facility reported nurse (2) has been involved in other count discrepancies involving Oxycodone medication. Further review of nurse (2)’s clinical documentation showed they did not follow nursing standards of practice with medication administration or documentation expectations. One alert and oriented resident reported she did not request prn (as needed) Oxycodone despite nurse (2)’s documentation showing it was being administered per their request. To help support these findings, management reviewed call light records associated with the Oxycodone administration. The resident had not utilized the call light around the date and time of when nurse (2) documented the administrations. Other staff reported witnessing nurse (2) exhibiting erratic behaviors, appearing tired, and falling asleep during previous shifts. However, no one reported seeing the nurse (2) divert any medications. Based on poor nurse practice findings, staff interviews and medication discrepancies, the facility substantiated the allegation of nurse (2) diverting medications. Nurse (2)’s employment was terminated. and management reported nurse (2) to their prospective licensing board. The facility reported the police arrested nurse (2) for charges of alleged drug diversion. Following the investigation, the facility took the opportunity to provide re-education to all nursing staff on medication handling and nursing standards. In addition, management implemented an auditing plan to monitor nursing staff and medication management. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.
Publication
Sent to facility 1/2/2024 · released to the public 1/9/2024.
6/23/2023Misappropriation of Property · ID 2302E994003Reported on time: Yes
Occurrence summary
DESCRIPTION OF OCCURRENCE: On 6/23/23, a resident, in his 90s, reported $350 from his wallet that was stored in his room. The wallet had not been secured. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian, and physician. A lock box was provided to the resident, and he was encouraged to safeguard his valuables. No employee witnessed any money or any money being taken. The facility was unable to determine what happened to the money. Staff was reminded that upon admission, residents should be offered a key to lock box in closet or encourage family to take money or any valuables home with them. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.
Publication
Sent to facility 9/25/2023 · released to the public 10/2/2023.