Deficiencies (last 3 years)
Deficiencies (over 3 years)
3.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
37% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Aug 15, 2024
Visit Reason
The inspection was conducted as an annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Deficiencies: 0
Date: Aug 15, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction for Advanced Health Care of Colorado Springs, documenting the results of a regulatory survey completed on 08/15/2024.
Findings
No health deficiencies were found during the survey.
Inspection Report
Routine
Deficiencies: 2
Date: Mar 16, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning and fall prevention at Advanced Health Care of Colorado Springs.
Findings
The facility failed to develop and implement a comprehensive person-centered care plan with measurable interventions for Resident #12's mental illness. Additionally, the facility failed to provide adequate supervision and timely interventions to prevent multiple falls for Resident #7 over a two-week period.
Deficiencies (2)
Failed to develop and implement a comprehensive person-centered care plan with measurable interventions and objectives for Resident #12's mental illness.
Failed to provide adequate supervision and assistance devices to prevent accidents, resulting in five falls for Resident #7 within two weeks.
Report Facts
Residents reviewed: 18
Falls: 5
Medication orders: 4
BIMS score: 15
BIMS score: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Registered Nurse | Interviewed regarding Resident #12's behavior tracking and care plan |
| Certified Nurse Aide #1 | CNA | Interviewed regarding Resident #12's behaviors and Resident #7's care |
| Admissions Coordinator | Admissions Coordinator | Interviewed regarding admission intake and behavior tracking for Resident #12 |
| Registered Nurse #1 | Registered Nurse | Interviewed regarding Resident #12's behaviors and Resident #7's fall risk |
| Director of Nursing | Director of Nursing | Interviewed regarding care planning and fall prevention for Residents #12 and #7 |
| MDS Coordinator | MDS Coordinator | Interviewed regarding care plan documentation for Resident #12 |
| Certified Nurse Aide #2 | CNA | Interviewed regarding standard resident checks and Resident #7's falls |
| Director of Therapies | Director of Therapies | Interviewed regarding interdisciplinary team communication about Resident #7's falls |
Inspection Report
Routine
Deficiencies: 2
Date: Mar 16, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning and fall prevention for residents at the nursing home.
Findings
The facility failed to develop and implement a comprehensive person-centered care plan with measurable interventions for one resident with mental illness. Additionally, the facility failed to provide adequate supervision and timely interventions to prevent multiple falls for another resident.
Deficiencies (2)
F 0656: The facility failed to develop a person-centered care plan for Resident #12's mental illness that included individualized behaviors, interventions, and non-pharmaceutical approaches.
F 0689: The facility failed to provide adequate supervision and assistance devices to prevent accidents for Resident #7, resulting in five falls over two weeks without timely revision of the fall prevention care plan.
Report Facts
Residents reviewed: 18
Falls: 5
Medication doses: 250
Medication doses: 500
Medication doses: 25
Medication doses: 25
MDS cognitive score: 10
MDS cognitive score: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Interviewed regarding Resident #12's behavior tracking and care plan | |
| Certified Nurse Aide #1 | Interviewed regarding Resident #12's behaviors | |
| Admissions Coordinator | Interviewed regarding admission and behavior tracking for Resident #12 | |
| Registered Nurse #1 | Interviewed regarding Resident #12's behaviors and care plan | |
| Director of Nursing (DON) | Interviewed regarding care planning and fall prevention for Residents #12 and #7 | |
| MDS Coordinator | Interviewed regarding care plan documentation for Resident #12 | |
| Certified Nurse Aide #2 | Interviewed regarding fall prevention and resident checks for Resident #7 | |
| Director of Therapies (DOT) | Interviewed regarding fall prevention approaches for Resident #7 |
Inspection Report
Annual Inspection
Deficiencies: 3
Date: Dec 16, 2021
Visit Reason
The inspection was conducted as a standard annual survey to assess compliance with regulatory requirements related to resident care, medication administration, infection control, and activities programming at Advanced Health Care of Colorado Springs.
Findings
The facility was found deficient in providing meaningful activities to meet resident interests, ensuring availability and administration of prescribed medications, and maintaining proper infection prevention and control practices during wound care. Deficiencies included failure to engage Resident #176 in activities, failure to provide prescribed Entresto medication to Resident #24 resulting in missed doses, and failure to perform hand hygiene and glove changes during wound care for Resident #131.
Deficiencies (3)
Failed to provide meaningful, engaging activities to meet the interests of Resident #176, who was observed spending all her time unengaged in her room.
Failed to ensure Resident #24 received Entresto medication as prescribed, resulting in 11 missed doses from November to December 2021.
Failed to establish and maintain an infection prevention and control program; specifically, failed to place a barrier before setting down clean wound care items, change gloves from dirty to clean, and perform hand hygiene during wound care for Resident #131.
Report Facts
Residents reviewed: 22
Missed medication doses: 11
Activities offered: 30
Activities participated: 2
Activities refused: 28
Activities director work hours: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing (DON) | Provided facility policies, interviewed regarding deficiencies in activities and medication administration | |
| Activities Director (AD) | Interviewed about activity assessments and participation; responsible for activity program | |
| Director of Therapy (DOT) | Interviewed about therapy and activity oversight and care plan completion | |
| Registered Nurse (RN) #1 | Interviewed regarding medication administration and MAR review for Resident #24 | |
| Pharmacy Representative | Interviewed about medication supply and pharmacy orders for Resident #24 | |
| Admission Nurse | Interviewed about admission medication review process | |
| Licensed Practical Nurse (LPN) #1 | Observed performing wound care with deficiencies in infection control | |
| Licensed Practical Nurse (LPN) #2 | Interviewed about wound care practices | |
| Infection Preventionist (IP) | Interviewed about infection control standards and wound care |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Dec 16, 2021
Visit Reason
The inspection was conducted to investigate complaints regarding failure to provide meaningful activities, medication administration issues, and infection prevention and control deficiencies at the nursing home.
Complaint Details
The investigation was complaint-driven, focusing on allegations that the facility failed to provide adequate activities, medication administration, and infection control. The findings substantiated these complaints with documented deficiencies.
Findings
The facility failed to provide engaging activities to meet resident interests, ensure timely medication administration for a resident missing 11 doses of Entresto, and maintain proper infection prevention practices during wound care, including hand hygiene and glove changes.
Deficiencies (3)
F 0679: The facility failed to provide meaningful, engaging activities to meet the interests of Resident #176, who spent all her time unengaged in her room without stimulation or one-to-one visits.
F 0755: The facility failed to ensure Resident #24 received Entresto as prescribed, resulting in 11 missed doses from November to December 2021 due to medication unavailability.
F 0880: The facility failed to implement infection prevention practices during wound care for Resident #131, including not placing a barrier before clean items, not changing gloves from dirty to clean, and not performing hand hygiene.
Report Facts
Missed medication doses: 11
Activities participation: 2
Activities refused: 28
Activities director work hours: 1
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