Inspection Reports for
Ahc of Lakewood LLC
11155 W 15TH PL, LAKEWOOD, CO 80215, CO
Back to Facility ProfileDeficiencies (last 2 years)
Deficiencies (over 2 years)
3.5 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
33% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Deficiencies: 7
Date: Dec 21, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements including resident care, discharge planning, staff performance reviews, medication administration, infection control, and facility assessment.
Findings
The facility was found deficient in honoring resident shower preferences, developing baseline care plans including dialysis care, discharge planning, nurse aide performance reviews, medication administration errors related to insulin pen priming, infection control practices, and conducting a comprehensive facility assessment.
Deficiencies (7)
F 0561: The facility failed to honor resident choices for showers for two residents by not ensuring they received two showers per week as identified in their care plans.
F 0655: The facility failed to develop a person-centered baseline care plan for one resident that included dialysis care and services.
F 0660: The facility failed to develop and implement an effective discharge plan for one resident, lacking documentation and communication of discharge goals and process.
F 0730: The facility failed to provide in-service education based on the outcome of performance reviews for three of five certified nurse aides.
F 0760: The facility failed to ensure a resident was free from significant medication errors by not priming the insulin pen before administration.
F 0838: The facility failed to conduct and document a facility-wide assessment including electronic elopement prevention, dialysis, and hospice services.
F 0880: The facility failed to maintain infection control by not storing IV administration sets in a sanitary manner and not cleaning the hub of an insulin pen prior to use.
Report Facts
Residents reviewed: 21
Performance reviews: 3
Insulin dose: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Administered insulin without priming the pen and did not clean insulin pen hub before needle application |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding shower refusals and documentation |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding infection control practices for IV tubing |
| CNA #6 | Certified Nurse Aide | Interviewed about shower schedules and refusals |
| CNA #7 | Certified Nurse Aide | Shower aide interviewed about shower refusals and documentation |
| Director of Nursing | Director of Nursing (DON) | Interviewed multiple times regarding shower refusals, baseline care plans, discharge planning, performance reviews, medication administration, infection control, and facility assessment |
Inspection Report
Deficiencies: 0
Date: Aug 31, 2022
Visit Reason
The document is a statement of deficiencies and plan of correction for a nursing home facility inspection.
Findings
No health deficiencies were found during the inspection.
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