Deficiencies (last 3 years)
Deficiencies (over 3 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
17% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 30, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide appropriate edema care and failure to properly inform residents about the nature and implications of the facility's arbitration agreement.
Complaint Details
The complaint investigation found substantiated issues with failure to notify the provider of significant weight changes for Resident #18 and failure to properly inform residents about the arbitration agreement terms and their rights.
Findings
The facility failed to notify the provider of significant weight changes for one resident (#18) as ordered, and failed to ensure five residents were adequately informed about the binding arbitration agreement, including their right to rescind it within 90 days.
Deficiencies (2)
F 0684: The facility failed to notify the provider of significant weight changes for Resident #18 as required by physician orders, despite multiple documented weight fluctuations without provider notification.
F 0847: The facility failed to ensure five residents were informed about the nature and implications of the binding arbitration agreement, including the right to rescind within 90 days and the binding nature of the agreement.
Report Facts
Residents in sample: 28
Residents affected by edema care deficiency: 1
Residents affected by arbitration agreement deficiency: 5
Weight changes: 3
Weight changes: 11.2
Weight changes: 11
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 30, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to provide appropriate edema care for Resident #18 and failure to properly inform residents or their representatives about the nature and implications of the facility's arbitration agreement.
Complaint Details
The complaint investigation focused on Resident #18's edema care and provider notification of weight changes, and on the facility's process for informing residents about the arbitration agreement. The investigation found substantiated deficiencies in both areas.
Findings
The facility failed to notify the provider of significant weight changes for Resident #18 as ordered, despite multiple documented weight fluctuations without provider notification. Additionally, the facility failed to ensure that five residents and/or their representatives were adequately informed about the binding arbitration agreement, including the right to rescind within 90 days and the binding nature of the agreement.
Deficiencies (2)
Failure to appropriately notify the provider of significant weight changes for Resident #18 as ordered.
Failure to ensure residents or their representatives were aware of the nature and implications of the facility's arbitration agreement, including the right to rescind within 90 days.
Report Facts
Residents reviewed for edema care: 28
Residents affected by edema care deficiency: 1
Residents reviewed for arbitration agreement: 28
Residents affected by arbitration agreement deficiency: 5
Weight changes documented without provider notification: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Aide #1 | CNA | Interviewed regarding weighing process and difficulties obtaining consistent weights for Resident #18 |
| Registered Nurse #2 | RN | Interviewed about documentation of provider notification of weight changes |
| Registered Dietitian | RD | Interviewed about monitoring residents' weights and provider notification |
| Director of Nursing | DON | Interviewed about review of weight changes and provider notification for Resident #18 |
| Admissions Coordinator #1 | AC | Interviewed about explanation and presentation of arbitration agreement to residents |
| Admissions Coordinator #2 | AC | Interviewed about explanation and presentation of arbitration agreement to residents |
| Nursing Home Administrator | NHA | Interviewed about arbitration agreement and facility policies |
| Human Resources Director | HRD | Interviewed about presenting arbitration agreements and staff education |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 28, 2023
Visit Reason
Annual survey inspection of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 28, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at the nursing home facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 12, 2023
Visit Reason
The inspection was conducted to investigate complaints regarding failure to promptly resolve resident grievances, including mistreatment by staff and missing personal items.
Complaint Details
The complaint investigation focused on Resident #8's reports of mistreatment by a certified nurse aide and missing glasses. The grievance was substantiated as the facility failed to promptly investigate and follow up on the resident's concerns.
Findings
The facility failed to promptly investigate and resolve a grievance related to mistreatment of Resident #8 by a staff member and did not timely follow up on the resident's concern about missing glasses. Additionally, the facility failed to ensure safe food handling practices in the kitchen, including proper hand hygiene and appropriate beverage temperatures.
Deficiencies (2)
F 0585: The facility failed to promptly investigate and resolve grievances for Resident #8 regarding mistreatment by a staff member and missing personal items, including lack of follow-up and documentation.
F 0812: The facility failed to ensure dietary staff followed proper hand hygiene during meal service and served beverages, including milk, at unsafe temperatures, risking cross-contamination and foodborne illness.
Report Facts
Residents in sample: 27
Resident BIMS score: 11
Milk temperature: 52.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding Resident #8's complaint of mistreatment by CNA #2 and missing glasses |
| CNA #2 | Certified Nurse Aide | Named in Resident #8's complaint of mistreatment and subject of staff education |
| CNA Lead | Certified Nurse Aide Lead | Interviewed about grievance follow-up and missing item tracking process |
| ADON | Assistant Director of Nursing | Interviewed regarding grievance awareness and staff education |
| MDSC | Minimum Data Set Coordinator | Interviewed about grievance process and staff education |
| DM | Dietary Manager | Interviewed about dietary infection control and food safety practices |
| IPRN | Infection Preventionist Registered Nurse | Interviewed about infection control involvement in dietary services |
| CCC | Corporate Clinical Consultant | Interviewed about facility education and grievance process improvements |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Jan 12, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to promptly and thoroughly investigate grievances and follow up on resident concerns, including mistreatment by a staff member and a missing pair of glasses.
Complaint Details
The complaint investigation focused on Resident #8 who reported mistreatment by a certified nurse aide and missing glasses. The grievance was not promptly investigated or resolved, and follow-up with the resident was lacking. The facility lacked a system to track missing items and did not generate a grievance form until late in the investigation.
Findings
The facility failed to promptly investigate and resolve a grievance related to mistreatment of Resident #8 by a certified nurse aide and did not timely follow up on the resident's concern about missing glasses. Additionally, the facility failed to ensure safe food handling practices in the kitchen, including proper hand hygiene and maintaining appropriate beverage temperatures.
Deficiencies (3)
Failed to promptly and thoroughly investigate a grievance and provide resident follow-up for resolution regarding potential mistreatment by a staff member.
Failed to timely follow up on Resident #8 concern of a missing pair of glasses.
Failed to prepare and serve food in a safe and sanitary manner to prevent cross-contamination and potential food borne illnesses, including failure to follow accepted hand hygiene practices and serving beverages at appropriate temperatures.
Report Facts
Residents Affected: 27
Residents Affected: 1
Temperature: 52.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding Resident #8's complaint about CNA #2's behavior and missing glasses |
| CNA #2 | Certified Nurse Aide | Named in Resident #8's complaint for mistreatment and failure to perform hand hygiene |
| CNA lead | Interviewed about grievance follow-up and education provided to CNA #2 | |
| ADON | Assistant Director of Nursing | Interviewed about grievance awareness and staff education |
| MDSC | Minimum Data Set Coordinator | Provided facility policy and interview information regarding grievance process and education |
| SS | Social Services Director | Interviewed about grievance and missing item tracking |
| DM | Dietary Manager | Interviewed regarding food safety deficiencies and follow-up actions |
| IPRN | Infection Preventionist Registered Nurse | Interviewed about infection control practices in dietary |
| CCC | Corporate Clinical Consultant | Interviewed about grievance process and staff education |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 16, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to prevent and properly care for a pressure ulcer in a resident.
Complaint Details
The complaint investigation focused on the failure to prevent and properly manage a pressure ulcer in Resident #26, including lack of preventive interventions and failure to conduct an investigation. Additionally, the facility failed to monitor psychotropic medication use and obtain proper consents for Resident #34.
Findings
The facility failed to provide appropriate pressure ulcer care and prevention, resulting in an unstageable pressure injury to a resident's coccyx. The facility also failed to conduct a root-cause analysis or investigation into the pressure ulcer and did not consistently implement turning and repositioning protocols.
Deficiencies (2)
F 0686: The facility failed to ensure a resident at risk did not develop an unstageable pressure ulcer. The resident lacked an air mattress, was not on a formal turning schedule, and the facility did not investigate the cause of the pressure ulcer.
F 0758: The facility failed to ensure behavior monitoring for psychotropic medication use for one resident. Target behaviors and sleep hours were not tracked, and consents for medications were missing or delayed.
Report Facts
Resident sample size: 27
Pressure ulcer measurement: 0.5
Pressure ulcer measurement: 0.75
Pressure ulcer measurement: 0.25
Braden scale score: 13
Braden scale score: 14
Sertraline dosage: 200
Trazodone dosage: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Observed and treated Resident #26's pressure ulcer on 9/16/21 |
| RN #3 | Registered Nurse / CNA | Provided care to Resident #26 and reported no wound or dressing observed on 9/16/21 |
| RN #4 | Registered Nurse | Reported assessment and notification of Resident #26's pressure injury on 9/6/21 |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding Resident #26's wound care and investigation |
| Nursing Home Administrator (NHA) | Administrator | Interviewed about facility policies and oversight of pressure ulcer prevention and psychotropic medication monitoring |
| Registered Nurse (RN) #1 | Registered Nurse | Interviewed about lack of behavior monitoring for Resident #34 |
| Regional Director of Operations (RDO) | Regional Director of Operations | Interviewed about behavior monitoring deficiencies for Resident #34 |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Sep 16, 2021
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing in a resident at risk.
Complaint Details
The complaint investigation focused on the failure to prevent pressure ulcers in Resident #26 and failure to monitor behavior related to psychotropic medication use in Resident #34. Resident #26 developed an unstageable pressure ulcer 16 days after admission, and the facility did not implement required preventative measures or conduct an investigation. Resident #34's psychotropic medication use was not properly monitored, and consents were missing or delayed.
Findings
The facility failed to prevent an avoidable unstageable pressure ulcer in Resident #26 by not implementing timely preventative interventions such as providing an air mattress and a formal turning and repositioning schedule. The facility also failed to conduct a root-cause analysis or investigation into the pressure ulcer development. Additionally, the facility failed to ensure behavior monitoring for psychotropic medication use in Resident #34, including tracking target behaviors, sleep hours, and obtaining consents.
Deficiencies (2)
Failure to provide appropriate pressure ulcer care and prevent new ulcers from developing in Resident #26.
Failure to ensure behavior monitoring for target behaviors related to psychotropic medication use in Resident #34.
Report Facts
Resident #26 pressure ulcer size: 0.4
Resident #26 pressure ulcer size: 0.5
Braden scale score: 13
Braden scale score: 14
Sertraline dosage: 200
Trazodone dosage: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Observed and treated Resident #26's pressure ulcer on 9/16/21 |
| RN #3 | Registered Nurse | Interviewed regarding care of Resident #26 and noted no wound or dressing observed |
| RN #4 | Registered Nurse | Reported assessment of Resident #26's pressure injury and communication with DON |
| DON | Director of Nursing | Interviewed multiple times regarding Resident #26's pressure ulcer and facility policies |
| NHA | Nursing Home Administrator | Interviewed regarding facility policies and oversight of pressure ulcer prevention and psychotropic medication monitoring |
| RN #1 | Registered Nurse | Interviewed regarding lack of behavior monitoring for Resident #34 |
| RDO | Regional Director of Operations | Interviewed regarding behavior monitoring deficiencies for Resident #34 |
Viewing
Loading inspection reports...
