Deficiencies (last 3 years)
Deficiencies (over 3 years)
1.7 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
67% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
4
3
2
1
0
Occupancy
Latest occupancy rate
36% occupied
Based on a April 2023 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Deficiencies: 0
Date: Oct 3, 2024
Visit Reason
The document is a statement of deficiencies and plan of correction related to a regulatory survey of Centre Ave Health and Rehabilitation LLC.
Findings
No health deficiencies were found during the survey.
Inspection Report
Complaint Investigation
Census: 32
Deficiencies: 3
Date: Apr 18, 2023
Visit Reason
The inspection was conducted due to complaints regarding failure to notify residents' physicians and families of changes in condition, failure to administer medications as ordered, and inadequate supervision to prevent accidents and falls.
Complaint Details
The investigation was complaint-driven based on allegations that the facility failed to notify physicians and families of residents' changes in condition and falls, failed to administer medications as ordered, and failed to prevent accidents and falls through adequate supervision and interventions.
Findings
The facility failed to notify physicians and family members of residents' changes in condition and falls, failed to administer medications according to physician orders for two residents, and failed to provide adequate supervision to prevent accidents and falls for multiple residents. Several residents experienced multiple falls with inadequate interventions and notifications.
Deficiencies (3)
F580: The facility failed to immediately notify the resident's physician and family of changes in condition for three residents related to skin tear and multiple falls.
F0684: The facility failed to ensure two residents were administered medications according to physician orders, with multiple documented medication refusals and no provider notification.
F0689: The facility failed to provide adequate supervision and accident hazard prevention, resulting in multiple falls and injuries for several residents, with inadequate fall interventions and notifications.
Report Facts
Sample residents reviewed: 32
Residents affected by notification failure: 3
Residents affected by medication administration failure: 2
Residents affected by supervision failure: 3
Falls for Resident #53: 4
Medication refusal dates for Resident #18: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding notification and medication administration failures |
| WN | Wound Nurse | Interviewed regarding failure to notify family and physician of skin tear and falls |
| CSM #1 | Clinical Services Manager | Interviewed regarding facility policies and notification requirements |
| CNC #1 | Clinical Nurse Consultant | Provided medication and treatment policy and interviewed about purposeful rounding |
| CN #2 | Charge Nurse | Interviewed about medication administration and resident refusals |
| ADON | Assistant Director of Nursing | Interviewed about medication administration and notification procedures |
| NHA | Nursing Home Administrator | Interviewed about fall prevention policies and communication of fall risk |
| CNA #1 | Certified Nurse Assistant | Interviewed about purposeful rounding and resident care |
| CNA #2 | Certified Nurse Assistant | Interviewed about toileting program and resident care |
| CNA #3 | Certified Nurse Assistant | Interviewed about purposeful rounding and toileting program |
| Admission Coordinator #1 | Admission Coordinator | Interviewed about communication of fall risk to staff |
Inspection Report
Complaint Investigation
Census: 28
Deficiencies: 2
Date: Feb 9, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to provide necessary assistance with activities of daily living and pressure ulcer care for residents.
Complaint Details
The complaint investigation substantiated that the facility failed to provide adequate assistance with eating and pressure ulcer care for Residents #16 and #18, resulting in minimal to actual harm.
Findings
The facility failed to provide adequate assistance with eating for Resident #16, resulting in a decline in activities of daily living. Additionally, the facility failed to provide timely and appropriate pressure ulcer care for Residents #16 and #18, including failure to implement pressure relieving interventions and inconsistent documentation of offloading boots use.
Deficiencies (2)
Failure to provide necessary assistance with eating for Resident #16, who required physical assistance and encouragement.
Failure to provide appropriate pressure ulcer care and prevent new ulcers for Residents #16 and #18, including delayed implementation of low air loss mattress and inconsistent offloading interventions.
Report Facts
Residents in sample: 28
Refusals of offloading boots: 6
Weight loss percentage: 4.7
Pressure ulcer stage: 2
Days delay for low air loss mattress: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DA #1 | Dietary Aide | Delivered meal tray to Resident #16 but did not provide physical assistance or encouragement to eat |
| CNA #1 | Certified Nurse Aide | Observed assisting Resident #16 with repositioning but did not physically assist with eating |
| WCN | Wound Care Nurse | Provided wound care for Resident #16 and reported on pressure ulcer status and interventions |
| DON | Director of Nursing | Provided facility policy and described assist to dine program and staff responsibilities |
| RD | Registered Dietitian | Provided nutritional assessments and orders for Resident #16 |
| DA #2 | Dietary Aide | Interviewed regarding assist to dine program and Resident #16's eating assistance |
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