Inspection Reports for
Englewood Post Acute and Rehabilitation
3575 S WASHINGTON ST, ENGLEWOOD, CO, 80113-3807
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 7, 2024
Visit Reason
The inspection was conducted to investigate allegations of resident-to-resident physical abuse and staff-to-resident neglect at Englewood Post Acute and Rehabilitation.
Complaint Details
The complaint involved allegations of resident-to-resident physical abuse and staff-to-resident neglect. The allegation was not substantiated as neither resident was injured or fearful. The facility implemented monitoring interventions for Resident #18 for 72 hours post-incident.
Findings
The facility failed to thoroughly investigate the resident-to-resident physical abuse incident between Resident #18 and Resident #60, including inadequate assessment of Resident #18's cognitive status and lack of a care plan addressing his history of aggression. The investigation did not substantiate abuse due to lack of injury or fear, but interventions were implemented to monitor Resident #18 post-incident.
Deficiencies (1)
F 0600: The facility failed to develop a care plan focus for Resident #18 with a known history of aggressive behavior. The investigation lacked thorough assessment of Resident #18's cognitive status and hallucinations as potential triggers for aggression. The facility did not adequately investigate the resident-to-resident physical abuse incident on 9/24/24 to protect residents in common areas.
Report Facts
Residents in sample: 40
Residents affected: 2
Date of incident: Sep 24, 2024
Date of investigation completion: Nov 7, 2024
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Nov 7, 2024
Visit Reason
The inspection was conducted to investigate complaints related to the facility's failure to maintain a safe, clean, and homelike environment, failure to thoroughly investigate resident-to-resident abuse allegations, failure to ensure accurate resident assessments, failure to comply with PASRR screening requirements, failure to meet professional standards in medication administration, and failure to maintain infection prevention and control practices.
Complaint Details
The complaint investigation focused on multiple issues including environmental conditions, abuse and neglect investigations, resident assessment accuracy, PASRR screening compliance, medication administration practices, and infection control procedures. The allegations were substantiated with findings of minimal harm and deficiencies in each area.
Findings
The facility was found deficient in maintaining a homelike environment with rooms in disrepair and unclean common areas. The facility failed to properly investigate resident-to-resident abuse and neglect allegations, did not ensure accurate Minimum Data Set (MDS) assessments, failed to submit required PASRR Level I screenings, left medications unattended, and did not follow infection control protocols including hand hygiene and disinfectant dwell times during cleaning and wound care.
Deficiencies (6)
F 0584: The facility failed to maintain resident rooms in good repair and keep baseboards in common areas clean, resulting in a non-homelike environment.
F 0600: The facility failed to thoroughly investigate resident-to-resident physical abuse and staff-to-resident neglect allegations, lacking sufficient evidence gathering and care planning to prevent further incidents.
F 0641: The facility failed to ensure accurate Minimum Data Set (MDS) assessments for three residents, omitting documentation of PASRR Level II diagnoses, hospice services, and dialysis.
F 0645: The facility failed to submit a required PASRR Level I screening for one resident with qualifying mental illness diagnoses on multiple occasions.
F 0658: The facility failed to meet professional standards by leaving medications unattended on the medication cart and in a resident's room during administration.
F 0880: The facility failed to maintain infection prevention and control by not following hand hygiene protocols, not allowing disinfectants proper dwell times, and improper wound care practices.
Report Facts
Residents affected: 40
Residents affected: 4
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication administration deficiency for leaving medications unattended |
| Maintenance Director | Named in environmental maintenance deficiencies | |
| Nursing Home Administrator | Named in environmental maintenance deficiencies and abuse investigation | |
| Minimum Data Set Coordinator | Named in wound care and MDS assessment deficiencies | |
| Housekeeper #1 | Named in infection control deficiencies related to cleaning practices | |
| Housekeeper #2 | Named in infection control deficiencies related to cleaning practices | |
| Director of Nursing | DON | Interviewed regarding multiple deficiencies including abuse investigation, medication administration, infection control, and MDS assessments |
| Social Services Director | SSD | Named in PASRR and abuse investigation deficiencies |
| Social Services Consultant | SSC | Named in PASRR and abuse investigation deficiencies |
Inspection Report
Routine
Deficiencies: 4
Date: Jun 6, 2023
Visit Reason
The inspection was conducted to evaluate compliance with regulations regarding medication self-administration, resident privacy, treatment and care according to orders, and management of mental disorders and psychosocial adjustment difficulties in a nursing home.
Findings
The facility failed to ensure proper assessment and storage for residents self-administering medications, failed to offer catheter bag options respecting resident preferences, failed to coordinate timely medical procedures resulting in significant weight loss for a resident, and failed to provide appropriate interventions for a resident with verbally aggressive behavior.
Deficiencies (4)
F 0554: The facility failed to ensure Resident #31's self-administered medications were stored appropriately and Resident #38 was assessed for safety and appropriateness of self-administration.
F 0583: The facility failed to ensure Resident #10's personal privacy by not offering a leg bag option for urinary catheter use.
F 0684: The facility failed to provide needed care resulting in actual decline for Resident #275, including failure to timely coordinate medical procedures and notify the health care proxy.
F 0742: The facility failed to ensure appropriate treatment and services for Resident #65 with mental disorder, lacking interventions for verbally aggressive behavior.
Report Facts
Residents reviewed: 33
Weight loss percentage: 21.6
Weight loss percentage: 10.7
Resident #275 weights: 108.4
Resident #275 weights: 85
BIMS scores: 12
BIMS scores: 9
BIMS scores: 5
BIMS scores: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #2 | LPN | Interviewed regarding medication self-administration assessment process |
| Certified Nurse Aide #1 | CNA with medication authority | Interviewed regarding medication storage and self-administration assessment |
| Director of Nursing | DON | Interviewed regarding medication self-administration policies and resident care |
| Minimum Data Set Coordinator | MDSC | Interviewed regarding self-administration assessments and medication storage |
| Restorative Nurse Assistant #1 | RNA | Interviewed regarding catheter bag preference for Resident #10 |
| Certified Nurse Aide #1 | CNA | Interviewed regarding catheter bag preference and resident refusals |
| Registered Dietitian | RD | Interviewed regarding Resident #275's weight loss and care interventions |
| Healthcare Proxy | Resident Representative | Interviewed regarding delayed notification and consent for Resident #275's procedure |
| Gastroenterology Physician Assistant | GPA | Interviewed regarding Resident #275's medical procedure and communication issues |
| Certified Nurse Aide #2 | CNA | Interviewed regarding Resident #65's aggressive behavior |
| Registered Nurse #1 | RN | Interviewed regarding Resident #65's behavior and roommate issues |
| Social Services Director | SSD | Interviewed regarding Resident #65's behavior and staff education |
Inspection Report
Routine
Deficiencies: 6
Date: Mar 10, 2020
Visit Reason
Routine inspection of Englewood Post Acute and Rehabilitation facility to assess compliance with resident rights, quality of care, grievance resolution, food safety, infection control, and pressure ulcer prevention.
Findings
The facility failed to honor resident shower preferences, resolve grievances timely, provide appropriate wheelchair and pressure ulcer care for a resident, maintain proper food safety practices, and implement adequate infection control measures including proper cleaning of blood glucose meters.
Deficiencies (6)
F 0561: Facility failed to honor resident shower preferences for three residents, resulting in missed showers and lack of choice.
F 0585: Facility failed to resolve grievances timely related to call light response delays and missing personal items for multiple residents.
F 0684: Facility failed to provide appropriate wheelchair and pressure relieving cushion for Resident #28, contributing to development of multiple stage 2 pressure ulcers on posterior thighs.
F 0686: Facility failed to provide appropriate pressure ulcer care and prevent new ulcers, including inconsistent skin evaluations and delayed therapy evaluations for Resident #28.
F 0812: Facility failed to properly clean thermometers between food items and dispose of expired dietary supplements.
F 0880: Facility failed to properly clean and store blood glucose meters and failed to implement a water management program for legionella testing.
Report Facts
Missed showers: 58
Call light response over 30 minutes: 74
Call light response over 1 hour: 24
Call light response over 30 minutes: 54
Call light response over 1 hour: 15
Call light response over 30 minutes: 15
Call light response over 1 hour: 3
Call light response over 30 minutes: 12
Call light response over 1 hour: 7
Weight: 254
Pressure ulcer size: 1.5
Expired dietary supplements: 15
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #4 | Registered Nurse | Observed improper cleaning of glucometer and blood glucose checks. |
| DON | Director of Nursing | Provided facility policies, acknowledged deficiencies in shower scheduling, wound care, and infection control. |
| DD | Dietary Director | Provided food safety policies and acknowledged improper thermometer cleaning and expired supplements. |
| LPN #3 | Licensed Practical Nurse | Described weekly skin evaluations and documentation requirements. |
| CNA #1 | Certified Nursing Assistant | Described skin observation and reporting procedures during showers. |
| Therapy Manager | Therapy Manager | Reported on therapy evaluations and wheelchair assessments for Resident #28. |
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