Inspection Reports for
Grace Manor Care Center
465 5TH ST, BURLINGTON, CO, 80807-1932
Back to Facility ProfileDeficiencies (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
Routine
Deficiencies: 2
Date: Apr 11, 2024
Visit Reason
The inspection was conducted to assess compliance with professional standards of care, medication storage, and labeling practices at Grace Manor Care Center.
Findings
The facility failed to ensure proper wound care orders were in place for a resident with a skin abrasion and failed to properly store and label medications, including the presence of loose and expired medications in medication carts and the medication room.
Deficiencies (2)
F 0684: The facility failed to have a wound care order in place prior to treatment being provided for Resident #19, who had a skin tear to his right elbow from a previous fall.
F 0761: The facility failed to ensure medications were not loose in medication carts and failed to remove expired medications from the medication storage room.
Report Facts
Loose medication tablets in medication cart #1: 29
Loose medication tablets in medication cart #2: 16
Expired medication quantity: 100
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Interviewed regarding wound care order absence and medication storage issues | |
| Director of Nursing (DON) | Interviewed regarding wound care order absence and medication storage policies |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Apr 19, 2023
Visit Reason
The inspection was conducted following a complaint and investigation of a resident fall incident at Grace Manor Care Center involving inadequate supervision and failure to provide required two-person assistance during bed mobility and toileting.
Complaint Details
The investigation was triggered by a complaint regarding a fall of Resident #1 on 2/27/23 when a nurse aide left him unattended on the edge of the bed. The fall caused injuries requiring emergency department evaluation. The complaint was substantiated with findings of inadequate supervision and failure to follow care plans for two-person assistance.
Findings
The facility failed to ensure adequate supervision and consistent two-person assistance for Resident #1, resulting in a fall from the edge of the bed causing head, neck, and shoulder injuries. The care plan and staff practices did not consistently reflect the resident's assessed needs, and staff education and documentation were deficient.
Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and provide adequate supervision to prevent accidents. Resident #1 fell from the edge of the bed due to staff leaving him unattended and failure to provide two-person assistance as required, resulting in serious injuries including head injury and scalp hematoma.
Report Facts
Pain level post-fall: 8
Date of fall: Feb 27, 2023
Number of persons required for assistance: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NA #1 | Nurse Aide | Left Resident #1 unattended on edge of bed leading to fall; interviewed regarding incident and care practices. |
| DON | Director of Nursing | Provided post-fall education and training to staff; acknowledged care plan inconsistencies and planned re-education. |
| RN #1 | Registered Nurse | Interviewed regarding care plan decisions and resident's fluctuating assistance needs. |
| CNA #1 | Certified Nurse Aide | Interviewed about incontinence care procedures and assistance provided to Resident #1. |
| CNA #2 | Certified Nurse Aide | Interviewed about incontinence care procedures and assistance practices. |
| NHA | Nursing Home Administrator | Acknowledged the fall was an accident caused by staff leaving resident unattended. |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jan 11, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to ensure residents were free from unnecessary psychotropic medications and to monitor targeted behaviors related to these medications.
Complaint Details
The complaint investigation focused on the inappropriate use and monitoring of psychotropic medications for residents #20 and #13, including failure to document behaviors and lack of physician notification. Additionally, the investigation found failures in infection control practices during medication administration.
Findings
The facility failed to monitor targeted behaviors for psychotropic medications for two residents, #20 and #13, and failed to maintain an infection control program by not performing hand hygiene during medication administration. The facility also lacked individualized behavior tracking for residents on psychotropic medications.
Deficiencies (2)
F 0758: The facility failed to ensure two residents were free from unnecessary psychotropic medications and failed to monitor targeted behaviors related to these medications, including lack of documentation and physician notification.
F 0880: The facility failed to maintain an infection control program by not performing hand hygiene before and after medication administration, including failure to don gloves when administering eye medications.
Report Facts
Residents in sample: 18
Residents affected: 2
Lorazepam as needed doses administered: 3
Lorazepam as needed doses administered: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Observed failing to perform hand hygiene during medication administration |
| Director of Nursing | Director of Nursing | Interviewed regarding medication monitoring and infection control deficiencies |
| Social Services Designee | Social Services Designee | Interviewed regarding psychotropic medication review committee and resident behavior tracking |
| CNA #1 | Certified Nurse Assistant | Interviewed about Resident #20's behaviors and care |
| CNA #2 | Certified Nurse Assistant | Interviewed about Resident #20's behaviors and care |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Administered medications to Resident #20 and interviewed about medication administration |
| Regional Nurse Consultant | Regional Nurse Consultant | Interviewed about behavior tracking process |
| Nursing Home Administrator | Nursing Home Administrator | Interviewed about facility plans to improve behavior tracking and medication monitoring |
| RN #1 | Registered Nurse | Interviewed about Resident #13's care and behaviors |
Inspection Report
Complaint Investigation
Census: 29
Deficiencies: 5
Date: Sep 16, 2021
Visit Reason
The inspection was conducted due to complaints regarding delayed call light response, frequent falls, inadequate staffing, and infection control issues at Grace Manor Care Center.
Complaint Details
The investigation was complaint-driven based on allegations of delayed call light response, frequent falls, insufficient staffing, and infection control deficiencies. The complaint was substantiated with findings of actual harm and minimal harm to residents.
Findings
The facility failed to ensure timely call light response resulting in undignified care and incontinence accidents for multiple residents. It also failed to prevent recurrent falls for a cognitively impaired resident due to inadequate supervision and interventions. Staffing levels were insufficient to meet resident needs. Infection control practices were deficient, including improper mask use, lack of hand hygiene before meals, and shared condiments. Additionally, expired foods were found in personal refrigerators without proper temperature logs.
Deficiencies (5)
F550: The facility failed to honor residents' rights to a dignified existence by not answering call lights timely for Residents #5, #18, #28, and #129, causing feelings of embarrassment and incontinence accidents.
F689: The facility failed to provide adequate supervision and interventions to prevent recurrent falls for Resident #11, who had six falls in seven weeks.
F725: The facility failed to provide sufficient nursing staff to meet resident care needs, resulting in delayed call light response and increased falls.
F813: The facility failed to maintain a policy and practice for safe storage and handling of foods brought by visitors, resulting in expired foods in personal refrigerators without temperature logs.
F880: The facility failed to implement an effective infection prevention and control program, including failure to ensure hand hygiene before meals, proper mask use by staff and residents, and removal of shared condiments.
Report Facts
Resident census: 29
Call light delays: 81
Call light delays: 36
Call light delays: 12
Call light delays: 27
Call light delays: 16
Call light delays: 5
Falls: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Acknowledged unacceptable call light wait times and staff responsibilities for infection control |
| CNA #1 | Certified Nurse Aide | Reported nursing staff shortage and frequent reassignment from administrative duties to CNA duties |
| RN #2 | Registered Nurse | Reported working extra shifts due to staff call-offs |
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