Inspection Reports for
Lamar Estates, LLC
205 S 10th St, Lamar, CO 81052, CO, 81052
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
92% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Sep 27, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with professional standards of practice, focusing on the development and implementation of comprehensive, person-centered care plans and the clarification of physician's orders for medication administration.
Findings
The facility failed to develop and implement comprehensive care plans for three residents (#13, #15, and #19) addressing hospice care, depression, and urinary catheter care. Additionally, the facility failed to clarify physician's orders with dose information for topical skin medications for six residents (#2, #3, #6, #12, #15, and #17).
Deficiencies (2)
Failed to develop and implement a complete care plan that meets all the resident's needs, including hospice care, depression, and urinary catheter care.
Failed to clarify physician's orders with dose information for administration of topical skin medications.
Report Facts
Residents reviewed: 24
Residents with deficient care plans: 3
Residents with unclear medication orders: 6
BIMS score: 4
BIMS score: 15
BIMS score: 15
Medication dosage frequency: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #1 | Interviewed regarding care for Residents #13, #15, and #19 | |
| Registered Nurse (RN) #1 | Interviewed regarding care and medication administration for Residents #13, #15, and #19 | |
| Director of Nursing (DON) | Interviewed regarding facility policies and care plan requirements |
Inspection Report
Annual Inspection
Deficiencies: 2
Date: Sep 27, 2023
Visit Reason
The inspection was conducted to assess compliance with professional standards of care and regulatory requirements for a nursing home, including review of care plans and medication administration.
Findings
The facility failed to develop and implement comprehensive, person-centered care plans for three residents, including hospice care, depression, and urinary catheter care. Additionally, the facility failed to clarify physician orders regarding dosage for topical skin medications for six residents.
Deficiencies (2)
F 0656: The facility failed to develop and implement a complete care plan that meets all the resident's needs, including hospice care for Resident #13, depression for Resident #15, and urinary catheter care for Resident #19.
F 0658: The facility failed to clarify physician's orders with dose information for topical skin medications for Residents #2, #3, #6, #12, #15, and #17, risking improper medication administration.
Report Facts
Residents reviewed: 24
Residents with care plan deficiencies: 3
Residents with medication order deficiencies: 6
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jun 29, 2022
Visit Reason
The inspection was conducted due to a complaint investigation regarding allegations of resident-to-resident physical abuse and failure to provide adequate dementia management care.
Complaint Details
The complaint investigation was triggered by allegations of physical abuse between Resident #2 and Resident #6, including failure to prevent resident-to-resident altercations and inadequate dementia management.
Findings
The facility failed to ensure residents were free from abuse, neglect, and exploitation, specifically failing to prevent a resident-to-resident physical altercation between Resident #2 and Resident #6. Additionally, the facility failed to provide appropriate respiratory care for Resident #7, ensure CNA competencies, provide adequate treatment for mental health and dementia-related behaviors, maintain medication storage security, and properly implement pneumococcal vaccination policies.
Deficiencies (7)
Failed to protect residents from abuse including a physical altercation between Resident #2 and Resident #6.
Failed to provide safe and appropriate respiratory care for Resident #7, including failure to ensure oxygen was administered as ordered.
Failed to ensure certified nurse aides had completed competencies prior to providing care.
Failed to provide appropriate treatment and services to Resident #7 with mental disorder, including lack of individualized care plan for behaviors.
Failed to provide appropriate treatment and services to Resident #2 with dementia, including insufficient supervision and failure to follow care plan interventions.
Failed to ensure medication storage room was secure; room was propped open with wandering residents nearby.
Failed to implement policies and procedures for pneumococcal vaccinations; Residents #6 and #12 were not offered or did not receive recommended pneumococcal vaccines.
Report Facts
Residents reviewed: 15
Behavioral symptoms frequency: 30
Oxygen flow rate: 3
Competencies missing: 4
Behavior episodes: 14
Vaccination dates: 2018
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Nursing Home Administrator | NHA | Provided facility policies, interviewed regarding resident care and staff training. |
| Registered Nurse #1 | RN | Observed resident behaviors and oxygen therapy issues. |
| Certified Nurse Aide #1 | CNA | Reported on resident behaviors and lack of competencies. |
| Certified Nurse Aide #2 | CNA | Reported on resident behaviors and lack of competencies. |
| Social Services Director | SSD | Interviewed about resident behavioral management and training. |
| Director of Nursing | DON | Interviewed about oxygen therapy, medication storage security, and resident behavior management. |
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Jun 29, 2022
Visit Reason
The inspection was conducted to investigate complaints related to resident abuse, respiratory care, staff competencies, mental health treatment, dementia care, medication storage security, and vaccination procedures at the nursing home.
Complaint Details
The complaint investigation focused on allegations of resident-to-resident abuse, inadequate respiratory care, staff competency deficiencies, failure to provide appropriate mental health and dementia care, unsecured medication storage, and failure to properly administer pneumococcal vaccinations. The investigation substantiated multiple deficiencies related to these issues.
Findings
The facility failed to prevent resident-to-resident abuse, ensure oxygen therapy was administered as ordered, verify CNA competencies, provide appropriate mental health and dementia care, secure medication storage, and properly implement pneumococcal vaccination policies. Several residents exhibited behavioral issues that were not adequately managed, and staff training and care plans were insufficient or inconsistently followed.
Deficiencies (7)
F600: The facility failed to protect residents from abuse by not preventing a physical altercation between two residents and failing to provide adequate supervision and dementia care.
F695: The facility failed to ensure oxygen was administered according to physician orders for one resident.
F726: The facility failed to ensure certified nurse aides completed competencies prior to providing care.
F742: The facility failed to provide appropriate treatment and services for a resident with mental disorder, lacking individualized care plans for disruptive behaviors.
F744: The facility failed to provide appropriate treatment and services for a resident with dementia, including insufficient supervision, failure to address escalating behaviors, and lack of staff knowledge of care plans.
F761: The facility failed to ensure the medication storage room was secure, leaving it propped open with wandering residents nearby.
F883: The facility failed to implement policies and procedures to offer and provide pneumococcal vaccines according to current guidelines for two residents.
Report Facts
Residents reviewed for abuse: 15
Residents reviewed for oxygen therapy: 15
Certified nurse aides reviewed for competencies: 4
Residents reviewed for mental disorder care: 15
Residents reviewed for dementia care: 15
Residents reviewed for pneumococcal immunizations: 15
Behavioral symptoms frequency: 30
Behavior episodes recorded: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Observed and intervened in resident altercation incident |
| NHA | Nursing Home Administrator | Provided policies, interviewed regarding multiple findings and staff training |
| CNA #1 | Certified Nurse Aide | Interviewed regarding resident behaviors and oxygen therapy |
| CNA #2 | Certified Nurse Aide | Interviewed regarding resident behaviors and oxygen therapy |
| DON | Director of Nursing | Interviewed regarding oxygen therapy, medication storage, and resident behaviors |
| SSD | Social Services Director | Interviewed regarding resident behavioral issues and staff training |
| RN #1 | Registered Nurse | Interviewed regarding oxygen therapy and resident behaviors |
| ASD | Activities/Social Services Director | Interviewed regarding resident behavioral management and diversion activities |
| AA #1 | Activity Assistant | Interviewed regarding resident behavioral management and diversion activities |
Inspection Report
Routine
Deficiencies: 6
Date: Apr 20, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, including activities, respiratory care, nursing administration, dementia care, medication management, and adaptive equipment use.
Findings
The facility failed to provide meaningful activities for residents, ensure oxygen therapy was administered per physician orders, designate a full-time director of nursing, provide appropriate dementia care interventions, properly label and date insulin pens, and ensure the use of a physician-ordered plate guard for a resident during meals.
Deficiencies (6)
Failed to provide a meaningful program of activities for three residents, including failure to follow the activity calendar and provide individualized activities.
Failed to ensure oxygen was administered according to physician orders for one resident.
Failed to designate a registered nurse to serve as the director of nursing on a full-time basis.
Failed to provide appropriate treatment and services for a resident with dementia, including ineffective interventions for wandering and spitting behaviors.
Failed to ensure drugs and biologicals were labeled and stored properly, including incorrect dating of insulin pens.
Failed to provide special eating equipment (plate guard) as ordered for a resident during meals.
Report Facts
Residents reviewed for activities: 14
Residents reviewed for oxygen therapy: 3
Residents reviewed for adaptive equipment: 3
Residents reviewed for dementia care: 5
Resident #18 behavior charting shifts with behaviors: 14
Resident #18 behavior charting shifts with behaviors: 57
Resident #18 behavior charting shifts with behaviors: 13
Resident #18 behavior charting shifts with behaviors: 93
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA #3 | Nursing Home Administrator | Interviewed regarding director of nursing role and insulin pen dating |
| RN #1 | Registered Nurse | Interviewed regarding oxygen administration and medication cart observations |
| CNA #2 | Certified Nurse Aide | Interviewed regarding resident activity participation and oxygen use |
| CNA #3 | Certified Nurse Aide | Interviewed regarding resident activity participation and oxygen use |
| AD | Activity Director | Interviewed regarding activity program and resident engagement |
| DM | Dietary Manager | Interviewed regarding plate guard use and tray covers |
| RN #3 | Registered Nurse | Interviewed regarding oxygen administration |
| NA #1 | Nurse Aide | Interviewed regarding resident wandering and spitting behaviors |
| NA #2 | Nurse Aide | Interviewed regarding resident wandering and spitting behaviors |
| CNA #6 | Certified Nurse Aide | Interviewed regarding resident wandering and spitting behaviors |
Inspection Report
Routine
Deficiencies: 6
Date: Apr 20, 2021
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, activities, respiratory care, nursing administration, dementia care, medication management, and dietary assistance.
Findings
The facility failed to provide meaningful activities for residents, ensure oxygen therapy was administered according to physician orders, designate a full-time director of nursing, provide appropriate dementia care interventions, properly label and store insulin pens, and provide special eating equipment as ordered for residents.
Deficiencies (6)
F0679: The facility failed to provide meaningful activities for three residents by not following the activity calendar, not encouraging participation, and not meeting individual activity needs.
F0695: The facility failed to ensure oxygen was administered according to physician orders for Resident #1, with oxygen used only at bedtime but observed during the day.
F0727: The facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis, with the nursing home administrator performing dual roles.
F0744: The facility failed to provide appropriate treatment and services for a resident with dementia, including ineffective assessment and interventions for wandering, spitting, and agitation.
F0761: The facility failed to ensure insulin pens were properly labeled with the date opened and resident identification, risking medication safety.
F0810: The facility failed to provide a physician-ordered plate guard for Resident #1 during meals, impacting the resident's ability to eat independently.
Report Facts
Behavior shifts charted: 6
Behavior shifts charted: 9
Behavior shifts charted: 13
Behavior shifts charted: 14
Scheduled hours: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| NHA #3 | Nursing Home Administrator | Interviewed regarding dual role as DON and NHA and insulin pen labeling |
| RN #1 | Registered Nurse | Observed medication carts and interviewed about insulin pen labeling and plate guard responsibility |
| CNA #2 | Certified Nurse Aide | Interviewed regarding Resident #18 wandering and spitting behaviors and Resident #1 plate guard use |
| CNA #3 | Certified Nurse Aide | Interviewed regarding Resident #1 plate guard use and oxygen therapy |
| Activity Director | Activity Director | Interviewed regarding activity participation and documentation |
| Dietary Manager | Dietary Manager | Interviewed regarding plate guard use and tray covers |
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