Deficiencies (last 4 years)
Deficiencies (over 4 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
54% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Routine
Census: 53
Deficiencies: 10
Date: Feb 27, 2024
Visit Reason
The inspection was a routine survey to assess compliance with regulatory requirements related to resident care, medication administration, ancillary services, safety, and facility operations.
Findings
The facility was found deficient in multiple areas including medication self-administration assessments, personal hygiene assistance, ancillary services such as vision, podiatry, and dental care, fall prevention and environmental safety, respiratory care including CPAP maintenance, medication administration errors, and medication storage and labeling.
Deficiencies (10)
Failed to ensure Resident #40 was assessed for appropriateness and safety of self-administration of topical medications and lacked physician orders for self-administration.
Failed to ensure Resident #33 received scheduled showers as required by care plan.
Failed to assist Resident #89 with arranging vision appointments despite impaired vision.
Failed to provide timely podiatry care for Resident #89 with thick, long toenails.
Failed to maintain a safe environment and implement effective fall prevention interventions for Residents #46 and #76, resulting in falls with injury.
Failed to label Resident #18's tube feeding bag with date/time hung, nurse initials, feeding type, and flow rate.
Failed to maintain, clean, sanitize, and store CPAP equipment properly for Residents #62 and #68; Resident #68 had a torn mask that did not seal properly.
Medication administration errors including incorrect medication dispensing, failure to have resident rinse after inhaler use, and incorrect application site for topical medication.
Failed to ensure medications were not left unattended on medication cart and tuberculin vials were not dated with open dates.
Failed to provide routine and emergency dental care for Resident #89, including referral for lost and loose dentures.
Report Facts
Medication error rate: 14.29
Residents reviewed: 53
Medication errors: 5
Medication administration opportunities: 35
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication self-administration and medication administration errors |
| LPN #2 | Licensed Practical Nurse | Observed administering medications and interviewed about medication errors and CPAP care |
| RN #1 | Registered Nurse | Interviewed regarding tube feeding and CPAP care |
| DON | Director of Nursing | Interviewed regarding multiple deficiencies including medication errors, fall prevention, CPAP care, and ancillary services |
| NHA | Nursing Home Administrator | Interviewed regarding facility policies and ancillary services |
| SSD | Social Services Director | Interviewed regarding ancillary services offerings and documentation |
| ADON | Assistant Director of Nursing | Interviewed regarding CPAP care and medication administration |
| CNA #1 | Certified Nurse Aide | Interviewed regarding shower assistance and CPAP care |
| CNA #2 | Certified Nurse Aide | Interviewed regarding ancillary services and toenail care |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding medication storage and tuberculin vial dating |
| CSD | Central Supply Director | Interviewed regarding bed maintenance and setup |
Inspection Report
Complaint Investigation
Deficiencies: 5
Date: Oct 9, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to clarify and follow basic life support choices, including CPR, according to the advance directive for Resident #2.
Complaint Details
The complaint investigation focused on the facility's failure to honor Resident #2's DNR order during a medical emergency. The investigation found that CPR was performed by EMS despite the DNR, the MOST forms were disorganized and not readily accessible, and documentation of the emergency response was incomplete. Interviews revealed lack of staff knowledge about the resident's code status and absence of facility policies for EMS calls.
Findings
The facility failed to follow the Do Not Resuscitate (DNR) order for Resident #2 by allowing emergency medical personnel to perform CPR despite the resident's DNR status. The facility also failed to assist the roommate and family out of the room during CPR and did not ensure that the resident's Medical Orders for Scope of Treatment (MOST) forms were readily accessible and properly organized. Documentation of the emergency response was incomplete, and there was no facility policy for handling 911/EMS calls.
Deficiencies (5)
Failure to follow the advance directive on Resident #2's MOST form by having emergency medical personnel perform CPR despite DNR status.
Failure to assist the roommate and family out of the room during CPR until prompted by EMS.
Failure to ensure resident's MOST forms were readily accessible and in the correct location.
Lack of documentation regarding paramedics' arrival, care provided, and nursing staff actions during the emergency.
No facility policy or procedure for when 911/EMS is called and when paramedics arrive.
Report Facts
Residents reviewed for CPR: 6
Residents affected: 1
Time of paramedics arrival: 17.34
Time of death: 17.37
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Weekend Supervisor | Interviewed regarding emergency response and CPR initiation during Resident #2's event. |
| LPN #2 | Licensed Practical Nurse | Called 911 and involved in emergency response for Resident #2; unsure about CPR initiation. |
| Medical Director #1 | Medical Director | Interviewed about facility policies and expectations regarding CPR and EMS calls. |
| Paramedic #1 | Paramedic | Interviewed about EMS response and lack of advanced directive information at arrival. |
Inspection Report
Deficiencies: 2
Date: May 4, 2023
Visit Reason
The inspection was conducted to evaluate the facility's compliance with discharge planning and discharge summary requirements for residents.
Findings
The facility failed to implement an effective discharge planning process for four of six residents reviewed and failed to ensure complete discharge summaries for four of five residents reviewed. Discharge plans and summaries lacked necessary updates, interdisciplinary involvement, and completeness, including missing critical information such as resident status, treatment details, and medication risks.
Deficiencies (2)
Failure to implement an effective discharge planning process for four residents, including lack of focus on discharge goals, incomplete discharge needs identification, and insufficient interdisciplinary team involvement.
Failure to ensure discharge summaries included a complete recapitulation of the resident's stay, final status, and other required information for four residents.
Report Facts
Residents reviewed: 9
Residents with discharge planning deficiencies: 4
Residents with discharge summary deficiencies: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Completed discharge summaries and described sections completed |
| Health Information Manager | Health Information Manager | Responsible for reviewing resident discharge summaries and auditing compliance |
| Case Manager | Case Manager | Primary discharge planner for skilled services and responsible for discharge arrangements |
| Social Service Director | Social Service Director | Interviewed regarding discharge planning roles |
| Social Service Assistant | Social Service Assistant | Interviewed regarding discharge planning roles |
Inspection Report
Routine
Deficiencies: 6
Date: Dec 1, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, safety, infection control, and food service in a nursing home facility.
Findings
The facility was found deficient in multiple areas including failure to maintain resident equipment (wheelchair armrests), failure to revise and update comprehensive care plans for pressure ulcers, inadequate pressure ulcer care and documentation, failure to prevent accidents due to improper use of mechanical lifts, failure to store and label food properly, and failure to ensure laundry staff wore appropriate personal protective equipment during handling of soiled linens.
Deficiencies (6)
Failed to maintain wheelchair armrests in good repair for Resident #8.
Failed to revise comprehensive care plan to address newly identified pressure ulcer and abscess for Resident #52.
Failed to consistently assess and document status of pressure ulcer to track healing for Resident #52.
Failed to ensure environment free from accident hazards and adequate supervision during mechanical lift transfer, resulting in injury to Resident #56.
Failed to store food in accordance with professional standards; food and beverages were not labeled, dated, or expired in warming kitchen.
Failed to ensure laundry staff wore necessary PPE including gowns when handling and sorting soiled linens, risking cross-contamination.
Report Facts
Residents sampled for wheelchair armrest deficiency: 26
Residents reviewed for pressure ulcers or other skin conditions: 4
Residents reviewed for pressure ulcers: 3
Residents reviewed for accidents: 3
Length of wound on Resident #52's left great toe abscess: 1
Length of wound on Resident #52's left second toe pressure injury: 0.7
Left arm wound measurement: 10
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant #7 | CNA | Confirmed wheelchair armrest tears for Resident #8 |
| Director of Rehabilitation Services | Director of Rehabilitation | Discussed wheelchair repair process and therapy department role |
| Administrator | Discussed wheelchair repair process confusion and care plan update expectations | |
| Maintenance Director | Described wheelchair repair process and lack of awareness of Resident #8's wheelchair condition | |
| Licensed Practical Nurse #14 | LPN, MDS Coordinator | Discussed care plan review and revision process for Resident #52 |
| Interim Director of Nursing | Interim DON | Discussed care plan expectations, wound rounds, and wound tracking for Resident #52 |
| Registered Nurse #15 | RN | Described wound discovery and treatment process |
| Licensed Practical Nurse #16 | LPN | Familiar with wounds on Resident #52's toes and dressing changes |
| Wound Care Doctor | WCD | Assessed Resident #52's wounds and described wound tracking process |
| Certified Nursing Assistant #4 | CNA | Involved in improper mechanical lift transfer causing injury to Resident #56 |
| Licensed Practical Nurse #5 | LPN | Described transfer incident and staff education for Resident #56 |
| Rehabilitation Director | Rehab Director | Discussed therapy assessments and transfer assistance for Resident #56 |
| Previous Director of Nursing | Previous DON | Discussed fall notification and mechanical lift training |
| Food Service Director | Confirmed food labeling and expiration deficiencies in warming kitchen | |
| Dietary Aide #8 | Dietary Aide | Removed undated and expired food items from warming kitchen refrigerator |
| Housekeeping Assistant #6 | HKA | Observed sorting soiled laundry without gown and PPE |
| Housekeeping Director | HD | Confirmed gown use expectation for laundry staff and availability of gowns |
| Executive Director | ED | Expected laundry personnel to wear protective gowns |
| Infection Preventionist | Stated laundry staff should wear gowns when sorting soiled laundry |
Inspection Report
Routine
Deficiencies: 9
Date: Aug 5, 2021
Visit Reason
The inspection was conducted to evaluate compliance with regulatory requirements related to resident rights, abuse prevention, activities programming, food safety, staff licensure, and behavioral health care.
Findings
The facility was found deficient in multiple areas including failure to provide notices in accessible formats, failure to prevent resident-to-resident abuse, inadequate assistance with activities of daily living for a resident with communication needs, insufficient and inconsistent activity programming, lack of qualified activities director, improper identification by contract phlebotomist, failure to develop a comprehensive behavioral care plan for a resident, food safety violations including improper food temperatures and sanitation, and employment of a staff member without proper licensure.
Deficiencies (9)
Facility failed to ensure residents received notices orally and in writing in a readable font size and accessible location.
Facility failed to protect Resident #25 from abuse by Resident #203 resulting in a skin tear.
Facility failed to provide necessary assistance and effective communication for Resident #254 with language barrier.
Facility failed to provide meaningful and consistent activity programming for residents, including lack of transportation and comprehensive assessments.
Facility failed to employ a qualified activities director to provide a program of activities.
Contract phlebotomist failed to correctly identify resident prior to blood draw, resulting in blood drawn from wrong resident.
Facility failed to develop and implement a comprehensive behavioral care plan for Resident #4 with depression and behavioral issues.
Facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional food safety standards including improper food temperatures, unsanitized thermometer use, and improper storage of therapy ice packs.
Facility employed a staff member as a licensed practical nurse without the required temporary license or full licensure from June 2020 to March 2021.
Report Facts
Residents reviewed: 55
Residents affected: 10
Temperature: 121.1
Temperature: 130
Temperature: 52
Mental status score: 11
Mental status score: 13
Mental status score: 14
Mental status score: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #7 | Certified Nurse Aide / Licensed Practical Nurse (unlicensed) | Worked as LPN without proper licensure from June 2020 to March 2021 |
| CNA #13 | Certified Nurse Aide | Reported resident-to-resident abuse incident involving Resident #25 and Resident #203 |
| Activity Director | Activity Director | Not certified or trained as qualified activities professional; responsible for deficient activity program |
| Interim Director of Nursing | Interim Director of Nursing | Interviewed regarding abuse investigation and language barrier issues |
| Licensed Practical Nurse #4 | Licensed Practical Nurse | Interviewed regarding communication with Resident #254 |
| Licensed Practical Nurse #6 | Licensed Practical Nurse | Notified about phlebotomist drawing blood from wrong resident |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety violations and staff jewelry policy |
| Certified Nurse Aide #12 | Certified Nurse Aide | Provided care to Resident #4 during behavioral health incidents |
| Regional Clinical Consultant #2 | Regional Clinical Consultant | Interviewed regarding unlicensed staff investigation |
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