Inspection Reports for
Life Care Center of Greeley

CO, 80634

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Deficiencies (last 3 years)

Deficiencies (over 3 years) 5.3 deficiencies/year

Deficiencies are regulatory violations found during state inspections.

2% worse than Colorado average
Colorado average: 5.2 deficiencies/year

Deficiencies per year

8 6 4 2 0
2021
2023
2024

Inspection Report

Routine
Deficiencies: 4 Date: Jul 16, 2024

Visit Reason
The inspection was conducted to assess compliance with professional standards of care related to medication administration, pressure ulcer prevention and care, accident prevention, and infection control at Life Care Center of Greeley.

Findings
The facility was found deficient in multiple areas including failure to consistently assess and document blood pressure prior to medication administration, failure to prevent development and timely treatment of a Stage 3 pressure ulcer, failure to prevent a resident fall from a mechanical lift resulting in injury, and failure to follow proper infection control procedures during medication administration and wound care.

Deficiencies (4)
Failed to assess and document Resident #44's blood pressure consistently prior to administering blood pressure medications.
Failed to provide care consistent with professional standards to prevent pressure ulcers, resulting in Resident #67 developing a Stage 3 pressure injury due to delayed interventions and wound care orders.
Failed to prevent Resident #6's fall from a mechanical lift during transfer, resulting in head trauma and fractured right clavicle.
Failed to follow proper infection control during medication administration and wound care, including improper hand hygiene by LPN #3 and failure to sanitize scissors used for Resident #21's wound care.
Report Facts
Residents reviewed for blood pressure management: 3 Residents reviewed for pressure-related skin conditions: 3 Residents reviewed for accidents: 9 Stage 3 pressure injury wound dimensions: 1.2 Stage 3 pressure injury wound dimensions: 0.5 Stage 3 pressure injury wound dimensions: 0.2 Slough tissue in wound: 70

Employees mentioned
NameTitleContext
LPN #3Licensed Practical NurseNamed in medication administration and infection control deficiencies
Director of NursingDirector of NursingInterviewed regarding medication administration and pressure ulcer care
RN #1Registered NurseProvided wound care and interviewed regarding infection control and mechanical lift incident
RN #3Registered NurseProvided wound care and observed using unclean scissors
CNA #1Certified Nurse AideInvolved in mechanical lift transfer incident
CNA #3Certified Nurse AideInvolved in mechanical lift transfer incident
Nursing Home AdministratorNursing Home AdministratorProvided facility policies and interviewed regarding incidents and corrective actions
Maintenance SupervisorMaintenance SupervisorInterviewed regarding mechanical lift inspection and incident
Infection PreventionistInfection PreventionistInterviewed regarding infection control deficiencies

Inspection Report

Deficiencies: 4 Date: Jul 16, 2024

Visit Reason
The inspection was conducted to investigate compliance with professional standards of care, infection prevention, accident prevention, and pressure ulcer care in a nursing home setting.

Findings
The facility failed to consistently assess and document blood pressure prior to medication administration, delayed wound care interventions leading to a Stage 3 pressure ulcer, failed to prevent a resident fall from a mechanical lift resulting in injury, and did not follow proper infection control procedures during medication administration and wound care.

Deficiencies (4)
F0684: The facility failed to assess and document Resident #44's blood pressure consistently prior to administering blood pressure medications, contrary to physician orders.
F0686: The facility failed to provide timely and consistent pressure ulcer care for Resident #67, resulting in a Stage 3 pressure injury due to delayed wound care orders and inadequate repositioning.
F0689: The facility failed to prevent Resident #6's fall from a mechanical lift during transfer, resulting in head trauma and a fractured clavicle, with no procedural failure identified during investigation.
F0880: The facility failed to maintain an infection prevention program by not ensuring proper hand hygiene during medication administration and failing to sanitize wound care scissors before and after use.
Report Facts
Residents reviewed for blood pressure management: 3 Residents reviewed for pressure-related skin conditions: 3 Residents reviewed for accidents: 9 Deficiency counts: 4 Wound dimensions: 1.2 Wound dimensions: 0.5 Wound dimensions: 0.2

Employees mentioned
NameTitleContext
LPN #3Licensed Practical NurseNamed in failure to assess blood pressure and improper infection control during medication administration.
CNA #1Certified Nurse AideInvolved in Resident #6's fall from mechanical lift and demonstrated proper lift use post-fall.
CNA #3Certified Nurse AideInvolved in Resident #6's fall from mechanical lift and demonstrated proper lift use post-fall.
RN #1Registered NurseObserved wound care and corrected improper use of wound care scissors.
DONDirector of NursingInterviewed regarding failures in blood pressure monitoring, pressure ulcer care, and mechanical lift incident.
NHANursing Home AdministratorProvided policies, investigation details, and corrective actions for multiple deficiencies.

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Feb 14, 2023

Visit Reason
The inspection was conducted due to a complaint investigation regarding neglect of Resident #51, who was left unattended on the toilet commode for approximately 70 minutes on 1/12/23.

Complaint Details
The complaint investigation found that Resident #51 was left unattended on the toilet for approximately 70 minutes on 1/12/23. The facility suspended two CNAs involved, conducted audits, and provided staff education. The neglect allegation was not substantiated as the investigation failed to prove intent of neglect.
Findings
The facility failed to ensure Resident #51 was not left unattended on the toilet for 70 minutes, constituting neglect. The facility conducted an investigation, suspended involved staff, audited other residents, and implemented corrective actions including staff education and new care plans. The neglect allegation was not substantiated as intent was not proven.

Deficiencies (1)
Facility failed to ensure Resident #51 was not left unattended on the toilet commode for 70 minutes on 1/12/23.
Report Facts
Residents affected: 5 Duration unattended: 70 Dates of staff education: Staff education and training began on 1/12/23 and was completed on 1/15/23.

Employees mentioned
NameTitleContext
Certified Nurse Aide #1CNAInvolved in miscommunication leading to Resident #51 being left unattended.
Certified Nurse Aide #4CNALeft Resident #51 unattended on the toilet due to miscommunication.
Social Services DirectorSSDSpoke with Resident #51 after the incident and stated resident was not in distress.
Nursing Home AdministratorNHAProvided facility policy and stated neglect allegations were not substantiated.
Director of NursingDONStated it was not appropriate for Resident #51 to be left unattended and described corrective actions.
Physical TherapistPTInterviewed regarding Resident #51's status and risk of falls.
Director of RehabilitationDORInterviewed regarding Resident #51's transfer and toileting abilities.

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Feb 14, 2023

Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged neglect of Resident #51 who was left unattended on the toilet commode for approximately 70 minutes on 1/12/23.

Complaint Details
The complaint investigation was triggered by an incident where Resident #51 was left unattended on the toilet for approximately 70 minutes. The facility's investigation did not substantiate neglect as intent was not proven. The resident showed no physical injury and was assessed as emotionally distressed at the time. Staff involved were suspended and corrective actions were implemented.
Findings
The facility failed to ensure Resident #51 was not left unattended on the toilet for 70 minutes. The investigation found no physical injury or substantiated neglect, but identified miscommunication between staff and inconsistent use of call light by the resident. The facility implemented corrective actions including staff suspension, education, audits, and a plan of correction to prevent recurrence.

Deficiencies (1)
F 0600: Protect each resident from all types of abuse including neglect. The facility failed to ensure Resident #51 was not left unattended on the toilet for 70 minutes on 1/12/23, resulting in potential for harm.
Report Facts
Residents in sample: 29 Residents affected: 5 Duration unattended: 70 Date of incident: Jan 12, 2023 Date survey completed: Feb 14, 2023

Employees mentioned
NameTitleContext
Certified Nurse Aide (CNA) #4Named as staff who left Resident #51 unattended on toilet
Certified Nurse Aide (CNA) #1Named as staff who was to assist Resident #51 back from bathroom
Social Services Director (SSD)Interviewed regarding resident condition post-incident
Primary Care PhysicianAssessed Resident #51 after incident
Physical Therapist (PT)Interviewed about resident's transfer and toileting abilities
Director of Rehabilitation (DOR)Interviewed about resident's abilities and incident
Nursing Home Administrator (NHA)Interviewed about incident and corrective actions
Director of Nursing (DON)Interviewed about incident and facility response

Inspection Report

Complaint Investigation
Deficiencies: 5 Date: Oct 21, 2021

Visit Reason
The inspection was conducted due to complaints regarding multiple unwitnessed falls and inadequate fall prevention interventions for residents at Life Care Center of Greeley.

Complaint Details
The complaint investigation focused on multiple unwitnessed falls involving Resident #27 and other residents, with concerns about inadequate supervision, failure to implement fall prevention interventions, and delayed medical follow-up. The investigation confirmed actual harm with several falls resulting in injuries and fractures.
Findings
The investigation found that Resident #27 experienced multiple falls with injuries, including fractures, and the facility failed to implement effective fall prevention interventions and timely therapy evaluations. Resident #42 also had multiple falls with insufficient staff education on frequent checks. Resident #39 had a history of falls and was at high risk, with documented falls during the survey period. Overall, the facility did not consistently follow care plans or document interventions adequately to prevent falls.

Deficiencies (5)
Failure to update care plans with effective interventions after resident falls, including lack of frequent checks and toileting plans for Resident #27.
Delayed therapy evaluation after falls and failure to follow up with orthopedic specialist timely for Resident #27.
Inadequate staff education and documentation regarding frequency of checks for high fall risk Resident #42.
Failure to implement appropriate fall prevention interventions for Resident #42 who was on psychotropic medications and had severe cognitive impairment.
Resident #39 had multiple falls despite documented fall risk and interventions; some falls occurred without call light in reach or proper footwear.
Report Facts
Fall risk scores: 20 Fall risk scores: 18 Fall risk scores: 22 Fall risk scores: 24 Fall risk scores: 22 Fall risk scores: 14 Fall risk scores: 22 Fall risk scores: 30 Fall risk scores: 20 Fall risk scores: 22 Fall risk scores: 20

Employees mentioned
NameTitleContext
RN #4Registered NurseDocumented fall investigations and hospital transfer for Resident #27
LPN #1Licensed Practical NurseDocumented fall investigation and health status notes for Resident #27
DONDirector of NursingDocumented plan of care notes and fall interventions for Resident #27
CNA #1Certified Nurse AideInterviewed regarding Resident #27's falls and care
RN #1Registered NurseInterviewed regarding Resident #27's falls and care
RN #2Registered NurseInterviewed regarding Resident #27's falls and care
LPN #2Licensed Practical NurseInterviewed regarding Resident #42's fall prevention interventions

Inspection Report

Complaint Investigation
Deficiencies: 1 Date: Oct 21, 2021

Visit Reason
The inspection was conducted to investigate complaints related to resident safety, fall prevention, and care interventions at Life Care Center of Greeley.

Complaint Details
The investigation focused on complaints regarding multiple falls of Resident #27 and Resident #42, including failure to implement fall prevention interventions, inadequate supervision, and lack of documentation of frequent checks. The complaints were substantiated with findings of actual harm.
Findings
The facility failed to implement appropriate fall prevention interventions for residents with cognitive impairments and high fall risk, resulting in multiple unwitnessed falls with injuries. Care plans were not consistently updated to reflect actual falls or effective interventions, and frequent checks were not documented or adequately performed.

Deficiencies (1)
F 0689: The facility failed to ensure a nursing home area was free from accident hazards and did not provide adequate supervision to prevent accidents, resulting in actual harm to residents.
Report Facts
Fall risk scores: 20 Fall risk scores: 18 Fall risk scores: 22 Fall risk scores: 24 Fall risk scores: 22 Fall risk scores: 14 Fall risk scores: 22 Fall risk scores: 30 Fall risk scores: 20 Fall risk scores: 22 Fall risk scores: 20

Employees mentioned
NameTitleContext
LPN #1Licensed Practical NurseDocumented fall investigation and health status notes for Resident #27
RN #4Registered NurseDocumented fall investigations, hospital transfer, and health status notes for Resident #27
CNA #1Certified Nurse AideInterviewed regarding Resident #27's care and fall prevention interventions
DONDirector of NursingDocumented plan of care notes and fall huddle notes for Resident #27
LPN #2Licensed Practical NurseInterviewed regarding Resident #42's fall prevention interventions

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