5 Reports
Inspection Report — Jul 16, 2024
Routine
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
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in medication administration and infection control deficiencies |
| Director of Nursing | Director of Nursing | Interviewed regarding medication administration and pressure ulcer care |
| RN #1 | Registered Nurse | Provided wound care and interviewed regarding infection control and mechanical lift incident |
| RN #3 | Registered Nurse | Provided wound care and observed using unclean scissors |
| CNA #1 | Certified Nurse Aide | Involved in mechanical lift transfer incident |
| CNA #3 | Certified Nurse Aide | Involved in mechanical lift transfer incident |
| Nursing Home Administrator | Nursing Home Administrator | Provided facility policies and interviewed regarding incidents and corrective actions |
| Maintenance Supervisor | Maintenance Supervisor | Interviewed regarding mechanical lift inspection and incident |
| Infection Preventionist | Infection Preventionist | Interviewed regarding infection control deficiencies |
Inspection Report — Jul 16, 2024
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
| Name | Title | Context |
|---|---|---|
| LPN #3 | Licensed Practical Nurse | Named in failure to assess blood pressure and improper infection control during medication administration. |
| CNA #1 | Certified Nurse Aide | Involved in Resident #6's fall from mechanical lift and demonstrated proper lift use post-fall. |
| CNA #3 | Certified Nurse Aide | Involved in Resident #6's fall from mechanical lift and demonstrated proper lift use post-fall. |
| RN #1 | Registered Nurse | Observed wound care and corrected improper use of wound care scissors. |
| DON | Director of Nursing | Interviewed regarding failures in blood pressure monitoring, pressure ulcer care, and mechanical lift incident. |
| NHA | Nursing Home Administrator | Provided policies, investigation details, and corrective actions for multiple deficiencies. |
Inspection Report — Feb 14, 2023
Complaint Investigation
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
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide (CNA) #4 | Named as staff who left Resident #51 unattended on toilet | |
| Certified Nurse Aide (CNA) #1 | Named as staff who was to assist Resident #51 back from bathroom | |
| Social Services Director (SSD) | Interviewed regarding resident condition post-incident | |
| Primary Care Physician | Assessed 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 — Oct 21, 2021
Complaint Investigation
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
| Name | Title | Context |
|---|---|---|
| RN #4 | Registered Nurse | Documented fall investigations and hospital transfer for Resident #27 |
| LPN #1 | Licensed Practical Nurse | Documented fall investigation and health status notes for Resident #27 |
| DON | Director of Nursing | Documented plan of care notes and fall interventions for Resident #27 |
| CNA #1 | Certified Nurse Aide | Interviewed regarding Resident #27's falls and care |
| RN #1 | Registered Nurse | Interviewed regarding Resident #27's falls and care |
| RN #2 | Registered Nurse | Interviewed regarding Resident #27's falls and care |
| LPN #2 | Licensed Practical Nurse | Interviewed regarding Resident #42's fall prevention interventions |
Report
3 CMS Surveys
CMS Survey — Oct 21, 2021
Oct 21, 2021
CMS Survey — Feb 14, 2023
Feb 14, 2023
CMS Survey — Jul 16, 2024
Jul 16, 2024
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