Deficiencies (last 3 years)
Deficiencies (over 3 years)
8.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
67% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 7, 2024
Visit Reason
The investigation was conducted due to complaints regarding the facility's failure to ensure adequate supervision and fall prevention interventions for residents at risk of falls.
Complaint Details
The complaint investigation focused on three residents (#89, #59, and #67) who sustained falls resulting in major injuries due to inadequate supervision and failure to implement person-centered fall interventions. The facility also failed to complete accurate fall risk assessments and root cause analyses.
Findings
The facility failed to implement accurate fall risk assessments and person-centered fall interventions for multiple residents, resulting in several falls with major injuries. The facility also failed to update care plans and conduct root cause analyses adequately.
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
Residents in sample: 41
Fall risk scores: 16
Fall risk scores: 18
Fall risk scores: 13
Fall risk scores: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| DON | Director of Nursing | Interviewed regarding fall risk assessments, care plans, and root cause analyses; discussed facility failures in fall prevention |
| CNA #6 | Certified Nurse Aide | Interviewed about Resident #59's fall prevention and call light use |
| LPN #4 | Licensed Practical Nurse | Interviewed about Resident #59's fall interventions and care plan |
Inspection Report
Routine
Deficiencies: 13
Date: Nov 7, 2024
Visit Reason
Routine state inspection survey of Life Care Center of Littleton to assess compliance with healthcare regulations and standards.
Findings
The facility had multiple deficiencies including failure to honor resident therapy preferences, inadequate incorporation of PASRR recommendations, incomplete restorative care plans, insufficient fall prevention interventions, lack of physician orders for catheter care, improper tube feeding administration, unsafe use of bed rails, failure to monitor psychotropic medication side effects, improper medication labeling and storage, unsanitary food handling and storage, incomplete hospice documentation, and lapses in infection control practices.
Deficiencies (13)
F 0561: The facility failed to honor Resident #201's right to self-determination by not scheduling rehabilitation therapy per her preference.
F 0644: The facility failed to incorporate PASRR Level II recommendations for Resident #39, specifically lack of psychiatric follow-up for medication management.
F 0688: The facility failed to include Resident #66's left hand brace in the restorative program and care plan, lacking physician orders and usage instructions.
F 0689: The facility failed to provide adequate supervision and fall prevention interventions for Residents #89, #59, and #67, resulting in multiple falls with major injuries.
F 0690: The facility failed to obtain physician orders and proper documentation for catheter care and maintenance for Resident #205 with an indwelling catheter.
F 0693: The facility failed to ensure Resident #21 received tube feeding as ordered and failed to label tube feeding containers properly.
F 0700: The facility failed to use a person-centered approach for Resident #59's grab bar/bed rail, lacking risk assessment, consent, alternatives, and routine maintenance.
F 0758: The facility failed to obtain consent prior to administering Risperdal to Resident #66, failed to monitor behavior tracking for Risperdal use, and failed to monitor Resident #56 for antipsychotic medication side effects.
F 0761: The facility failed to label medications to facilitate safe administration and failed to ensure medications were labeled and dated appropriately in two medication carts.
F 0812: The facility failed to ensure food was prepared, distributed, and served under sanitary conditions and failed to ensure safe and appropriate storage of food items in nourishment room refrigerators.
F 0813: The facility failed to implement policy regarding safe storage and handling of foods brought by family and visitors in Resident #51 and Resident #42's personal refrigerators.
F 0880: The facility failed to disinfect high-touch areas when cleaning residents' rooms and failed to follow appropriate infection control practices during catheter care.
F 0881: The facility failed to implement an antibiotic stewardship program that included protocols and monitoring of antibiotic use for Resident #69, including lack of justification for long-term antibiotic use.
Report Facts
Sample residents reviewed: 41
Residents affected: 1
Residents affected: 5
Residents affected: 1
Residents affected: 1
Residents affected: 3
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 2
Medication carts observed: 6
Residents affected: 2
Residents affected: 1
Residents affected: 1
Residents affected: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Involved in medication labeling and administration observations |
| CNA #7 | Certified Nurse Aide | Provided catheter care and interviewed regarding hospice and behavior monitoring |
| LPN #4 | Licensed Practical Nurse | Interviewed regarding psychotropic medication monitoring and catheter care |
| CNA #5 | Certified Nurse Aide | Observed providing catheter care with infection control lapses |
| HSKP #1 | Housekeeper | Observed cleaning rooms without disinfecting high-touch areas |
| HSKS | Housekeeping Supervisor | Interviewed about cleaning protocols and staff training |
| RN #1 | Registered Nurse | Interviewed about tube feeding administration and hydration |
| RN #2 | Registered Nurse | Interviewed about catheter care orders |
| LPN #3 | Licensed Practical Nurse, Unit Manager | Interviewed about catheter care orders and device management |
| DM | Dietary Manager | Interviewed about food storage and refrigerator monitoring |
| RDC | Regional Dietary Consultant | Interviewed about food handling and staff training |
| SSD | Social Services Director | Interviewed about hospice care coordination and psychotropic medication consent |
| DON | Director of Nursing | Interviewed about multiple deficiencies including medication monitoring, fall prevention, hospice care, and infection control |
| IP | Infection Preventionist | Interviewed about antibiotic stewardship and infection control |
| RNC | Regional Nurse Consultant | Interviewed about antibiotic use and urologist recommendations |
Inspection Report
Routine
Deficiencies: 5
Date: May 18, 2023
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, medication administration, food service, and infection control at the Life Care Center of Littleton.
Findings
The facility was found deficient in multiple areas including incomplete neurological assessments post-fall, a high medication error rate with delayed antibiotic administration, poor food quality and unsafe food temperatures, and inadequate infection control practices including improper cleaning techniques and chemical mixing.
Deficiencies (5)
F0684: The facility failed to ensure neurological assessments accurately reflected resident status post-fall for Resident #248, with incomplete documentation on multiple occasions.
F0759: The facility failed to maintain a medication error rate below 5%, with a 40% error rate observed during medication administration.
F0760: The facility failed to ensure timely administration of antibiotics for Residents #251 and #252, with delays of over four to five hours.
F0804: The facility failed to provide food that was palatable, attractive, and served at safe temperatures, with multiple resident complaints and observed cold food items above safe temperature limits.
F0880: The facility failed to maintain an effective infection control program by not following proper cleaning techniques, not disinfecting high-touch areas, not adhering to surface disinfectant contact times, and mixing incompatible chemicals.
Report Facts
Medication administration error rate: 40
Medication administration delay: 5
Medication administration delay: 4
Food temperature: 48
Food temperature: 52
Food temperature: 47
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in medication administration delay and error findings. |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding neurological assessment procedures. |
| DON | Director of Nursing | Interviewed regarding neurological assessments, medication administration, and infection control. |
| PC | Pharmacy Consultant | Interviewed regarding importance of timely antibiotic administration. |
| HSKP #1 | Housekeeper | Observed and interviewed regarding cleaning practices and disinfectant use. |
| HSKP #3 | Housekeeper | Observed and interviewed regarding cleaning practices and disinfectant use. |
| DOH | Director of Housekeeping | Interviewed regarding housekeeping training and chemical mixing. |
| NSD | Nutrition Service Director | Interviewed regarding food service and temperature control. |
Inspection Report
Routine
Deficiencies: 7
Date: Mar 24, 2022
Visit Reason
Routine state inspection of Life Care Center of Littleton to assess compliance with healthcare regulations including medication education, environment, staff competencies, psychotropic medication use, hospice services, pest control, and staff training.
Findings
The facility failed to ensure residents were fully informed about medications with black box warnings, maintain a sanitary environment, ensure nursing staff competencies, properly manage psychotropic medications, coordinate hospice services, maintain an effective pest control program, and provide required staff training on dementia care and abuse prevention.
Deficiencies (7)
F 0552: The facility failed to fully inform Resident #344 about the risks, benefits, and side effects of five black box warning medications administered as part of his regimen.
F 0584: The facility failed to store and label residents' personal items separately and ensure towels in double occupancy rooms were separated to prevent cross-contamination.
F 0726: The facility failed to ensure nursing staff completed competencies prior to providing skilled services as ordered for three nurses reviewed.
F 0758: The facility failed to re-evaluate PRN psychotropic medication use within 14 days, obtain signed consents, provide education, and monitor behaviors effectively for multiple residents.
F 0849: The facility failed to orient hospice staff to facility policies and procedures and did not have a system to ensure hospice visit notes were integrated into residents' medical charts.
F 0925: The facility failed to maintain an effective pest control program, resulting in an ongoing ant infestation in seven resident rooms and one hallway.
F 0943: The facility failed to ensure 13 certified nurse aides, including 10 agency CNAs, received current dementia care and abuse prevention training.
Report Facts
Residents reviewed: 38
Residents affected: 5
Residents affected: 3
Residents affected: 6
Rooms with ant infestation: 7
CNAs without dementia training: 3
Agency CNAs without abuse prevention training: 10
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