Inspection Reports for
North Shore Health &Amp; Rehab Facility
1365 W 29TH ST, LOVELAND, CO, 80538-2561
Back to Facility ProfileDeficiencies (last 4 years)
Deficiencies (over 4 years)
6.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
21% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 8
Date: May 16, 2024
Visit Reason
The inspection was conducted to assess compliance with healthcare regulations including pressure ulcer care, pain management, medication use, food service, infection control, and sanitation practices at North Shore Health & Rehab Facility.
Findings
The facility was found deficient in multiple areas including failure to properly assess and treat pressure ulcers, inadequate pain management for residents, failure to monitor psychotropic medication effects and behaviors, improper preparation of mechanically altered diets, inadequate dishwashing sanitization, poor hand hygiene by dietary staff, and lapses in infection control during vaccination administration and equipment cleaning.
Deficiencies (8)
Failure to assess, accurately document, and provide treatment for pressure ulcers for Resident #32, including failure to identify reopened coccyx wound and obtain appropriate physician orders.
Failure to provide safe, appropriate pain management for Residents #32 and #1, including inadequate pain control during incontinence care, failure to administer PRN pain medication, and lack of documentation of pain levels and non-pharmacological interventions.
Failure to ensure Resident #1 was free from unnecessary psychotropic medications, including lack of monitoring for side effects, behaviors, and use of non-pharmacological interventions.
Failure to ensure residents prescribed level six soft and bite-sized mechanically altered diets received food prepared according to diet orders; residents were served regular wheat rolls and peas instead of puree bread and cooked carrots.
Failure to ensure proper sanitation of dishes in the high temperature dishwashing machine, which did not reach required rinse temperature of 180°F and lacked proper monitoring with irreversible registering temperature indicator strips; chemical sanitizer concentration was below required levels.
Failure of dietary staff to perform proper hand hygiene while plating and serving resident meals, including touching face masks, hair, and other unclean surfaces without handwashing.
Failure to follow proper infection control procedures during vaccination administration by contract pharmacist, including improper glove use and lack of hand hygiene before and after glove use.
Failure to follow infection control processes for cleaning and disinfecting mechanical lifts and vital signs equipment on the Parkview unit, including failure to disinfect equipment after use and lack of cleaning wipes with equipment.
Report Facts
Deficiency count: 8
Scheduled doses received: 13
Scheduled acetaminophen doses received: 52
Dish machine rinse temperature: 170
Dish machine rinse temperature: 172
Dish machine rinse temperature: 166
Chemical sanitizer concentration: 10
Resident #1 BIMS score: 3
Resident #32 BIMS score: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in pain management deficiency for Resident #32 |
| NP #1 | Nurse Practitioner | Interviewed regarding pain management and wound care for Resident #32 |
| DON | Director of Nursing | Interviewed regarding wound care, pain management, medication monitoring, and infection control |
| LPN #1 | Licensed Practical Nurse | Interviewed regarding pain management and psychotropic medication monitoring for Resident #1 |
| CNA #1 | Certified Nurse Aide | Observed failing to disinfect mechanical lift after use |
| CK #1 | Cook | Observed failing to perform proper hand hygiene during meal service |
| DM | Dietary Manager | Interviewed regarding diet preparation and dish machine issues |
| IP | Infection Preventionist | Interviewed regarding infection control lapses during vaccination and equipment cleaning |
Inspection Report
Routine
Deficiencies: 4
Date: Jun 26, 2023
Visit Reason
The inspection was conducted to evaluate compliance with residents' rights, dignity, self-determination, activities of daily living, and the cleanliness and safety of the nursing home environment.
Findings
The facility failed to ensure timely response to call lights for several residents, honor resident preferences for wake up times, provide consistent bathing according to care plans, and maintain a clean and comfortable environment in resident rooms. Multiple residents reported long wait times for call light responses and inconsistent bathing schedules. Several rooms were observed with trash, dirty linens, and debris on the floor.
Deficiencies (4)
Failed to ensure residents had the right to a dignified existence by timely answering call lights for four residents.
Failed to identify and honor resident preferences regarding wake up times for three residents.
Failed to provide consistent baths according to care plans for four residents.
Failed to maintain a sanitary and comfortable environment in five resident rooms, with trash, dirty clothes/linens, and debris on the floor.
Report Facts
Residents affected: 4
Residents affected: 4
Residents affected: 3
Rooms observed: 15
Bath frequency: 1
Bath refusal: 1
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nurse Aide #1 | CNA | Interviewed regarding call light response and proper call light handling |
| Certified Nurse Aide #2 | CNA | Interviewed regarding resident wake up time preferences and bathing schedules |
| Certified Nurse Aide #3 | CNA | Interviewed regarding call light response, resident preferences documentation, and bathing schedules |
| Certified Nurse Aide #4 | CNA | Interviewed regarding resident preferences documentation and responsibility for cleaning |
| Nursing Home Administrator | NHA | Interviewed regarding call light policies, resident preferences, bathing schedules, and facility cleanliness |
| Director of Nursing | DON | Interviewed regarding bathing schedules and facility staffing |
| Housekeeping Supervisor | HSKS | Interviewed regarding cleaning schedules and staff responsibilities for cleanliness |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Mar 10, 2020
Visit Reason
The inspection was conducted based on complaint investigations related to multiple issues including failure to credit interest on residents' personal funds, failure to notify residents approaching Medicaid eligibility limits, failure to protect residents from abuse, failure to provide individualized activity plans, failure to properly label and store medications, and failure to implement an effective infection prevention and control program.
Complaint Details
The complaint investigation revealed multiple issues including financial mismanagement of resident funds, failure to notify residents about Medicaid eligibility limits, abuse incidents between residents, inadequate activity programming, medication storage and labeling violations, and infection control failures during outbreaks of RSV and influenza.
Findings
The facility failed to ensure Medicaid funded residents received interest on personal funds, notify residents nearing Medicaid eligibility limits, protect residents from abuse, provide individualized activity programs, properly label and store medications, and implement effective infection control measures including isolation precautions and prevention of infection spread during outbreaks.
Deficiencies (6)
Failed to allocate interest accrued to Medicaid funded residents with accounts over $50.00 and under $100.00.
Failed to notify Medicaid funded residents when account balances were within $200 of eligibility resource limit.
Failed to provide sufficient interventions to protect a resident from physical abuse by another resident.
Failed to develop and implement an individualized plan of activities based on resident interests.
Failed to date medications when opened, discard expired medications, and ensure medications were stored at appropriate temperatures.
Failed to implement a comprehensive infection prevention and control program including surveillance, isolation precautions, and prevention of cross contamination during dining services.
Report Facts
Residents reviewed: 54
Residents affected: 5
Residents affected: 2
Residents affected: 1
Residents affected: 1
Staff trained: 68
Staff trained: 102
Residents infected: 14
Staff infected: 8
Residents infected: 7
Staff infected: 14
Residents infected: 10
Staff infected: 10
Inspection Report
Complaint Investigation
Deficiencies: 7
Date: Mar 5, 2019
Visit Reason
The inspection was conducted based on complaints and allegations regarding failure to accommodate resident needs, failure to promote resident self-determination, failure to timely report abuse, failure to provide timely assistance with toileting, failure to maintain sanitary food service practices, and failure to maintain an infection control program.
Complaint Details
The complaint investigation included substantiated findings of failure to accommodate resident needs, failure to promote resident self-determination, failure to report abuse, failure to provide timely assistance, and infection control deficiencies.
Findings
The facility was found deficient in multiple areas including failure to provide dignified toileting assistance for Resident #70, failure to ensure Resident #42 received preferred bathing frequency, failure to report verbal abuse allegations for Resident #47, failure to provide timely toileting assistance for Resident #24, failure to provide adequate meal assistance for Resident #258, failure to follow proper food service sanitation and temperature monitoring practices, and failure to maintain an effective infection control program including lack of a water management program for Legionella prevention.
Deficiencies (7)
Failure to promote toileting in a dignified manner for Resident #70, including not accommodating bathroom size needs, not following occupational therapist recommendations, and inadequate follow-up after incontinence episodes.
Failure to ensure Resident #42 received a minimum of two baths per week according to resident preference.
Failure to timely report allegations of verbal abuse for Resident #47 to the State survey and certification agency.
Failure to provide timely toileting assistance for Resident #24, with documented long call light response times.
Failure to provide meal assistance according to plan of care for Resident #258, resulting in inadequate nutrition intake.
Failure to follow proper food service sanitation practices including improper glove use, failure to sanitize probe thermometers between uses, failure to monitor refrigerator temperatures, and failure to properly reheat food to required temperatures.
Failure to maintain an infection control program including improper disinfectant contact times during room cleaning, failure to clean from clean to dirty surfaces, and lack of a water management program to prevent Legionella transmission.
Report Facts
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 1
Call light response times over 20 minutes: 25
Call light response times over 20 minutes: 8
Temperature log missing days: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #3 | Charge Nurse | Interviewed regarding Resident #70 toileting and care plan adherence |
| CNA #3 | Certified Nurse Aide | Interviewed regarding Resident #70 toileting assistance and call light response |
| Restorative Nurse Supervisor | Interviewed regarding Resident #70 voiding diary and toileting program | |
| Therapy Director | Interviewed regarding Resident #70 therapy and toileting recommendations | |
| Director of Nursing | DON | Interviewed regarding toileting dignity and resident care expectations |
| Social Services Director | SSD | Interviewed regarding Resident #47 verbal abuse investigation |
| Nursing Home Administrator | NHA | Interviewed regarding Resident #47 verbal abuse reporting and facility policies |
| Certified Nurse Aide #5 | CNA | Interviewed regarding Resident #24 toileting assistance and safety checks |
| Certified Nurse Aide #6 | CNA | Interviewed regarding Resident #24 assistance and independence |
| Registered Nurse #1 | RN | Interviewed regarding Resident #24 call light response and toileting |
| Physical Therapy Assistant #1 | PTA | Interviewed regarding Resident #24 therapy progress and call light use |
| Certified Nurse Aide #2 | CNA | Interviewed regarding Resident #258 meal assistance |
| Registered Dietitian | RD | Interviewed regarding Resident #258 nutrition and food intake |
| Dietary Manager | DM | Interviewed regarding food service glove use, reheating, and thermometer sanitization |
| Dietary Aide #3 | DA | Observed and interviewed regarding glove use and food handling |
| Dietary Aide #4 | DA | Observed and interviewed regarding glove use, food reheating, and thermometer use |
| Housekeeping Supervisor | HKS | Interviewed regarding housekeeping training and cleaning procedures |
| Housekeeper #1 | HK | Observed and interviewed regarding room cleaning and disinfectant use |
| Housekeeper #2 | HK | Observed cleaning resident rooms |
| Staff Development Coordinator | SDC | Interviewed regarding infection control program and housekeeping policies |
| Maintenance Director | MSD | Interviewed regarding water management program and legionella prevention |
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