Deficiencies (last 3 years)
Deficiencies (over 3 years)
7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
35% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Oct 23, 2024
Visit Reason
The inspection was conducted to evaluate the facility's antibiotic stewardship program and compliance with protocols for antibiotic use, specifically reviewing antibiotic administration and monitoring practices for residents.
Findings
The facility failed to implement an effective antibiotic stewardship program, resulting in inappropriate antibiotic use for two residents. The facility did not ensure clinical signs and symptoms of infection were identified or culture results obtained prior to antibiotic administration, leading to multiple antibiotic prescriptions and ineffective treatments.
Deficiencies (1)
Failure to implement a program that monitors antibiotic use.
Report Facts
Residents reviewed for antibiotic use: 33
Residents with antibiotic use issues: 2
Antibiotic doses: 875
Antibiotic doses: 500
Antibiotic doses: 800
Antibiotic doses: 160
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed practical nurse #1 | LPN | Interviewed regarding failure to follow McGeer Criteria for antibiotic use |
| Infection preventionist | IP | Interviewed about antibiotic stewardship program and criteria adherence |
| Director of Nursing | DON | Interviewed about antibiotic stewardship program and education plans |
| Registered nurse #1 | RN | Interviewed about procedures for UTI symptom assessment and antibiotic use |
| Physician | PH | Interviewed about antibiotic prescribing practices and adherence to McGeer criteria |
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Jul 31, 2024
Visit Reason
The inspection was conducted due to complaints regarding medication errors and inadequate supervision leading to accidents at the nursing facility.
Complaint Details
The complaint investigation found substantiated medication administration delays for Residents #2 and #3, and a fall incident involving Resident #1 during a hoyer lift transfer that caused a new large posterior scalp hematoma and left ankle trauma. The facility failed to conduct root cause analysis or provide adequate staff re-education after the fall.
Findings
The facility failed to ensure residents were free from significant medication errors, with two residents receiving medications late beyond the acceptable one-hour window. Additionally, the facility failed to prevent a fall during a mechanical lift transfer, resulting in actual harm to a resident. The facility did not conduct adequate root cause analysis or staff re-education following the fall.
Deficiencies (2)
Failed to ensure Residents #2 and #3 received medications as scheduled according to physician's orders, resulting in significant medication errors.
Failed to ensure one resident (#1) received adequate supervision and services to prevent an accident during transfer with a hoyer lift, resulting in a fall and new head injury.
Report Facts
Residents reviewed for medication errors: 15
Residents reviewed for accidents: 15
Medication administration delays for Resident #2: 10
Medication administration delays for Resident #3: 4
Hospitalization days for Resident #1: 3
Number of personal care skills on competency checklist: 53
Date of medication administration policy received: Jul 30, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding medication administration process and delays |
| Director of Nursing | DON | Interviewed regarding medication administration, fall incident, and staff training |
| Certified Nurse Aide #1 | CNA | Involved in Resident #1 fall during hoyer lift transfer |
| Certified Nurse Aide #2 | CNA | Involved in Resident #1 fall during hoyer lift transfer |
| Licensed Practical Nurse #2 | LPN | Responded to Resident #1 fall incident |
| Registered Nurse #1 | RN | Evaluated Resident #1 after fall incident |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 27, 2023
Visit Reason
The inspection was conducted as an annual survey of the nursing home facility to assess compliance with health and safety regulations.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 1
Date: Apr 13, 2023
Visit Reason
The inspection was conducted to evaluate the facility's infection prevention and control program, specifically regarding adherence to COVID-19 related PPE protocols while caring for Resident #136 who was positive for COVID-19.
Findings
The facility failed to ensure appropriate use of personal protective equipment (PPE) by staff and visitors when providing care to Resident #136 in isolation for COVID-19. Multiple staff and a hospice caseworker were observed not wearing N95 masks or eye protection, failing to sanitize hands before and after PPE use, and improper doffing and disposal of PPE, increasing risk of infection transmission.
Deficiencies (1)
Failure to provide and implement an infection prevention and control program ensuring appropriate PPE use for Resident #136 positive for COVID-19.
Report Facts
Residents Affected: Some
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Observed not wearing N95 mask or eye protection when entering Resident #136's room |
| CNA #4 | Certified Nurse Aide | Observed wearing N95 mask over surgical mask and improper sanitization after exiting Resident #136's room |
| Director of Nursing | Director of Nursing | Interviewed regarding PPE protocols and staff training |
| Infection Control Nurse | Infection Control Nurse | Interviewed regarding PPE protocols and staff training |
Inspection Report
Routine
Deficiencies: 8
Date: Apr 12, 2023
Visit Reason
The inspection was conducted to assess compliance with health and safety regulations, including environmental conditions, resident care, food service, infection control, emergency equipment, and facility safety.
Findings
The facility was found deficient in multiple areas including maintaining a sanitary and comfortable environment, ensuring safety of exit doors, accommodating resident food preferences, food safety and sanitation practices, infection control including PPE use, emergency equipment maintenance, backflow prevention in showers, and ventilation in resident bathrooms.
Deficiencies (8)
Facility failed to maintain a sanitary, orderly, and comfortable environment in 10 of 25 resident rooms with issues such as damaged walls, ceilings, floors, and missing repairs.
Facility failed to ensure exit doors to second and third floor balconies were locked from outside without allowing re-entry, posing accident hazards.
Facility failed to ensure residents received food that accommodated their preferences for three residents.
Facility failed to store, prepare, distribute, and serve food in a sanitary manner including improper labeling, unclean equipment, poor personal hygiene, improper food holding temperatures, and lack of staff training.
Facility failed to ensure appropriate PPE use while providing care for a resident positive for COVID-19, including improper mask use, lack of eye protection, and improper donning and doffing.
Facility failed to maintain emergency patient care equipment in safe operating condition and remove expired medical supplies from emergency response crash carts.
Facility failed to ensure backflow prevention devices were installed on hand held showers in 12 private shower rooms, increasing risk of contamination to water supply.
Facility failed to provide adequate outside ventilation by ensuring resident bathroom exhaust fans were functioning on four resident hallways.
Report Facts
Resident rooms with environmental deficiencies: 10
Resident sample size for food preference issues: 6
Residents affected by food preference deficiencies: 3
Number of patios with doorbell issues: 3
Number of expired items found on emergency carts: 12
Number of private shower rooms without backflow prevention valves: 12
Number of hallways with non-functioning bathroom exhaust fans: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified nurse assistant #9 | CNA | Interviewed regarding patio door safety and resident supervision |
| Certified nurse assistant #1 | CNA | Interviewed regarding patio door safety and resident supervision |
| Certified nurse assistant #2 | CNA | Interviewed regarding patio door safety and resident supervision |
| Registered nurse #4 | RN | Interviewed regarding patio door safety and resident supervision |
| Director of Nursing | DON | Interviewed multiple times regarding environmental concerns, food service, infection control, and emergency equipment |
| Housekeeping Supervisor | HKS | Interviewed regarding environmental concerns, patio door safety, backflow prevention, and ventilation |
| Dietary Manager #1 | DM | Interviewed regarding food service issues, sanitation, and staff training |
| Registered Dietitian | RD | Interviewed regarding food service and staff training |
| Dietary Aide #2 | DA | Observed and interviewed regarding sanitation practices |
| Certified nurse aide #4 | CNA | Observed and interviewed regarding PPE use with COVID positive resident |
| Registered nurse #1 | RN | Observed and interviewed regarding PPE use with COVID positive resident |
| Hospice Caseworker | HCW | Observed and interviewed regarding PPE use with COVID positive resident |
| Assistant Director of Nursing | ADON | Interviewed regarding emergency response cart maintenance |
Inspection Report
Routine
Census: 79
Deficiencies: 9
Date: Jan 25, 2022
Visit Reason
The inspection was conducted as a routine regulatory survey to assess compliance with healthcare facility regulations, including resident rights, care quality, infection control, and safety.
Findings
The facility was found deficient in multiple areas including failure to ensure resident rights to be informed and participate in care, failure to honor resident shower preferences, failure to provide physician orders for IV fluids, development of an avoidable pressure ulcer, inadequate pain management, serving food that was not palatable or at proper temperature, failure to accommodate resident allergies and diet textures, and failure to maintain an effective infection control program including improper PPE use and inadequate COVID-19 testing procedures.
Deficiencies (9)
Failed to ensure resident's right to be informed and participate in treatment decisions, including failure to include resident's wife in care planning.
Failed to honor residents' shower preferences and provide showers as scheduled.
Failed to have a physician's order for intravenous fluid that infused continuously for four days.
Failed to provide appropriate pressure ulcer care resulting in an avoidable unstageable pressure ulcer to resident's left heel.
Failed to manage pain consistent with professional standards, care plan, and resident preferences, resulting in resident experiencing pain greater than acceptable levels.
Failed to ensure food was palatable and served at proper temperature.
Failed to ensure meals were served according to resident allergies and diet texture preferences.
Failed to maintain an infection control program including improper PPE use by staff and visitors, failure to offer resident hand hygiene before meals, and inadequate COVID-19 testing area disinfection.
Failed to perform COVID-19 testing in accordance with infection control guidelines including disinfecting surfaces within six feet of specimen collection area after each test and hourly disinfecting of testing area.
Report Facts
Residents affected: 4
Residents affected: 2
Residents affected: 2
Residents affected: 4
Residents affected: 2
Residents affected: 5
Residents affected: 79
Staff positive for COVID-19: 19
Residents positive for COVID-19: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Named in findings related to improper mask use and IV fluid order entry | |
| RN #1 | Named in findings related to IV fluid order entry and COVID-19 testing procedures | |
| LPN #3 | Named in wound care documentation and pressure ulcer findings | |
| RN #2 | Named in COVID-19 testing procedures and infection control findings | |
| DON | Director of Nursing | Named in multiple interviews and findings related to care planning, shower preferences, IV fluids, pressure ulcer care, pain management, infection control |
| IP | Infection Preventionist | Named in infection control and COVID-19 testing findings |
| EC | Executive Chef | Named in food service and diet findings |
| CNA #9 | Named in pain management findings | |
| LPN #2 | Named in pain management findings | |
| RN #4 | Named in pain management findings | |
| NHA | Nursing Home Administrator | Named in infection control and COVID-19 outbreak status |
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