Inspection Reports for
The Center at Northridge, LLC
12285 PECOS ST, WESTMINSTER, CO, 80234-3439
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Apr 2, 2024
Visit Reason
The inspection was conducted to investigate complaints regarding the facility's failure to develop and implement an effective discharge planning process focusing on residents' discharge goals, and to ensure safety and supervision to prevent accidents.
Complaint Details
The complaint investigation focused on discharge planning failures for Residents #76, #47, and #64, and safety failures related to falls for Resident #66. The findings were substantiated with interviews, record reviews, and staff statements.
Findings
The facility failed to involve residents and their representatives adequately in discharge planning for three residents reviewed, and discharge care plans lacked appropriate goals and approaches. Additionally, the facility failed to ensure safety and supervision to prevent falls for one resident during therapy.
Deficiencies (2)
F 0660: The facility failed to involve residents and their representatives in discharge planning and did not develop discharge care plans with appropriate goals for three residents reviewed.
F 0689: The facility failed to ensure Resident #66 was safe while ambulating with therapy, resulting in two falls including one with head injury.
Report Facts
Sample residents reviewed: 38
Residents reviewed for discharge planning: 5
Residents affected by discharge planning deficiency: 3
Residents reviewed for falls: 3
Residents affected by falls deficiency: 1
BIMS scores: 11
BIMS score: 14
Discharge plan duration: 90
Date of falls: Mar 26, 2024
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CM #1 | Case Manager | Involved in discharge planning and communication with Residents #76 and #47 |
| SSA #1 | Social Services Assistant | Responsible for discharge planning coordination and care plan reviews |
| SSA #2 | Social Services Assistant | Responsible for discharge planning coordination and care plan reviews |
| SSA #3 | Social Services Assistant | Interviewed regarding discharge planning for Resident #64 |
| PTA #1 | Physical Therapy Assistant | Involved in therapy and falls of Resident #66 |
| CNA #1 | Certified Nurse Aide | Interviewed about assistance provided to Resident #66 |
| RN #1 | Registered Nurse | Interviewed about assistance provided to Resident #66 |
Inspection Report
Deficiencies: 1
Date: Jan 10, 2023
Visit Reason
The inspection was conducted to assess compliance with nutritional and dietary requirements, specifically to ensure menus met residents' nutritional needs and were properly followed.
Findings
The facility failed to ensure residents were served the correct therapeutic diets and did not follow correct portion sizes, resulting in inadequate nutrition. Observations, record reviews, and staff interviews confirmed these deficiencies.
Deficiencies (1)
F 0803: The facility failed to ensure residents were served the correct diets, including renal and carbohydrate controlled diets, as residents received incorrect food items and portions. Portion sizes were not measured correctly, leading to inadequate nutrition for residents on minced and moist diets.
Report Facts
Scoop size: 4
Scoop size: 3.25
Date of observation: Jan 9, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Dietitian (RD) | Interviewed regarding diet liberalization and portion size requirements | |
| Nursing Home Administrator (NHA) | Interviewed regarding staff training on therapeutic diet menus |
Inspection Report
Routine
Deficiencies: 12
Date: Sep 30, 2021
Visit Reason
Routine state inspection survey of a nursing home facility to assess compliance with regulatory requirements.
Findings
The facility was found deficient in multiple areas including residents' rights, grievance follow-up, medication administration, activity programming, quality of care, accident prevention, IV and respiratory care, medication storage, food safety, infection control, and psychotropic medication monitoring.
Deficiencies (12)
F 0578: Facility failed to ensure resident's right to request, refuse, or discontinue treatment and to formulate advance directives, including accurate MOST form documentation for Resident #186.
F 0585: Facility failed to provide prompt efforts to resolve grievances for Resident #187.
F 0658: Facility failed to document administration or disposal of narcotic medications for Residents #2, #71, and #384.
F 0679: Facility failed to provide meaningful activity programs for Residents #285, #32, and #133, including consistent programming and resident-centered activities.
F 0684: Facility failed to provide appropriate treatment and care including wound care, blood pressure medication parameters, antibiotic administration, and pain medication parameters for multiple residents.
F 0689: Facility failed to provide a safe environment by not protecting Resident #61's feeding tube site and failing to transfer Resident #382 with two staff as recommended.
F 0694: Facility failed to maintain a sterile field during PICC line dressing change for Resident #15, risking infection.
F 0695: Facility failed to ensure Resident #285 received oxygen therapy per physician orders and failed to monitor oxygen levels appropriately.
F 0758: Facility failed to track and monitor target behaviors and have a personalized care plan for Resident #133 receiving psychotropic medication Lithium Carbonate.
F 0761: Facility failed to maintain vaccine refrigerators within required temperature parameters and lacked digital data logger thermometers.
F 0812: Facility failed to store, prepare, distribute, and serve food in a sanitary manner including improper food temperatures, moist stacked pans, lack of internal thermometers in walk-in units, and improper sanitation of equipment.
F 0880: Facility failed to implement an effective infection control program including failure to offer hand sanitation prior to meals, inadequate visitor screening and education, and improper housekeeping cleaning practices.
Report Facts
Deficiencies cited: 12
Residents affected: 38
Temperature: 45
Temperature: 50
Oxygen flow rate: 6
Spaghetti temperature: 106
Hamburger temperature: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #4 | Licensed Practical Nurse | Acknowledged missed antibiotic dose for Resident #189 and failure to notify physician. |
| DON | Director of Nursing | Interviewed multiple times regarding deficiencies including PICC care, medication administration, infection control, and wound care. |
| NHA | Nursing Home Administrator | Interviewed regarding deficiencies and facility policies. |
| LPN #2 | Licensed Practical Nurse | Observed performing PICC dressing change with sterile field breaches. |
| DM | Dietary Manager | Interviewed regarding food temperature and sanitation deficiencies. |
| IP | Infection Preventionist | Interviewed regarding infection control program deficiencies. |
| Housekeeper #1 | Housekeeping Staff | Observed improper cleaning and hand hygiene practices. |
| Housekeeper #2 | Housekeeping Staff | Observed improper cleaning and handling of personal items. |
| RN #3 | Registered Nurse | Interviewed regarding transfer procedures for Resident #382. |
| OT #1 | Occupational Therapist | Interviewed regarding transfer requirements for Resident #382. |
| RD | Rehab Director | Interviewed regarding transfer requirements for Resident #382. |
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