Deficiencies (last 4 years)
Deficiencies (over 4 years)
4.3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
17% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Annual Inspection
Census: 35
Deficiencies: 5
Date: Mar 27, 2024
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with professional standards of care, medication administration, staff performance evaluations, medication storage, infection control, and nurse aide training requirements.
Findings
The facility was found deficient in timely medication administration for Resident #25, failure to conduct annual CNA performance reviews and training, improper medication storage and labeling, inadequate infection prevention and control practices including improper cleaning procedures and use of unapproved cleaning chemicals, and failure to ensure CNAs received required annual in-service training.
Deficiencies (5)
Failed to administer medications in a timely manner per physician orders for Resident #25.
Failed to conduct yearly certified nurse aide (CNA) performance reviews and provide training based on the outcome for three CNAs.
Failed to ensure medications and biologicals were stored and labeled properly, including expired medications stored with current ones, improper refrigerator use, and used medication vials stored in medication cart.
Failed to maintain an infection control program ensuring sanitary cleaning, appropriate disinfectant dwell time, hand hygiene by housekeeping staff, and cleaning of high touch surfaces.
Failed to ensure certified nurse aides received the required 12 hours of annual in-service training to ensure continued competence.
Report Facts
Residents in sample: 19
Residents affected by medication deficiency: 1
Medication late administration instances: 26
Facility average census: 35
CNAs reviewed: 5
CNAs missing annual performance reviews: 3
CNAs reviewed for annual training: 24
CNAs without required annual training: 23
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse #1 | LPN | Interviewed regarding medication administration delays and emergencies affecting timing |
| Director of Nursing | DON | Interviewed regarding medication administration standards, CNA performance reviews, medication storage, infection prevention, and CNA training |
| Registered Nurse #1 | RN | Observed medication cart and storage room; interviewed about medication storage practices |
| Human Resources Director | HRD | Interviewed regarding CNA performance reviews, training, and housekeeping oversight |
| Housekeeper #1 | HSK | Observed and interviewed regarding cleaning practices and use of cleaning chemicals |
| Housekeeper #2 | HSK | Lead housekeeper responsible for training new housekeepers |
| Executive Director | ED | Interviewed regarding facility policies, housekeeping training, and CNA training compliance |
Inspection Report
Annual Inspection
Deficiencies: 0
Date: Sep 27, 2023
Visit Reason
The inspection was conducted as an annual survey to assess compliance with health and safety regulations at the facility.
Findings
No health deficiencies were found during the inspection.
Inspection Report
Routine
Deficiencies: 7
Date: Dec 15, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to medication administration, colostomy care, psychotropic medication use, drug storage, and infection control at Springs at St Andrews Village nursing home.
Findings
The facility failed to ensure immediate physician notification for out-of-range blood sugar levels for Resident #122, failed to follow physician orders for insulin administration for Resident #9, lacked physician orders and a care plan for colostomy care for Resident #122, did not monitor hours of sleep for Resident #9 on hypnotic medication, improperly stored narcotics and failed to date opened influenza vaccine vials, and failed to perform proper hand hygiene and sanitize medical equipment between residents during medication administration.
Deficiencies (7)
Failed to ensure immediate physician notification for out-of-range blood sugar levels for Resident #122.
Failed to follow physician orders for insulin administration for Resident #9 when blood sugar readings were out of range.
Failed to have physician orders and a comprehensive care plan for colostomy care for Resident #122.
Failed to monitor hours of sleep to evaluate effectiveness of hypnotic medication for Resident #9 and lacked non-pharmacological interventions for insomnia.
Failed to ensure narcotics were stored properly; narcotics were left unattended on nurses station counter.
Failed to date opened vial of influenza vaccine as required.
Failed to perform proper hand hygiene between residents during medication administration and failed to sanitize multiple use medical equipment between residents.
Report Facts
Blood glucose readings out of range: 14
Days medication used without monitoring: 33
Medication count: 60
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #1 | Registered Nurse | Interviewed regarding medication administration and colostomy care; observed failing to perform hand hygiene and sanitize equipment. |
| Registered Nurse #2 | Registered Nurse | Interviewed regarding medication administration, physician notification, and colostomy care. |
| Director of Nursing | Director of Nursing | Provided facility policies, interviewed regarding medication administration, colostomy care, psychotropic medication monitoring, and medication storage. |
| Assistant Director of Nursing / Infection Preventionist | Assistant Director of Nursing / Infection Preventionist | Interviewed regarding colostomy care and infection prevention practices. |
| MDS Coordinator | MDS Coordinator | Interviewed regarding care plan additions and back-dating for colostomy care. |
| Transitional Care Director | Transitional Care Director | Identified as the person who signed for medication delivery and left narcotics unattended on nurses station counter. |
| Certified Nurse Aide #1 | Certified Nurse Aide | Interviewed regarding hand hygiene and sanitizing vital sign equipment. |
| Licensed Practical Nurse #1 | Licensed Practical Nurse | Observed failing to perform hand hygiene and sanitize equipment during medication administration. |
| Infection Preventionist | Infection Preventionist | Interviewed regarding hand hygiene and sanitizing medical equipment. |
Inspection Report
Annual Inspection
Deficiencies: 5
Date: Aug 24, 2021
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements related to resident rights, grievance resolution, nutritional status, dental care, and food service quality.
Findings
The facility was found to have multiple deficiencies including failure to provide residents with dignified dining experiences, failure to promptly resolve grievances such as lost dentures, failure to prevent significant weight loss in a resident due to inadequate nutritional interventions, failure to provide timely dental services, and failure to ensure food was palatable and served at appropriate temperatures.
Deficiencies (5)
Failure to ensure residents were provided independence and dignity while dining, including avoiding daily use of disposable cutlery and dishware.
Failure to promptly resolve grievance of a lost denture for Resident #25, resulting in weight loss and difficulty eating.
Failure to implement timely interventions to prevent significant weight loss for Resident #17, including lack of appropriate nutritional assessments and assistance at meals.
Failure to provide timely dental services for Residents #21, #24, and #25, including failure to arrange routine and emergency dental care.
Failure to ensure food was palatable, attractive, and served at safe and appetizing temperatures, including serving cold cole slaw and dry chicken difficult to cut with disposable utensils.
Report Facts
Weight loss: 13.6
Weight loss: 2.6
Weight loss: 3
Temperature: 61
Temperature: 110
Temperature: 113.7
Temperature: 109.7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Dietitian (RD) #1 | Registered Dietitian | Interviewed regarding nutritional assessments and meal service. |
| CNA #3 | Certified Nursing Assistant | Interviewed regarding meal delivery difficulties and missing meal items. |
| Director of Nursing (DON) | Director of Nursing | Interviewed regarding dining services, grievance process, and nutritional care. |
| Kitchen Services Manager (KSM) | Kitchen Services Manager | Interviewed regarding meal service and utensil availability. |
| Dining Room Services Manager (DRSM) | Dining Room Services Manager | Interviewed regarding meal preparation and delivery. |
| Social Service Director (SSD) | Social Service Director | Interviewed regarding grievance process and dental service arrangements. |
| Nursing Home Administrator (NHA) | Nursing Home Administrator | Interviewed regarding grievance process and facility follow-up. |
| Resident #25's daughter | Interviewed regarding lost dentures grievance and dental appointment. | |
| Speech Therapist (ST) | Speech Therapist | Interviewed regarding swallowing evaluation and meal assistance recommendations. |
| RN #1 | Registered Nurse | Observed and interviewed during meal delivery. |
| RN #2 | Registered Nurse | Interviewed regarding resident feeding and dental service process. |
| CNA #2 | Certified Nursing Assistant | Interviewed regarding resident feeding assistance. |
| Nurse Practitioner (NP) | Nurse Practitioner | Interviewed regarding resident nutritional status and recommendations. |
| Primary Care Physician (PCP) #1 | Primary Care Physician | Interviewed regarding resident weight loss and nutritional care. |
| Chef | Interviewed regarding meal preparation and food temperature. |
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