Lowry Hills Care And Rehabilitation

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide pharmaceutical services to meet the needs of one (#64) of five residents out of 51 sample residents.Specifically, the facility failed to ensure Resident #64's anti-anxiety medication was ordered and delivered to the facility in a timely manner.Findings include: I. Facility policy and procedureThe Pharmacy Services policy, undated, was received from the nursing home administrator (NHA) on 6/4/26 at 1:04 p.m. It read in pertinent part, The facility will provide pharmaceutical services to include procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice.II. Resident #64A. Resident status Resident #64, age less than 65, was admitted on [DATE]. According to the June 2026 computerized physician orders (CPO), diagnoses included Wernicke's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to:-Ensure enhanced barrier precautions (EBP) were followed during high contact resident care areas for Resident #9, who had an indwelling urinary catheter and Resident #3, who had a tracheostomy (airway created through the neck); and, -Ensure Resident #83 and Resident #9's urinary catheter drainage bags and catheter tubing were not dragging on the ground.Findings include:I. Failure to ensure EBP were followed during high contact resident care areas for Resident #9 and Resident #3A. Facility policy and procedureThe EBP policy and procedure, no revision date, was received from the nursing home administrator (NHA) on 6/4/26 at 1:04 p.m. It documented in pertinent part, Enhanced barrier precautions (EBP) refer to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services and assistance for bathing for one (#6) of three residents reviewed for ADLs out of 13 sample residents. Specifically, the facility failed to provide Resident #6, who had cognitive impairments, incontinence care in a timely manner. Findings include: I. Facility policy and procedure The Incontinence policy and procedure, dated August 2024, was provided by the nursing home administrator (NHA) on 6/26/25 at 8:27 a.m. It revealed in pertinent part, Based on the resident's comprehensive assessment, all incontinent residents will receive appropriate treatment and services. II. Resident #6 A. Resident status Resident #6, age [AGE], admitted on [DATE]. According to the June 2025 computerized physician's orders (CPO), diagnoses included dementia, glaucoma (high eye pressure) and chronic kidney disease. The 6/10/25 minimum data set (MDS)…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (#1 and #6) of three residents reviewed for activities programming out of 10 sample residents. Specifically the facility failed to: -Offer and provide personalized activity programs for Resident #1 and Resident #6 as documented in their care plans; -Ensure Resident #1 and Resident #6 were invited and encouraged to attend activities of their preference; and, -Ensure Resident #6 was meaningfully engaged during activities. Findings include: I. Resident #1 A. Resident status Resident #1, age less than 65, was admitted on [DATE] and discharged on 5/28/25 to the community. According to the May 2025 computerized physician orders (CPO), diagnoses included multiple sclerosis (a disease that…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide food and drinks that accommodated resident allergies, intolerances and preferences for one (#4) of four residents out of 13 sample residents. Specifically, the facility failed to ensure Resident #4 was provided a vegetarian diet per her preference. Findings include: I. Facility policy and procedure The Resident Food Preferences, revised July 2017, was received from the nursing home administrator (NHA) on 6/26/25 at 5:23 p.m. The policy read in pertinent part, Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Nursing staff will document the resident's food and eating preference in the careplan. II. Resident #4 A. Resident status Resident #4, age [AGE], was initially admitted on [DATE] and readmitted on [DATE]. According to the June 2025 computerized physician orders (CPO) diagnoses included multiple sclerosis (disease that affects the nerves), dementia and shortness of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease. Specifically, the facility failed to ensure: -A clean location was provided for wound care supplies; and, -Enhanced barrier precautions (EBP) and proper hand hygiene were followed for wound care activities. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC), Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDRO)'s, (4/2/24), retrieved on 4/23/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employ target gown and glove use during high contact resident activities. EBP may be indicated (when contact precautions do not otherwise apply) for residents with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one (#3) of three residents were free from abuse out of seven sample residents. Specifically, the facility failed to protect Resident #3 from physical abuse by Resident #2. Findings include: I. Facility policy and procedure The Abuse, Neglect, and Exploitation policy, revised 1/5/25, was provided by the director of nursing (DON) on 3/13/25. It read in pertinent part, The facility will implement policies and procedures to prevent and prohibit all types of abuse, neglect, misappropriation of resident property, and exploitation that achieves the identification, ongoing assessment, care planning for appropriate interventions, and monitoring of residents with needs and behaviors which might lead to conflict or neglect. II. Facility investigations A. Incident of physical abuse by Resident #2 towards Resident #3 on 2/8/25 The facility's investigation documented an incident occurred on 2/8/25 between Resident #2 and Resident #3. Another resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure consent was obtained for the use of psychotropic medications for three (#46, #25 and #47) of five residents reviewed for unnecessary medications out of 34 sample residents. Specifically, the facility failed to ensure informed consents, which included the risks associated with taking a psychotropic medication, were obtained for Resident #46, Resident #25 and Resident #47. Findings include: I. Facility policy and procedure The Use of Psychotropic Medications policy and procedure, revised 4/12/24 was provided by the nursing home administrator (NHA) on 5/7/24 at 12:47 p.m. It read in pertinent part, Residents are not given psychotropic drugs unless the medication is necessary to treat a specific condition, as diagnosed and documented in the clinical record, and the medication is beneficial to the resident, as demonstrated by monitoring and documentation of the residents response to medications. Residents and/or representatives shall be educated on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for five (#1, #4, #5, #6 and #7) of five certified nurse aides. Specifically, the facility had not completed annual performance reviews for certified nurse aide (CNA) #1, #4, #5, #6 and #7 in order to determine potential training needs. Findings include: I. Facility policy and procedure The Evaluation Process policy, revised 4/12/24, was provided by the nursing home administrator (NHA) on 5/6/24 at 3:13 p.m. It read in pertinent part, It is the policy of our facility to review the work performance of employees with a formal written evaluation. Factors that will be considered in making decisions include job performance, achieving goals, attendance record and adherence to workplace policies. II. Record review Annual performance reviews were requested on 5/6/24 at 1:59 p.m for CNAs #1, #4, #5, #6 and #7. The facility was unable to provide annual performance evaluations…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in a sanitary manner. Specifically, the facility failed to: -Ensure staff performed hand hygiene appropriately while washing dishes and handling clean dishes; and, -Ensure food was labeled, dated and disposed of timely in the nourishment refrigerator. Findings include: I. Ensure staff performed hand hygiene appropriately while washing dishes and handling clean and sanitized dishes A. Professional reference The Colorado Retail Food Regulations, (3/16/24), retrieved on 5/9/24 from https://cdphe.colorado.gov/environment/food-regulations, The regulations read in pertinent part, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service and single-use articles. After handling soiled equipment or utensils; during food preparation, as often as necessary to remove soil and contamination and to prevent cross…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to maintain an environment for residents, staff and the public that is safe, functional, sanitary and comfortable for one of two shower rooms at the facility. Specifically, the facility failed to ensure the shower room was sanitary and safe for residents to use. Finding include: I. Facility policy and procedure The Housekeeping Services policy and procedure, revised on 4/12/24, was provided by the director of nursing (DON) on 5/7/24 at 3:17 p.m. It read in pertinent part, It is the policy of this facility to ensure the provision of routine cleaning and disinfection in order to provide a safe, sanitary environment and to prevent the development and transmission of infections to the extent possible. II. Observations On 5/7/24 at 2:30 p.m. the shower room between unit 100 and 200 was observed. The following was observed: The shower room had two wooden fabric woven chairs used for residents besides the shower. Both chairs were damp to touch and had visible brown stains on them. The shower curtain divider that hung between both…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to ensure five (#1, #4, #5, #6 and #7) of five certified nurse aides (CNA) received the required 12 hours of annual in-service training for continued competence. Specifically, the facility failed to ensure CNA #1, #4, #5, #6 and #7 received 12 hours of training annually. Findings include: I. Facility policy and procedure The Nurse Aide Training Program policy, revised 4/12/24, was provided by the nursing home administrator (NHA) on 5/6/24 at 3:13 p.m. It read in pertinent part, The facility maintains an appropriate and effective nurse aide in-service training program for the purpose of ensuring the continuing competence of nurse aides. The staff development coordinator (SDC), with oversight from the director of nursing (DON), shall be responsible for the coordination and/or provision of nurse aide education. Each nurse aide shall be provided at least 12 hours of in-service training annually, based on his/her employment date, not calendar year. II. Training review A review of all five CNAs annual training was reviewed on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure a Level II preadmission and resident review (PASRR) was completed for one (#33) of three residents out of 34 sample residents reviewed for PASRR to gain and maintain their highest practical medical, emotional, and psychosocial well-being. Specifically, the facility failed to ensure a Level II PASRR was in place for Resident #33. Findings include: I. Facility policy and procedure The Behavioral Health policy, revised 4/12/24, was provided by the nursing home administrator (NHA) on 5/6/24 at 3:13 p.m. It read in pertinent part, It is the policy of the facility to ensure all residents receive necessary behavioral health services to assist them in reaching their highest level of mental and psychosocial functioning. II. Resident status Resident #33, age younger than 65, was admitted on [DATE]. According to the May 2024 computerized physician orders (CPO), diagnoses included mild neurocognitive disorder due to unknown physiological condition with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for two (#69 and #35) of three residents reviewed out of 34 sample residents. Specifically, the facility failed to ensure Resident #69 and Resident #35, who were dependent on staff for bathing, received their scheduled showers. Findings include: I. Facility policy and procedure The Resident Shower policy, revised 4/12/24, was provided by the nursing home administrator (NHA) on 5/9/24 at 10:48 a.m. It read in pertinent part, It is the practice of the facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues. The Activity of Daily Living policy, revised 4/12/24, was provided by the NHA on 5/6/24 at 3:13 p.m. It read in pertinent part, The facility will, based on the resident's comprehensive assessment and consistent with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (#60 and #58) of six residents out of 34 sample residents reviewed for nutrition status. Specifically, the facility failed to obtain weekly weights per the physician's orders for Resident #60 and Resident #58. Findings include: I. Facility policy and procedure The Weight Monitoring policy, revised 4/12/24, was provided by the nursing home administrator (NHA) on 5/7/24 at 4:00 p.m. The policy read in pertinent part, Weight can be a useful indicator of nutritional status. Significant unintended changes in weight (loss or gain) or insidious weight loss (gradual unintended weight loss over a period of time) may indicate a nutritional problem. A weight monitoring schedule will be developed upon admission for all residents: Weights should be recorded at the time obtained. Newly admitted residents and residents with weight loss will have weight…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for one (#46) of five residents reviewed for unnecessary medications out of 34 sampled residents. Specifically the facility failed to ensure: -Acetaminophen (pain medication) administered to Resident #46 did not exceed the recommended 3 grams (gm) in a 24-hour period; and, -As needed (PRN) medication was administered per physician's orders. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.[NAME], St. Louis Missouri, pp. 606-607, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards in one of three medication carts and one of two medication storage rooms. Specifically the facility failed to: -Ensure expired medications and vaccines were disposed of timely; -Ensure insulin pens (medication used for glucose control) were labeled with open dates; and, -Ensure Tubersol (used to test for tuberculosis) vials were labeled with open dates. Findings include: I. Professional references According to the Lantus glargine insulin package insert, retrieved on 4/29/24 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2022/021081s076lbl.pdf, When not in use store in refrigerated temperatures of 36 to 46 degrees fahrenheit (F). When in use, can be kept at room temperature for up to 28 days. According to the Novolog insulin package insert, retrieved on 5/8/24 from https://www.accessdata.fda.gov/drugsatfda_docs/label/2015/020986s082lbl.pdf After initial use a vial may be kept at temperatures below 30 degrees…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs. Specifically, the facility failed to ensure residents who were prescribed mechanical soft diets had food prepared according to their diet orders of mechanical soft as indicated on their meal tray cards. Findings include: I. Facility policy and procedure The Therapeutic Diet Orders policy and procedure, revised 4/12/24, was provided by the nursing home administrator (NHA) on 5/6/24 at 3:00 p.m. The policy read in pertinent part, The facility provides all residents with foods in the appropriate form and/or the the appropriate nutritive content as prescribed by a physician, and/or assessed by the interdisciplinary team to support the resident's treatment/plan of care, in accordance with his/her goals and preferences. Mechanically altered diet is one in which the texture or consistency of food is altered to facilitate oral intake. Examples include soft solids, pureed foods, ground meat and thickened liquids. Dietary…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection on two of six units. Specifically, the facility failed to: -Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high frequency touched areas (call lights, door handles and handrails); -Ensure housekeeping staff were trained appropriately on housekeeping procedures; -Ensure housekeeping staff used the correct surface disinfectant products; and, -Ensure surface disinfectant times were adhered to. Finding include: I. Professional reference Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 5/9/24. It revealed in pertinent part, High-touch…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in one of one facility kitchens. Specifically, the facility failed to: -Ensure the overall kitchen area were free from hanging dust; and -Ensure serving tables are free from chipped paint. Findings include: I. Professional reference According to the Colorado Department of Public Health and Environment (CDPHE)The Colorado Retail Food Establishment Rules and Regulations, 1/1/19, retrieved on 2/5/23 from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. Equipment food-contact surfaces and utensils shall be clean to sight and touch. The food-contact surfaces of cooking equipment and pans shall be kept free of encrusted grease deposits and other soil accumulations. Non food contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. Non food-contact surfaces of equipment shall be cleaned at a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review, observation,and interviews the facility failed to provide prompt responses and resolutions to grievances from residents. Specifically, the facility failed to respond to resident grievances regarding missing laundry and implement an acceptable resolution for the resident right to keep and use personal belongings and have the facility protect the resident property from theft and or loss. Findings include: I. Facility policy and procedure A Grievance/Complaint policy and procedure was requested on 1/26/23 and was not received from the facility. II. Record Review A. Resident laundry grievances On 8/24/22 Resident #38 reported that a fleece jacket had gone missing. According to the grievance document it was not found in the residents room or laundry. On 8/28/22 Resident #8 reported that three shirts and one pair of pants had gone missing. According to the grievance document the items were not found in the residents room or laundry. On 10/6/22 Resident #21 reported that four personally owned sheet sets and a blanket had been lost in the laundry. According to the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interviews the facility failed to ensure medications and biologics were stored and labeled properly on two of four medications carts and one of two medication storage rooms. Specifically, the facility failed to ensure: -Insulin (medication for diabetes) vials and pen injection devices were stored and labeled appropriately with open dates; -Vials of tubersol (used to test for Tuberculosis) were labeled appropriately with open dates; -Ensure the treatment cart was kept free from expired wound dressing supplies; and, -Medication carts were kept clean and free of loose pills. Findings include: I. Manufacturer recommendations According to the Humalog package insert, retrieved [DATE] from: https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/020563s115lbl.pdf In-use humalog vials, cartridges, pens, and humalog KwikPen should be stored at room temperature, below 86°F (30°C) and must be used within 28 days or be discarded, even if they still contain humalog. Unopened humalog should be…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure two residents (#60 and #67) of two residents reviewed out of 39 sample residents, had the right to participate in the development and implementation of his or her person centered plan of care. Specifically the facility failed to conduct consistent care planning meetings and invite Resident #60 and #67 to attend a care plan meeting to discuss and develop a person centered plan of care and services that the facility would provide to them. Findings include I. Facility policy and procedure The Care Planning-Resident Participation policy, undated, received from the chief clinical officer (CCO) on 1/27/23 at 6:29 p.m., revealed in pertinent part, The facility supports the resident's rights to be informed of, and participate in, his or her care planning and treatment. The facility will inform the resident in advance of changes to the plan of care. The plan of care will be discussed at regular scheduled care plan conferences. The facility will discuss…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to honor resident choices for one (#19) of two reviewed for self-determination, out of 39 sample residents. Specifically, the facility failed to ensure dependent Resident #19, received showers consistently according to the resident's preference. Findings include: I. Facility policy and procedure An undated Resident Shower policy was provided by the nursing home administrator (NHA) on 1/26/23 at 2:08 p.m. It read, in pertinent part It is the practice of this facility to assist residents with bathing to maintain proper hygiene, stimulate circulation and help prevent skin issues as per current standards of practice. Residents will be provided showers as per request or as per facility schedules protocols and based on resident safety. II. Resident #19 A. Resident status Resident #19, under age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the January 2023 computerized physician orders (CPO), diagnoses included bipolar disorder, mild…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review, and interviews, the facility failed to ensure one (#55) of three residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good nutrition and hygiene, out of 39 sample residents. Specifically, the facility failed to: -Provide timely incontinent care; -Provide timely consistent feeding assistance; and, -Update care plan for Resident #55 to reflect feeding assistance needs. Findings include: I. Facility policy The Incontinence Care policy, undated, was provided by the nursing home administrator (NHA) on 2/26/23 at 2:08 p.m. It read in pertinent part: Based on the resident's comprehensive assessment, all residents that are incontinent will receive appropriate treatment and services. Residents that are incontinent of bladder or bowel will receive appropriate treatment to prevent infections and to restore continence to the extent possible. The Activity of Daily Living (ADLs) policy, undated, was provided by the NHA on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, interview, and observation the facility failed to ensure the residents' environment remained as free from accident hazards as possible, for two (#20 and #42) of six residents reviewed for accident/hazards out of 39 sample residents Specifically, the facility failed to: -Provide effective monitoring and supervision of Resident #20's safety when the resident left the facility without notifying facility staff of an extended absence;. -Provide health assessment and document the assessment (if done) of Resident #20 upon the resident's return from extended and overnight absences for the facility when the resident was out in the community in potential unsafe conditions unsupervised by facility staff; -Provide Resident #20 with appropriate interventions and supervision to prevent the resident from eloping and being missing for hours before staff became aware of the resident's absence; and, -Ensure Resident #42 had a safe and appropriate mattress that was a compatible fit for the bed frame; so the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observation, and interview the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for one (#20) out of one resident reviewed for a person-centered care plan that supports the resident's behavioral health needs, out of 39 sample residents. Specifically, the facility failed to: -Develop and follow a process to ensure a resident with a substance abuse history was properly monitored for unsafe addicting chemical substances use; -Ensure the facility staff monitored the resident for chemical substance withdrawals and documented concerns when the resident presented with intoxication; and, -Provide a person centered care plan to address Resident #20's mental health needs related to substance use disorder for monitoring and assessment when the resident was actively using an addictive substance, that include and support identified behavioral health care needs. Findings include I.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to ensure the medication error rate was less than five percent for two residents (#29 and #45). Specifically, the facility had a medication error rate of 7.41%, which was two errors out of 27 opportunities for error. Findings include I. Professional reference According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: 1. The right medication 2. The right dose 3. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection. Specifically the facility failed to: -Perform wound care in a sanitary manner for Resident #237; and, -Sanitize multiple use items after use; when providing wound care for Resident #237. Findings include I. Professional reference According to the Center for disease control (CDC) control and prevention, Hand Hygiene Basics retrieved on 2/2/23 from: http://www.cdc.gov/handhygiene/basics.html (2019), it read in pertinent part, healthcare providers should practice hand hygiene at key points in time to disrupt the transmission of microorganisms to patient including before patient contact; after contact with blood,body fluids, or contaminated surfaces (even if gloves worn); before invasive procedures; and after removing gloves (wearing gloves is not enough to prevent the transmission…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.