Eben Ezer Lutheran Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on and observations, record review and interviews, the facility failed to ensure six (#1, #2, #3, #4, #5 and #6) of seven residents out of seven sample residents were kept free from abuse.Specifically, the facility failed to:-Ensure Resident #2, Resident #3 and Resident #5 were kept free from physical abuse from Resident #1; -Ensure Resident #1 and Resident #4 were kept free from abuse towards each other; and,-Ensure Resident #6 was kept free from physical abuse by Resident #7.Findings include:I. Facility policy and procedureThe Abuse policy and procedure, revised 9/13/23, was provided by the nursing home administrator (NHA) on 12/3/25 at 5:58 p.m. It revealed in pertinent part, Each resident will be free from abuse. Abuse can include verbal, mental, sexual or physical abuse, corporal punishment or involuntary seclusion. It is the policy of this community that all team members monitor residents and will know how to identify potential signs and symptoms of abuse. Occurrences, patterns and trends that may…

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 the main kitchen and two of four kitchenettes. Specifically, the facility failed to: -Ensure food was labeled, dated and discarded in a timely manner; -Ensure staff performed hand hygiene before donning (putting on) gloves to serve ready-to-eat food; and, -Ensure food was reheated to the appropriate temperature. I. Failed to ensure food was labeled, dated and disposed of timely A. Professional reference The Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 8/21/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view read in pertinent part, A date marking system that meets the criteria may include: Using a method approved by the Department for refrigerated, ready-to eat potentially hazardous food (time/temperature control for safety food) that is frequently rewrapped, such as lunch…

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 establish a sanitary environment to help prevent the transmission of communicable diseases and infections on two of four hallways. Specifically, the facility failed to: -Ensure housekeeping completed proper hand hygiene when cleaning resident rooms; and, -Ensure nursing followed proper standards of practice during wound care and followed enhanced barrier precautions appropriately. Findings include: I. Failure to ensure housekeeping completed proper hand hygiene when cleaning resident rooms A. Facility policy and procedure The Hand Hygiene policy, revised 5/6/21, was received from the nursing home administrator (NHA) on 8/15/24 at 10:18 a.m. It documented in pertinent part, All staff will perform proper hand hygiene to prevent the spread of infection to other personnel, neighbors and visitors. This applies to all working staff in all locations within the facility. Hand hygiene is a general term for cleaning your hands by handwashing 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 one (#26) of six out of 32 sample residents were provided services that met professional standards of quality. Specifically, the facility failed to: -Ensure the physician's orders for Resident #26 contained the dose of the medication the nurse was to administer to the resident. Findings include: I. Professional reference According to the National Institutes of Health (NIH), National Library of Medicine, Nursing Rights of Medication Administration (September 2023), retrieved on 8/21/24 from https://www.ncbi.nlm.nih.gov/books/NBK560654/, It is standard during nursing education to receive instruction on a guide to clinical medication administration and upholding patient safety known as the 'five rights' or 'five R's' of medication administration. Incorrect dosage is a prevalent modality of medication administration error. This error type stems from nurses giving a patient an incorrect dose of medications, even if it is the correct…

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 were provided an environment as free of accident hazards as possible for one (#55) of four residents reviewed for accidents and hazards out of 32 sample residents. Specifically, the facility failed to: -Ensure identified interventions were implemented consistently and monitored for effectiveness; and, -Update and revise Resident #55's care plan with new interventions after each skin injury. Findings include: I. Resident #55 A. Resident status Resident #55, age [AGE], was admitted on [DATE]. According to the August 2024 computerized physician orders (CPO), diagnoses included dementia, abdominal aortic aneurysm, acute kidney disease, localized edema and history of falling. The 7/10/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status (BIMS) score of 15 out of 15. He required total assistance with toileting and dressing. He required setup assistance for…

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 use a person-centered approach when determining the use of bed rails for one (#57) of 15 residents reviewed for bed rails out of 32 sample residents. Specifically, for Resident #57, the facility failed to: -Assess and review what interventions were attempted prior to the use of side rails; -Ensure the resident's comprehensive care plan was person centered; -Ensure assessments of the resident's use of the bed rails were completed regularly after they were installed; and, -Obtain consent that included the risks and benefits for using bed rails from the resident and/or the resident's representative before the bed rail installation. Findings include: I. Professional reference The U.S. Food and Drug Administration (FDA) Clinical Guidance for the Assessment and Implementation of Bed Rails In Hospitals, Long Term Care Facilities, (2/27/23) was retrieved on 8/19/24 from…

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 one of five certified nurse aides (CNA) reviewed. Specifically, the facility did not provide regular in-service education based on the outcome of the annual performance review for CNA #5. Findings include: I. Record review CNA #5 (hired before 8/14/23) had an annual performance review on 10/1/23. The performance review indicated CNA #5 scored a 50% in the areas of complaints and grievances, environment, quality improvement, workplace violence and sexual harassment. -CNA #5 did not have an in-service education plan based on the outcome of the annual performance review. II. Staff interview The director of nursing (DON) was interviewed on 8/15/24 at 1:52 p.m. The DON said she was not aware the performance reviews needed to include a regular in-service plan based on the outcome of the reviews. The DON said if a CNA scored 50% on a test, the score indicated the CNA…

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, observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, for one of three medication storage rooms and one of three medication carts. Specifically, the facility failed to discard expired medications and to lock a medication cart, when left unattended. Findings include: I. Facility policy The Medication Storage, dated January 2023, was requested and received on 3/2/23. The policy documented in pertinent part: -Medications and biologicals are stored properly, following manufacturer's or provider pharmacy recommendations, to maintain their integrity and to support safe effective drug administration. The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medication; -Outdated medications and containers are immediately removed from stock, disposed of according to medication disposal procedures; -Medication storage conditions were monitored on a regular basis as a random…

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 who were diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for one (#66) out of three residents reviewed out of 32 sample residents. Specifically, the facility failed to implement identified person centered interventions for Resident #66, a person with dementia and behavioral disturbances; alternatively the resident was given multiple medications which caused sedation. (cross reference to F758: use of unnecessary psychotropic medications) Findings include: I. Facility policy Per the nursing home administrator (NHA), the facility did not have an official policy related to dementia care, however, did require training of their staff. The following was provided on 11/21/21 at 2:09 p.m. by the NHA, We have required the Hand in Hand training in the past as well as the [NAME] Alternative curriculum Reframing Dementia…

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.