Colonial Rehabilitation And Nursing, LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#22) of two residents reviewed out of 39 sample residents.Specifically, the facility failed to ensure Resident #22's feeding tube was in place prior to administering a bolus feeding per physician's orders.Findings include: I. Facility policy and procedureThe Care and Treatment of Feeding Tubes policy and procedure, undated, was provided by the regional nurse consultant (RNC), on 7/24/25 at 5:34 p.m. It read in pertinent part, In accordance with facility protocol, licensed nurses will monitor and check that the feeding tube is in the right location. Tube placement will be verified before beginning a feeding and before administering medications.II. Resident statusResident #22, age less than 65, was admitted on [DATE] and readmitted on [DATE]. According to the July 2025 computerized physician orders (CPO), the diagnoses included hemiplegia (weakness 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 observations, record review and interviews, the facility failed to ensure residents who displayed or were diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practical physical, mental, and psychological well-being for one (#47) of two residents reviewed for dementia care out of 39 sample residents. Specifically, the facility failed to develop and implement effective dementia management-focused interventions to prevent Resident #47 from wandering into other residents' rooms, shower rooms, the nurses' station and standing over the top of other residents. Findings include: I. Resident #47 A. Resident status Resident #47, age [AGE], was admitted on [DATE]. According to the July 2025 computerized physician orders (CPO), diagnoses included Alzheimer's disease, anxiety disorder, depression and cognitive communication deficit. The 7/23/25 minimum data set (MDS) assessment revealed the resident was severely cognitively impaired, with a brief interview…

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 drug regimens were free from unnecessary medications for two (#61 and #42) of five residents reviewed for unnecessary medications out of 39 sample residents. Specifically, the facility failed to ensure Resident #61 and Resident #42 were monitored for hours of sleep for insomnia (difficulty sleeping) medications.Findings include: I. Facility policy and procedureThe Use of Psychotropic Medications policy and procedure, revised 4/28/25, was provided by the regional clinical resource (RCR) on 7/24/25 at 5:08 p.m. It read in pertinent part, The effects of the psychotropic medications on a resident's physical, mental, and psychosocial well-being will be evaluated on an ongoing basis and in accordance with nurse assessments and medication monitoring parameters consistent with clinical standards of practice, manufacturer's specifications, and the resident's comprehensive plan of care.II. Resident #61A. Resident statusResident #61, age [AGE], was…

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 possible development and transmission of infectious disease. Specifically, the facility failed to ensure the staff followed proper infection control procedures for Resident #7, who was on enhanced barrier precautions (EBP).Findings include: I. Professional reference 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 (MDROs) (4/2/24), was retrieved on 3/20/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part,Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care 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.

Based on interviews and record review, the facility failed to ensure residents had the right to choose his or her preferred attending physician for four ( #1, #2, #3 and #4) of six residents out of 12 sample residents. Specifically, the facility failed to assist residents to make an informed choice for selecting their attending physician when the facility changed medical provider groups. Findings include: I. Facility policy and procedure The Resident Rights policy, revised December 2016, was provided by the regional nurse consultant (RNC) on 10/16/24 at 2:48 p.m. It read in pertinent part, Federal and state laws guarantee certain basic rights to all residents of this facility. These rights include the resident ' s right to be informed about his or her rights, be informed of, choose an attending physician, and participate in decision-making regarding his or her care. II. Resident interviews Resident #4, who was cognitively intact based on facility assessment, was interviewed on 10/16/24 at 1:12 p.m. Resident #4 said she was aware her attending physician had changed. She said she was…

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, observations and record review, the facility failed to consistently serve food that was palatable, attractive and at the appropriate temperature. Specifically, the facility failed to ensure resident food was palatable in taste, texture, temperature and appearance. Findings include: I. Resident group interview A group interview was conducted on 8/29/23 at 3:26 p.m. with five cognitively independent residents (#29, #42, #44, #49, and #65). All the residents in the group interview said that the food was not palatable. Residents said the hot food came cold. II. Individual resident interviews Resident #62 was interviewed on 8/28/23 at 9:34 a.m. She said the meat served at dinner was sour and bland. She said the meat would have been better with salt and pepper. She did not know if there was salt and pepper served on the tray. Resident #42 was interviewed on 8/28/23 at 2:15 p.m. The resident said the meals were too salty. He said he did not ask for an alternative because it was too late to order an…

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 menus were followed to meet the residents' nutritional needs. Specifically, the facility failed to: -Follow the correct portion sizes to ensure adequate nutrition was provided to the residents; and, -Ensure the correct items were served in accordance with the posted menu. Findings include: I. Facility policy and procedure The Meal Distribution policy and procedure, revised September 2017, was received from the Regional Clinical Consultant (RCC) on 8/31/23 at 3:39 p.m. It read in pertinent part, All meals will be assembled in accordance with the individualized diet order, plan of care, and preferences. The dining services department staff will assemble the meal in accordance with the individual meal card. II. Failure to follow the correct portion sizes to ensure adequate nutrition was provided to the residents Observations and record review During a continuous observation during the breakfast meal tray line on 8/30/23 starting at 7:09 a.m. and ending at 8:40 a.m., cook #2 and dietary service aide (DSA)…

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 staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness. Specifically, the facility failed to ensure food items removed from their original packaging and opened had a dating system. Findings include: I. Professional reference The Colorado Department of Public Health and Environment (2019) Colorado Retail Food Establishment Rules and Regulations, retrieved on 9/10/23 from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_Eff Jan2019.pdf revealed in pertinent part: A date marking system 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 meat or a roast, or for which date marking is impractical, such as soft serve mix or milk in a dispensing machine; Marking the date or day of preparation, with a procedure to discard the food on or before the last date or day by…

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 residents were free from resident to resident abuse for two (#48 and #52) of four residents reviewed for physical abuse out of 32 sample residents. Specifically the facility failed to ensure Resident #48 was free from physical abuse from Resident #52. Cross reference F744, dementia care. Findings include: I. Facility policy and procedure The Abuse Policy was provided by the nursing home administrator (NHA) on 8/28/23 at 12:47 p.m. It read in pertinent part, Communities do not condone resident abuse and shall take every precaution possible to prevent resident abuse by anyone, including staff members and other residents. Residents have the right to be free from abuse, neglect, misappropriation of residents property, and exploitation. Identification of abuse shall be the responsibility of every employee. Physical abuse is defined as abuse that results in bodily harm with intent. It includes hitting, slapping, pinching and kicking. Willful means…

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 offer sufficient fluid intake to sustain hydration and ensure each resident was able to maintain the highest practical level of health and wellbeing for two residents (#21and #25) of 5 reviewed for hydration. Specifically, the facility failed to ensure: -Resident #21 and Resident #25 were provided with sufficient hydration in accordance with the resident's plan of care. Findings include: I. Facility policy The Hydration Policy, revised November 2019, was received from the nursing home administrator on 8/30/23. It read in pertinent part,Residents are provided with sufficient fluid intake to maintain proper hydration and health. Resident's identified at risk for fluid volume deficit will be assessed timely and provided appropriate interventions to promote adequate hydration. Residents identified with potential/actual hydration issues will be reviewed/assessed by the interdisciplinary team (IDT) for contributing risk factors/conditions.…

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 prevent significant medication errors for two (#41 and #49) of five residents reviewed for medication errors out of 32 sample residents. Specifically, the facility failed to ensure: -Resident #41 received prescribed daily doses of Vraylar (antipsychotic) and Trazodone (antidepressant), as ordered by the resident's physician; and -Resident #49 received a prescribed daily dose of Abilify (antipsychotic) and Lialda (anti-inflammatory agent used to treat ulcerative colitis), as ordered by the resident's physician. Findings include: I. Professional standards According to [NAME], P.A. and [NAME], A.G. et.al., (2021), Fundamentals of Nursing, 10 edition, pp 599 - 609. Nurses play an important role in patient safety, especially in the area of medication administration. The safe administration of medications is also an important topic for current nursing researchers. As a nurse you need to know how to calculate medication doses accurately and understand 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, interviews and record review, the facility failed to provide a therapeutic diet as prescribed by the physician to two Residents (#69 and #67) of 16 sample residents for a therapeutic diet, out of a total sample of 32 residents. Specifically, the facility failed to follow the physician orders for Resident #69 and Resident #67 to receive a carbohydrate controlled diet (CCD: meals that contain carbohydrate-rich foods in fairly equal amounts to help control the blood sugar levels). Findings include: I. Facility policy and procedure The Diabetic Management Policy and Procedure, dated 7/28/23, was received from the nursing home administrator (NHA) on 8/30/23 at 2:17 p.m. It read in pertinent part, Diabetic management involves both preventative measures and treatment of complications. From admission, the interdisciplinary team works together to implement a plan of care to minimize complications. The Therapeutic Diets Policy and Procedure, dated 1/12/16, was received by the NHA on 8/30/23 at 4:56…

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 staff interviews, the facility failed to ensure food items were served under sanitary conditions in the main kitchen. Specifically, the facility failed to ensure warm food items were held at the proper temperature to reduce the potential risk of food borne illness; and sanitary conditions were maintained in the kitchen. Findings include: I. Ensure hot food items were held at the proper temperature to reduce the risk of food borne illness. A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; The food shall have an initial temperature of 41ºF (Fahrenheit) or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control. B. Facility policy and procedure The Food Preparation policy, revised September 2017 was provided by the dietary regional manager (DRM) on 10/16/19 at 1:03…

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 that three (#15, #57 and #65) out of three residents reviewed for dignity out of 36 sample residents, were treated in a dignified manner Specifically, the facility failed to ensure: -Resident #57 and Resident #65 were informed and/ or offered to be assisted away from the table prior to housekeeping personnel sprayed sanitizing chemical on the tables, while residents were still seated at the dining table; and -Ensure resident #15 wishes were honored around going to bed. -Ensure resident #15 wishes around plugging in motor scooter were honored. Findings include: I. Facility policy The Resident Dignity and Personal Privacy policy, with a revision date of June 2007, was provided by the director of nursing (DON) on 10/15/19 at 5:37 p.m. It reads, in pertinent part .Dignity means that when interacting with residents, staff carries out activities that assist the resident in maintaining and enhancing his or her self-esteem and self-worth.…

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 provide a clean, comfortable and homelike environment. Specifically, the facility failed: -To provide clean hand towels and wash clothes to the residents, and; -Maintain clean dining room floors. Findings include: I. Towels A.Resident council A resident council meeting was conducted on 10/15/19 at 10:30 a.m. with six residents selected by the facility. The residents said they had to ask for towels from the certified nurse aides or grab extras from the shower rooms when they showered. The resident said towels were not passed out on a daily basis. B. Observations The resident ' s rooms were observed on 10/15/19 at 12:30 p.m. During these observations, the resident ' s shared restrooms were sparsely supplied with towels, some restrooms having none at all. Towels not found in rooms on 10/15/19 at 12:30 p.m. The observations were as follows: room [ROOM NUMBER] had one towel for two residents. room [ROOM NUMBER] had one towel for two residents. room [ROOM…

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 staff interview, the facility failed to ensure two (#67 and #15) of two out of 36 sample residents were without restraints. Specifically, the facility failed to ensure: -Resident #67's legs was not propped up on an electric recliner that resident was not able to remotely control; and -Resident #15 had an assessment that justified the use of a wander guard. Findings Include: I. Facility policy The Restraint Management System policy with a revision date of November 2017 was provided by the life engagement coordinator (LEC) on 10/14/19 at 10:17 a.m. The policy documented in pertinent part that .Restraints are implemented in accordance with State and Federal regulations. If indicated, the least restrictive restraint is used for the least amount of time. Restraints are not used as a disciplinary action or for the convenience of the facility to control behavior. The policy further defined physical restraint and reported that it is any manual method, physical or mechanical…

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 III. PICC line A. Professional reference Nursing licensure requirements in Colorado (2019) https://www.nursinglicensure.org/state/nursing-license-colorado.html#lpn (retrieved on 10/15/19). It read in pertinent part; A licensed practical nurse (LPN) who completed an intravenous (IV) training should get transcripts and course descriptions from the training center; the candidate should also secure a competency checklist from a former instructor or registered nurse (RN) supervisor. The LPN license in Colorado does not automatically grant IV authority. An IV certification course for LPNs was required to perform any IV procedures on residents within their scope of practice. B. policy The administration of an intermittent infusion policy revised May 2016 provided by the director of nurses (DON) on 10/15/19 at 2:00 p.m. read in pertinent part; The nurse is responsible and accountable for obtaining and maintaining competence with infusion therapy within his or her scope of practice. IV. Resident #277 A. Resident #277,…

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 licensed nurses had competencies. Specifically the facility failed ensure the licensed nurses were trained on the crash carts. Finding include: I. Facility policy The nasotracheal suctioning policy revised December 2018 provided by the director of nurses (DON) on 10/15/19 at 3:00 p.m. read in pertinent part; .Tracheal suctioning involves the removal of secretions from the trachea or bronchi by means of a catheter inserted through the mouth or nose. The procedure helps maintain a patent airway to promote optimal exchange of oxygen and carbon dioxide and to prevent pneumonia that can result from pooling of secretions . II. Observations and interviews The facility had three crash carts in the building, one for each station. The licensed nurses were interviewed in regards to how to operate the crash carts, in the event of an emergency. However, the observations and interviews showed, the nurses had not been trained on how to operate.…

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 observation, record review and interviews the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication pass observation error rate was 46.15 %, or 12 errors out of 26 opportunities for error. Findings include: I. Facility policy The Medication Administration policy, revised date of June 2008, provided by the director of nurses (DON) on 10/15/19 at 1:00 p.m., read in pertinent part: Administer medications within 60 minutes of the scheduled time. Unless otherwise specified by the physician. II. Medication errors A. Resident #24 1. Observation Registered nurse (RN) #4 was observed on 10/14/19 at 4:15 p.m. looking at the MAR (medication administration record) for Resident # 24. The electronic MAR showed the medication highlighted in a red color, to indicate they were late. The medications were scheduled to be given at 3:00 p.m. The RN said she did not administer the medications because the resident wanted to take them when she ate dinner. 2. Record review The computerized physician orders (CPO), dated 8/1/19,…

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 interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure: -Resident food was palatable in taste, texture, appearance, and temperature Findings include: I. Policy and procedures The Food Quality and Palatability policy, revised September 2017 was provided by the dietary regional manager (DRM) on 10/16/19 at 1:03 p.m. It read in pertinent part, Food will be prepared by methods that conserve nutritive value, flavor, and appearance. Food will be palatable, attractive and served at a safe and appetizing temperature. The cook will be responsible for food preparation techniques which minimize the amount of time that food items are exposed to temperatures greater than 41Fahrenheit (F) and/or less than 135F. II. Group interview A group interview was conducted on 10/15/19 at 10:30 a.m. with six alert and oriented residents selected by the facility, who were all active in the resident council monthly meetings. All of the residents in 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, record review and interviews, the facility failed to complete a comprehensive and accurate assessment of functional capacity after a significant change of condition for one (#70) of 36 sample residents. Specifically, the facility failed to comprehensively assess changes of condition in multiple areas of the resident's physical condition. Findings included: I. Resident #70 Resident #70, under age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders, diagnoses included schizoaffective disorder and muscle weakness. Record review revealed Resident #70 made improvements in bed mobility, transfers, locomotion on the unit, dressing, eating, toileting, and hygiene. The resident also had an increase in verbal and physical behaviors and refusing care. The resident also had significant weight loss. Review of the initial minimum data set (MDS) assessment, dated 2/2/19 revealed the resident was coded as follows: -Bed Mobility- 3/2 (limited assist of one person)…

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, interviews and record review, the facility failed to provide assistance for four (#2, and #44) of four residents reviewed for activities of daily living (ADLs) assistance of 36 sample residents. Specifically, the facility failed to: - Ensure Resident #2 received assistance with communicating her needs; and -Ensure Resident #44 received assistance with meals. Findings include: I. Communication A. Facility policies and procedures The Communicating with Persons with Limited English Proficiency policy, revised October 2015, was provided by the nursing home administrator(NHA) on 10/16/19 at 1:03 p.m. It reads, in pertinent part .It is facility policy to ensure that persons with limited english proficiency are identified and that the facility is capable of communicating information to such persons efficiently . B. Resident #2 1. Resident status Resident #2 over the age of 90, was admitted on [DATE].According to the October 2019 computerized physician orders (CPO), diagnoses included vascular…

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 two (#4) of 36 sample residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene. Specifically, the facility failed to provide timely incontinent care to Resident #4 Findings include I Facility Policy The Incontinence Management policy revised on December 2018 was provided by the director of nurses (DON) on 10/15/19 at 3:00 p.m., it read in pertinent part; . Moisture-associated skin damage and infection may result from incontinence II.Resident #4 A. Resident #4, age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders (CPOs), diagnosis included dementia. The 8/14/19 minimum data set (MDS) assessment revealed, Resident #4 was rarely understood and therefore a brief interview for mental status (BIMS) assessment was not attempted. The resident required extensive assistant with two persons for bed mobility,…

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 sufficient fluid intake to maintain proper hydration and health for one (#60) out of six residents out of 36 sample residents reviewed. Specifically the facility failed to: -Ensure Resident #60 met his hydration needs Findings include: I. Facility policy The Hydration Management policy revised date July 2017 provided by the director of nurses (DON) on 10/15/19 at 3:00 p.m. read in pertinent part; .Residents are provided with sufficient fluid intake to maintain proper hydration and nutritional status. Residents hydration status will be monitored on a regular basis . II. Resident #60 A. Resident #60, age [AGE], was admitted on [DATE]. According to the October 2019 computerized physician orders (CPOs), diagnoses include dementia and diabetes. The 9/7/19 minimum data set (MDS) assessment revealed, Resident #60 was able to complete the assessment with had moderate cognitive impairments with a brief interview for mental status (BIMS)…

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 (#49) out of one out of 36 sampled residents reviewed for quality of care received treatment and care in accordance with the comprehensive person-centered care plan. Specifically, the facility failed: -To implement person-centered care plan treatment and care resulting in self injurious behaviors of biting and chewing on arms and hands; -To provide preferred activities to the resident; and -To communicate with the resident while providing care. Findings include: I. Failed the facility failed to implement person-centered care plan treatment and care due to her anxiety and related self injurious behaviors of biting and sucking. II. Facility Policy and Procedure A copy of the policy Skin Management was provided by the director of nursing (DON) on 10/15/19 at 5:33 p.m. It read in pertinent part .Residents receive care to aid in the prevention or worsening of wounds and/or pressure ulcers. Individuals at risk for skin compromise…

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 infection control practices were followed to prevent the spread of infection. Specifically, the facility failed to: -Follow proper hand hygiene with glove uses when working between dirty and clean processes; and -Follow proper sanitization of equipment is between resident use. Finding include: I. Hand washing II. Facility policy The hand hygiene policy revised on February 2018 was provided by the director of nurses (DON) on 10/15/19 at 3:00 p.m. read in pertinent part; .To decrease the risk of transmission of infection by appropriate hand hygiene . III. Observations Certified nurse aide (CNA) #12 was observed on 10/14/19 at 9:28 a.m.to remove the mechanical lift and sling from Resident #49. The CNA left that in the hallway and did not disinfect that after resident use. Registered nurse (RN) #5 was observed on 10/09/19 at 11:47 a.m. to push the wound treatment cart into Resident # 63s room and wound care was completed for the resident. The treatment cart was then pushed out of the room into the hallway.…

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.