Lemay Avenue Health And Rehab LLC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to provide appropriate treatment and services to prevent urinary tract infections (UTI) for one (#16) of four residents out of 16 sample residents.Specifically, the facility failed to prevent recurring UTIs for Resident #16.Findings include:I. Facility policy and procedureThe Incontinence policy, revised 12/1/25, was provided by the regional vice president of operations on 6/1/26 at 6:00 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 Infection Prevention and Control Program policy, revised 12/1/25, was provided by the regional vice president of operations on 6/1/26 at 6:00 p.m. It read in pertinent part, This facility has established and maintains an infection prevention and…

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 interviews, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice for two (#3 and #14) of four residents reviewed of 16 sample residents. Specifically, the facility failed to ensure Resident #3 and Resident #14 received oxygen therapy in accordance with the physician's orders.Findings include:I. Professional referenceAccording to National Library of Medicine, National Center for Biotechnology Information, dated 2026, retrieved on 6/10/26 fromhttps://urldefense.proofpoint.com/v2/url?u=https-3A__www.ncbi.nlm.nih.gov_books_NBK551617_&d=DwICAg&c=sdnEM9SRGFuMt5z5w3AhsPNahmNicq64TgF1JwNR0cs&r=F6R-BWIUxqh9IqzzEaBXT9YWHUnChmp6u0hLTAxMezU&m=fR9UKZ2WivqmKsbBTslFP3UR6BBqsRa-mqc7zWWU79ugNfcxTb6JkaXk8jtat7ys&s=NyHFcX8Cm3wLDxzgAoz-uZPKFS5061mqlh5eL6zCOm4&e= Oxygen therapy is a critical medical intervention designed to ensure adequate oxygen delivery to the body's cells, supporting essential functions and preventing…

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 diagnosed with dementia received the appropriate treatment and services to attain or maintain their highest practical physical, mental, and psychological well-being an prevevent re for two (#6 and #12) of five residents out of 16 sample residents. Specifically, the facility failed to develop individualized interventions related to Resident #6 and Resident #12 behavioral symptomatology for becoming aggressive towards other individuals (resident and visitors) when they did not like what was going on in their environment/surroundings; to prevent each of them from initiating an aggressive altercation directed towards other individuals.Findings include:I. Facility policy and procedureThe Dementia Care policy and procedure, revised 12/1/25, was provided by the nursing home administrator (NHA) on 6/1/26 at 5:27 p.m. It read in pertinent part, This facility will provide dementia treatment and services which may include,…

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 provide medications as ordered for one (#1) of three residents of 16 sampled residents.Specifically, the facility failed to have a physician's ordered medications available at the facility to administer to Resident #1.Findings include:I. Professional referenceAccording to the National Library of Medicine, Medline Plus, Valacyclovir, dated 2026, retrieved on [DATE] from https://medlineplus.gov/druginfo/meds/a695010.html Valacyclovir is used to treat certain viral infections including varicella infections including herpes zoster (shingles) and chicken pox. It is in a class of medications called antivirals. It works by stopping the spread of the herpes virus in the body.According to Skinlight, Shingles (Zoster), last revised [DATE], retrieved on [DATE] from https://skinsight.com/skin-conditions/zoster-shingles/?Imiw9cApl=1 Oral antiviral medication such as valacyclovir may help if given within 72 hours after shingles lesions first appear. These medicines…

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 eight units.Specifically, the facility failed to:-Ensure the vital signs machine was disinfected after being used in a COVID-19 positive room;-Ensure the vital signs machine was disinfected between each resident's use on the secure unit; and,-Ensure housekeeping staff doffed (took off) their personal protective equipment (PPE) and closed the trash bags before exiting a COVID-19 positive room.Findings include:I. Failed to ensure the vital signs machine was disinfected after being utilized in a COVID-19 positive roomA. Professional referenceAccording to the Centers for Disease Control And Prevention's (CDC) Guideline for Disinfection and Sterilization in Healthcare Facilities, updated June 2024, retrieved 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure three (#13, #11 and #12) of three residents out of 11 sample residents had their grievances resolved promptly by the facility. Specifically, the facility did not promptly respond to Resident #13, Resident #11 and Resident #12's grievances of long call light times. Findings include: I. Facility policy and procedure The Grievance Procedure policy, revised on 10/31/24, was provided by the nursing home administrator (NHA) on 2/19/25 at 6:10 p.m. The policy revealed the purpose of the policy was to protect resident rights and ensure prompt resolution of grievances. If at any time, a resident or representative had a grievance, it was their responsibility to express it orally or in writing to the nursing home administrator (NHA) or designee. Each resident had the right to voice grievances without discrimination, reprisal, or retribution. The facility had a Grievance Committee, which consisted of the NHA or their designee, a resident selected by 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.

Based on observations, record review and staff interviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Demonstrate proper hand hygiene while assisting a residents with their meals; -Ensure control measures for monitoring and preventing Legionella and waterborne pathogens growth were included in the facility's water management plan; and, -Pass medications in a sanitary manner. Findings include: I. Proper hand hygiene A. Professional reference The Colorado Retail Food Regulations, effective 1/1/19 and retrieved 11/20/23 from https://cdphe.colorado.gov/environment/food-regulations revealed in pertinent part, Cleaned and sanitized utensils shall be handled, displayed, and dispensed so that contamination of food and lip-contact surfaces is prevented. B. Facility policy and procedure The Standard Precautions policy and procedure, revised November 2023, 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 observation, interviews, record review, facility policy review, and facility document review, it was determined that the facility failed to prevent a resident (Resident #36), who was severely cognitively impaired with known wandering and exit-seeking behaviors, from exiting the facility unsupervised on 06/09/2022. This affected one (Resident #36) of three residents reviewed for wandering behaviors. Findings included: A review of the facility's Elopement Prevention and Missing Resident policy, dated 12/15/2004 and revised on 08/15/2022, revealed, The facility provides a safe environment for each resident with avoidance of occurrences that would place a resident in danger. Every effort will be made to prevent an elopement episode while maintaining the least restrictive environment for residents who remain at risk. Interventions will be implemented immediately and will be based upon the individual resident's condition. All departments will be alerted to the wandering/exit seeking actions and asked to watch…

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, review of the facility's policy, and interviews, it was determined the facility failed to ensure one (Hall 2500) of four medication carts were locked while not in use and unattended. Findings included: A review of the facility's policy titled, Medication Receiving, Storage, and Destruction revised 06/23/2022 revealed, A. Only those individuals who are assisting in receiving, storage, destruction or administration of medications will be allowed access to medications. Medication rooms, carts, and medication supplies are locked or attended by persons with authorized access to protect each resident's medications from use by other residents, visitors, and staff. During an observation on 08/18/2022 at 8:00 AM, the medication cart on Hall 2500 was observed at the end of residential Hall 2500. The medication cart was unattended and unlocked. At 8:09 AM, Registered Nurse (RN) #6 exited a resident's room. The resident's room (#2506) was two rooms away and approximately twenty-five feet from the medication cart. The door to the resident's room had been closed while the RN…

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, interview, record review, and facility policy review, the facility failed to maintain infection control practices during wound care for one (Resident #62) of one resident observed for wound care. Findings included: Review of the facility policy, Skilled Nursing Facility Wound Management, dated 08/18/2022, revealed, G. Infection control practices, including the use of standard precautions, is observed during wound care. A review of the facility's Dressing Change Guidelines, dated 2017, revealed the guideline was prepared and provided for educational and information purposes and to promote the safe and effective use of the products provided. Treatment Procedure 10. Place at designated bedside table which has already been cleaned/prepped for use. Clean field should be arranged per facility policy, and it is suggested to arrange items on field in order of use. Obtain appropriate trash receptacle or red biohazard bag for discarded dressings and used supplies. Wash hands, don gloves and open dressing packs and leave on bottom half of wrapper if possible. Write date,…

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.