Grace Pointe Cont Care Sr Campus, Skilled Nursing

Based on observations, record review and interviews, the facility failed to ensure proper storage of medications in one of two medication storage rooms and two of three medication storage carts.Specifically, the facility failed to:-Ensure medications were labeled with accurate dates opened; and,-Ensure expired medications were removed and discarded from medication carts and storage rooms.Findings include:I. Professional referenceThe United States Food and Drug Administration (USFDA) (10/31/24) Don't Be Tempted to Use Expired Medications, was retrieved on 2/27/26 from https://www.fda.gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part, Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed there is no guarantee that the medicine will be safe and effective. If your…

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 diseases and infection. Specifically, the facility failed to ensure facility staff followed appropriate infection control practices and hand hygiene when providing wound care to Resident #1 and Resident #46.Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention's (CDC) Hand Hygiene for Healthcare Workers, updated 2/27/24, retrieved on 3/4/26 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html: Know when to clean your hands: immediately before touching a patient, before performing an aseptic task such as placing an indwelling device or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or patient's surroundings, after contact with blood, body fluids, or contaminated surfaces and immediately after glove…

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 allow residents the right to make choices about aspects of his or her life in the facility that were significant to the resident for two (#12 and #6) of two residents reviewed out of 29 sample residents. Specifically, the facility failed to assess, document and care plan Resident #12 and Resident #6's relationship preferences. Findings include: I. Resident #6 A. Resident status Resident #6, age [AGE], was admitted on [DATE]. According to the November 2023 computerized physician orders (CPO) the diagnoses included Parkinson's disease (deterioration of the nervous system), vascular dementia with mood disturbance, depression and insomnia (difficulty sleeping). The 10/15/23 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) with a score of 11 out of 15. She was dependent for self care, indoor mobility and functional cognition. She required substantial/maximal assistance…

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 all drugs and biologicals were properly stored and labeled in one of two medication rooms. Specifically, the facility failed to ensure multiple use vials were labeled appropriately. Findings include: I. Manufacturer's recommendations According to the Aplisol package insert, retrieved on 11/20/23 from: https://www.fda.gov/media/74862/download Vials in use for more than 30 days should be discarded. II. Facility policy and procedures The Medication Storage policy and procedure, undated, received from the nursing home administrator (NHA) on 11/15/23 at 12:59 p.m. read in pertinent part Medications will be stored in a secure manner that will provide a safe environment for residents. No discontinued, outdated, or deteriorated drugs or biologics may be retained for use. III. Observations On 11/14/23 at 2:32 p.m. The second floor medication room was reviewed with certified nurse aide with medication authority (CNA/MA) #1. One multidose vial of Aplisol Tuberculin purified derivative diluted (injectable medication to test 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.

Based on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure appropriate use of gloves when handling ready-to-eat foods; -Ensure the freezer was functioning properly; -Prevent potential cross-contamination with the ice machine; -Ensure cold food items were held at the proper temperature to reduce the potential risk of foodborne illness; and, -Ensure staff wore masks in the kitchen during a pandemic. I. Ensure appropriate use of gloves when handling ready-to-eat foods A. Professional reference The Colorado Retail Food Establishment Rules and Regulations (CRFERR) retrieved 8/16/22, revised January 2019, read in pertinent part, Employees prevent bare hand contact with ready-to-eat food by properly using suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. If used, single-use gloves shall be used for only one task, such as working with ready-to-eat food. Single-use gloves shall be used for no other…

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 ensure that professional standards of practice were followed for one (#24) of five out of 27 sample residents. Specifically the facility failed to ensure medications were administered as ordered and timely for Resident #24. Findings include: I. Facility policy The Medication Administration Nursing Procedure policy and procedure, dated March 2019, provided by the nursing home administrator (NHA) on 8/11/22 at 2:20 p.m., read in pertinent part, The licensed nurse or qualified person will administer medications according to the physician's orders and facility time schedule. Administration will be timely to achieve the optimum benefit. Medications are administered within 60 minutes of scheduled time, except before or after meal orders, which are administered precisely as ordered. For example, if the medication is ordered for 8:00 a.m., it must be given between 7:00 a.m. and 9:00 a.m. in order to be considered timely. II. Resident #24 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and record review the facility failed to provide one (#26) of three out of 27 sample residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, personal hygiene, toileting, and repositioning. Specifically, the facility failed to reposition Resident #26 for an extended period of time (4.5 hours), who was at high risk of pressure ulcers and required two person assistance with transfers and bed mobility. Findings include: I. Professional reference National Pressure Injury Advisory Panel (2016), Pressure Injury Prevention Points, retrieved from https://npiap.com/page/PreventionPoints (retrieved on 8/23/22) It read in pertinent part, the process for turning and repositioning residents included the following steps: -Turn and reposition all individuals at risk for pressure injury, unless contraindicated due to medical condition or medical treatments. -Choose a frequency for turning based on the support surface…

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 (#204) of two out of 27 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being. Specifically, the facility failed to ensure Resident #204 was assessed and provided the correct diet to meet her nutrition needs and preferences. Findings include: I. Resident #204 Resident #204, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the August 2022 computerized physician orders (CPO), the diagnoses included fracture of first, second, and third vertebra, unsteadiness on feet, history of falling and fusion of the spine. The 8/5/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status score of 15 out of 15. She required limited assistance of one person for bed mobility, transfers, dressing, toileting and set-up assistance for eating. The MDS did not indicate any…

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 manage the pain of one (#6) of two residents reviewed out of 27 sample residents in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Resident #6 admitted to the facility on [DATE] with a history of falls, dislocated hip and cervical fracture. The facility failed to reassess the resident's pain after she had a fall on 8/2/22. The facility failed to timely follow-up on the radiologist recommendations for further evaluations after the resident's x-rays were obtained 8/3/22 if the resident continued to have symptoms (see radiology report below). The resident experienced intermittent pain, at times severe, along with a decline in functional ability for over seven days following an unwitnessed fall on 8/2/22, until she was transferred to the hospital on 8/10/22. The resident was evaluated and diagnosed with a sacral fracture. Additionally, the facility failed…

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 interview, the facility failed to ensure menus were followed to meet the resident's nutritional needs. Specifically, the facility failed to follow recipe modifications for mechanically altered diets. Findings include: I. Professional reference According to The Nutrition Care Manual website, Transitioning Texture-Modified Diet Terminology and Definitions to IDDSI (International Dysphagia Standardization Initiative) Framework, retrieved from https://www.nutritioncaremanual.org/auth.cfm on 6/9/22, Dysphagia Level 3: Advanced or mechanical soft diet: no hard sticky, or crunchy foods, foods should be moist, mixed-consistency foods are allowed if tolerated and should be assessed by clinician (Speech language pathologist), food particles are served in bite-sized pieces (less than 1 inch), meats are cut up, chopped or ground (moist), crusty dry breads not allowed, most other moist breads are bread products allowed, salad, raw vegetables, and most fresh fruit are not allowed, adequate dentition and chewing ability expected. II. Facility policy 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.