Oakwood Care And Rehabilitation

Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen.Specifically, the facility failed to ensure ready-to-eat foods were handled in a sanitary manner to prevent cross-contamination. Findings include:I. Professional referenceThe Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 9/15/25. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. (3-301.11)II. ObservationsDuring a continuous observation of the lunch meal service on 9/10/25, beginning at 10:35 a.m. and ending at 12:22 p.m. the following was observed:At 11:40 a.m. cook (CK) #2 began preparing a cheeseburger. CK #2 removed the lids for each cold container of hamburger toppings and set them aside. CK #2 donned a glove on one hand, grabbed a piece of lettuce and placed it on a plate. CK #2 then removed the glove and placed…

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 the necessary services to maintain personal hygiene for one (#53) of nine residents reviewed for services to maintain highest practicable quality of life out of 46 sample residents.Specifically, the facility failed to ensure Resident #53 received timely incontinence care and repositioning. Findings include:I. Facility policy and procedureThe Activities of Daily Living (ADLs) policy and procedure, revised 4/3/25, was received from the nursing home administrator (NHA) on 9/11/25 at 11:51 a.m. It read in pertinent part, Care and services will be provided for the following activities of daily living: transfer and ambulation and toileting. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral hygiene.II. Resident #53A. Resident statusResident #53, age [AGE], was admitted on [DATE]. According to the September 2025 computerized…

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 implement an activities program that met the interests of and supported the physical, mental, and psychosocial well-being of each resident for one (#53) of one resident out of 46 sample residents.Specifically, the facility failed to: Provide a meaningful activities program for Resident #53; and, -Ensure Resident #53's activity participation was accurately documented.Findings include:I. Facility policy and procedureThe Delivery of Activity Services policy and procedure, revised March 2025, was received from the nursing home administrator (NHA) on 9/11/25 at 11:16 a.m. It read in pertinent part, Should a resident be considered medically or mentally incompetent, or physically unable to participate in such programs, an entry will be made in the resident's medical record (chart) stating fully the reason(s) for the restriction(s). Such an entry will be signed and dated by the person recording such data. Some activities can be adapted to…

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 two of three certified nurse aides (CNA).Specifically, the facility failed to complete annual performance reviews and/or provide regular in-service education based on the outcome of the reviews for CNA #7 and CNA #11. Findings include:I. Record reviewAnnual performance reviews for CNA #7 and CNA #11 were requested on 9/9/25 at 1:34 p.m. The facility was unable to provide annual performance evaluations for CNA #7 (hired on 3/1/24) and CNA #11 (hired on 3/1/24).-The CNAs did not have an annual performance review completed and the CNAs did not have an in-service education plan based on the outcome of the review.The facility provided a document on 9/9/25 at 3:03 p.m. which identified that a performance improvement plan (PIP) had been initiated on 8/22/25 regarding outstanding annual performance reviews. The PIP stated an audit had been completed and identified staff…

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 effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease.Specifically, the facility failed to:-Ensure staff performed appropriate hand hygiene assisting residents with eating; and,-Ensure staff handled residents' drinkware in a sanitary manner.Findings include:I. Failed to ensure staff performed hand hygiene while assisting residents with eatingA. Professional referenceAccording to The Centers for Disease Control and Prevention's (CDC) Hand Hygiene for Healthcare Workers (2/27/24), retrieved on 9/15/25 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html, included the following recommendations for hand hygiene, Hand hygiene protects both healthcare personnel and patients. Cleaning your hands reduces the potential spread of germs, including those resistant to antibiotics. Clean your hands immediately before touching a patient and after touching a patient or the patient'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 record review and interviews, the facility failed to ensure certified nurse aides (CNA) received the required 12 hours of training per year for two out of three CNAs reviewed.Specifically, the facility failed to:-Ensure a system was in place to track the CNAs training to ensure they met the annual training requirements; and,-Ensure CNA #7 and CNA #11 received the required 12 hours of training per year. Findings include:I. Facility policy and procedureThe Nurse Aide Training policy and procedure, revised March 2025, was provided by the nursing home administrator (NHA) on 9/11/25 at 11:50 a.m. It read in pertinent part, This 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 (or designee), with oversight from the director of nursing, 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…

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 promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Specifically, the facility failed to maintain residents' dignity and ensure residents were provided equal access to incontinence care supplies. Findings include: I. Resident interviews Resident #1 was interviewed on 6/11/25 at 3:15 p.m. Resident #1 said he did not have briefs for four days because the facility ran out of briefs. Resident #1 said he asked a nurse manager what to use for briefs if the facility ran out and the nurse manager told him to use a towel instead. Resident #1 said he was not sure what the facility meant by using a towel but there were no briefs available. Resident #1 said the issue started on a Friday and the new briefs were delivered on a Tuesday. Resident #9 was interviewed on 6/12/25 at 9:45 a.m. Resident #9 said a certified nurse aide (CNA) told him the facility did not order briefs. Resident #9 said he only had one pair 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that the transfer or discharge was documented accurately in the resident's medical record and appropriate information was communicated to the receiving health care institution or provider for one (#2) of three residents reviewed for discharge out of 12 sample residents. Specifically, for Resident #2, the facility failed to: -Ensure the resident's discharge summary included the resident's need for two transfer poles; -Ensure the resident's discharge care plan included the resident's medical equipment needs, specifically the two transfer poles -Document communication and responses from the referral sources to confirm the resident's discharge needs; and, -Ensure the resident's discharge date documented in the physician's orders was accurate and the physician's order was obtained timely. Findings include: I. Resident #2 A. Resident status Resident #2, age [AGE], was admitted on [DATE] and discharged to home on 5/21/25. According to the June 2025…

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 were free from significant medication errors for one (#9) of five residents reviewed for medications errors out of 12 sample residents. Specifically the facility failed to ensure Resident #9 was administered Farxiga (for chronic kidney disease and diabetes mellitus type 2) 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 consistently every time you administer medications. Many medication errors can be linked in some way to 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 interviews, observations and record review, the facility failed to ensure residents consistently received food prepared by methods that conserved nutritive value, were palatable in taste and temperature. Specifically, the facility failed to ensure the residents' food was palatable in temperature. I. Facility policy and procedure The Timely Meal Service and Food Temperature policy, undated, was provided by the nursing home administrator (NHA) on 1/30/25 at 4:00 p.m. It read in pertinent part, Food will be delivered promptly to ensure safe, palatable and high-quality food served at the proper temperature. Food will be served at preferable temperatures (hot foods hot and cold foods cold) as discerned by the patients/residents and customary practice (not to be confused with proper holding temperatures). II. Resident interviews Resident #28 was interviewed on 1/27/25 at 11:47 a.m. Resident #28 said the food was bad. Resident #10 was interviewed on 1/27/25 at 3:27 p.m. Resident #10 said food was often served cold and the facility seemed to run out of common food items. 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 observations and interviews the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and in three of five nourishment rooms. Specifically, the facility failed to ensure safe and appropriate storage of food items in the kitchen and three of five nourishment room refrigerators. Findings include: I. Professional reference The Colorado Retail Food Establishment Rules and Regulations, (3/16/24), retrieved on 2/4/25 read in pertinent part, The day or date marked by the food establishment may not exceed a manufacturer's use-by-date if the manufacturer determined the use-by date based on food safety. (Chapter 3-25) Medicines that require refrigeration and are stored in a food refrigerator shall be stored in a package or container and kept inside a covered, leakproof container that is identified as a container for the storage of medicines (Chapter 7-207.12) II. Facility policy and procedure The Foods Brought by Family or Visitor/Personal Food Storage, undated, 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 record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification agency in accordance with state law for two (#2 and #24) of 11 residents reviewed for abuse out of 28 sample residents. Specifically, the facility failed to report incidents of potential verbal and physical abuse involving Resident #2 and Resident #24 to the State Survey Agency (SSA). Findings include: I. Facility policy and procedure The Abuse Prevention and Reporting-Guideline policy, revised August 2021, was provided by the nursing home administrator (NHA) on 1/27/25 at 11:49 a.m. It read in pertinent part, It is the policy of this facility that all allegations of abuse are investigated. Residents will be free from verbal abuse, physical abuse, mental abuse, sexual abuse, involuntary seclusion, neglect and exploitation. Verbal abuse is any use of oral, written or gestured language that includes knowingly threatening a resident causing fear or imminent, serious bodily…

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 resident 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 (#2) of five residents reviewed for mood and behavior out of 28 sample residents. Specifically, the facility failed to a implement person-centered care plan upon admission to address Resident #2's history of physical aggression towards others in order to prevent physical altercations with other residents. Findings include: I. Resident status Resident #2, age greater than 65, was admitted on [DATE] and discharged on 1/19/25 to the hospital. According to the January 2025 computerized physician orders (CPO), diagnoses included cerebral palsy (disease that affects movement and muscle tone), acute respiratory failure, dementia with behavioral disturbance, violent behavior, depression, need for assistance with personal care and cognitive communication deficit.…

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 on one of six units. Specifically, the facility failed to ensure facility staff followed enhanced barrier precautions (EBP) when performing high contact activity with Resident #12, who had a suprapubic catheter and stage 4 (damage extending through all skin layers, reaching underlying muscle, tendon or bone, often with exposed tissue and high risk of infection) pressure wounds. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Enhanced Barrier Precautions in Nursing Homes, updated 7/12/22, retrieved on 2/3/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html, 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. Effective…

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 proper treatment and assistive devices to maintain vision abilities for three (#93, #40 and #57) of four residents out of 49 sample residents. Specifically, the facility failed to arrange optometry services timely for Resident #93, #40 and #57. Findings include: I. Facility policy and procedure The Hearing and Vision Services policy, revised March 2024, was provided by the nursing home administrator (NHA) on 4/10/24 at 4:41 p.m. It read in pertinent part, It is the policy of this facility to ensure that all residents have access to hearing and vision services and receive adaptive equipment as indicated. The social worker/social services designee is responsible for assisting residents, and their families, in locating and utilizing available resources (Medicare or Medicaid program payment, local health organizations offering items and services which are available free to the community), for the provision of vision and hearing…

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 effectively address the care and treatment needs of residents in the secured dementia care unit for the residents to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being and provide person-centered care for ten (#84, #78, #71, #89, # 8, #97, #90, #69, #41 and #52) of 18 residents residing on the secured unit out of 49 sample residents. Specifically, the facility failed to: -Provide a consistent and engaging activity program that was meaningful for Resident #84, #78, #71, #89, # 8, #97, #90 and #69, all of whom resided in the secure unit; -Offer and provide Resident #84, #78, #71, #89, # 8, #97, #90, #69, #41 and #52 unrestricted access to supplies and items for independent activities; -Interact in a safe, non-confrontational and appropriate manner with Resident #71; -Provide adequate supervision to keep Resident #78, who had been involved in a previous resident-to-resident altercation in…

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 assist residents in obtaining routine or emergency dental services, as needed for four (#57, #40, #93 and #84) of four residents reviewed for dental services out of 49 sample residents. Specifically, the facility failed to ensure: -Resident #57 was provided follow-up dental services recommended by the dentist; -Resident #40 was provided dentures in a timely manner; -Dental services were offered to Resident #93; and, -Refer Resident #84 to a dental specialist as recommended by the facility dentist for follow up on the resident's dental issues. Findings include: I. Facility policy and procedure The Dental Services policy, dated November 2007, was provided by the nursing home administrator (NHA) on 4/10/24 at 4:41 p.m. It read in pertinent part, It is the policy of this facility to assist residents in obtaining routine (to the extent covered under the State plan) and emergency dental care. 'Routine dental services means an annual inspection of the oral…

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 maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases. Specifically, the facility failed to: -Ensure housekeeping staff changed gloves and performed hand hygiene consistently when appropriate; -Ensure housekeeping staff performed hand hygiene appropriately when performed; -Ensure housekeeping staff properly used a disinfectant chemical when cleaning resident rooms and bathrooms; -Ensure tracking, offering and administration of the COVID-19 vaccination; -Follow infection control practices during wound care; and, -Ensure proper hand hygiene was conducted during medication administration. Findings include: I. Housekeeping A. Facility policy and procedure The Infection Control Policy and Procedure for Housekeeping services, dated January 2009, was provided by the maintenance director (MTD) on 4/9/24 at 2:22 p.m.…

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 implement policies and procedures related to pneumococcal immunizations for five (#63, #68, #84, #3 and #31) of five residents reviewed for immunizations out of 49 sample residents. Specifically, the facility failed to: -Ensure Resident #63, #68, #84, #3 and #31's electronic medical record (EMR) was up to date with their vaccination history; and, -Determine which pneumococcal vaccine was given to Resident #63, #68, #84, #3 and #31 and determine if additional doses were needed. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2022, retrieved on 4/16/24, from: https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, in pertinent part: Routine vaccination - pneumococcal -For those ages 19 to 64 with an additional risk factor or another indication was: One (1) dose PCV15 (pneumococcal…

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 provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure the laundry room was free from multiple environmental concerns observed during tours of the facility. Findings include: I. Facility policies and procedures The Laundry policy and procedure, dated November 2007, was provided by the maintenance director (MTD) on 2/9/24 at 2:22 p.m. It revealed in pertinent part, The facility launders linens and clothing in accordance with current CDC (Centers for Disease Control) guidelines to prevent transmission of pathogens. Laundry equipment will be used and maintained according to manufacturer's instructions. II. Observations of the laundry room on 4/9/24 At 10:16 a.m. the laundry room floor was wet. There was a large drain on the floor that did not have a drain cover on it. There was water leaking from the ceiling onto the floor and the washing machines. The laundry room was wet and slippery. There was a container of sharps…

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 ensure resident choices for two (#87 and #57) of three residents reviewed for activities of daily living out of 49 sample residents. Specifically, the facility failed to: -Ensure Resident #87 and #57 received showers consistently according to their choice of frequency; and, -Ensure Resident #87 and #57's preferences were included in their plan of care. Findings include: I. Facility policy and procedure The Bath, Shower policy, revised August 2021, was provided by the nursing home administrator (NHA) on 4/10/24 at 4:41 p.m. It read in pertinent part, It is the policy of this facility to promote cleanliness, stimulate circulation and assist in relaxation. Residents have the choice between bed bath, shower or bath. When residents admit please review the preference sheet with the Resident. Resident may choose the days of the week they choose to bath or shower. We offer the following options to residents: shower, tub bath or bed bath.…

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 clean, comfortable, homelike environment for residents for one (#93) resident out of 49 sample residents. Specifically, the facility failed to ensure Resident #93's living space was comfortable to him by having access to fresh outside air. Findings include: I. Facility policy and procedure The Safe, Homelike Environment policy, dated October 2007, was provided by the NHA on 4/10/24 at 4:41 p.m. It read in pertinent part, Comfortable and safe temperature levels means the ambient temperature should be in a relatively narrow range that minimizes residents' susceptibility to loss of body heat and risk of hypothermia/hyperthermia and is comfortable for the residents. A homelike environment is the one that de-emphasizes the institutional character of the setting, to the extent possible, and allows the resident to use those personal belongings that support a homelike environment. A determination of homelike should include 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 interviews and record review, the facility failed to initiate and complete a thorough investigation of alleged violations and take appropriate corrective action following the investigation. Particularly relevant when the allegation was verified for one (#79) of four residents reviewed for abuse out of 48 sample residents to alleviate after effects contributing to residents experiencing, among other emotions, anxiety, fear, and humiliation. Specifically, the facility failed to, for Resident #79: -Complete thorough investigations of the alleged violation of mental and verbal abuse that included sufficient evidence to allow the nursing home administrator (NHA) to determine what actions were necessary to protect the resident from further abuse that contributed to residents experiencing, among other emotions, anxiety, fear, and humiliation; -Gather all pertinent unbiased observations to identify pertinent facts of the events that occurred before, during and immediately following the incident to determine…

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 the necessary services to maintain personal hygiene for one (#60) of six residents reviewed for services to maintain highest practicable quality of life out of 49 sample residents. Specifically, the facility failed to provide bathing/showering assistance, grooming for nail care, assistance to change and put on clean clothing. Findings include: I. Facility policy The Activities of Daily living (ADL) policy was provided by the nursing home administrator (NHA) on 4/10/24 at 4:14 pm. It revealed in part, Residents who are unable to carry out activities of daily living (ADL) will receive necessary services or support from staff to maintain: ADL documentation will be maintained in the electronic health record under tasks, care plan, assessments, and therapy documentation including the following areas of care: eating, grooming, personal hygiene, communication, oral hygiene, transfers and ambulation. ADL's will be carefully planned to…

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 (#87) of two sample residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan out of 49 sample residents. Specifically, the facility failed to assess and document Resident #87's blood pressure consistently prior to administering blood pressure medications. Findings include: I. Professional reference According to Khashayar, F., [NAME], J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine, retrieved from: https://www.ncbi.nlm.nih.gov/books/NBK532906 on 4/11/24. Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockage of these receptors with beta-blocker medications can lead to many adverse effects. Bradycarida (low heart rate) and hypotension (low blood pressure) are two adverse effects that may commonly occur. The patient's heart rate and blood pressure require monitoring while using beta-blockers.…

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, staff interviews, and record review, the facility failed to consistently provide catheter care, treatment and services to minimize the risk of urinary tract infections for two (#13 and #83) of two residents reviewed for catheter care out of 49 sample residents. Specifically, the facility failed to ensure there were orders for catheter care and maintenance for Resident #13 and #83. Findings include: I. Facility policy and procedure The Catheter care policy and procedure, revised November 2017, was provided by the nursing home administrator (NHA) on 4/10/24 at 4:41 p.m. It read in pertinent part: It is the policy of this facility that each resident with an indwelling urinary catheter will receive the necessary care and services related to minimizing the risks and promoting the highest practicable well-being. This includes but is not limited to physician's order for medical necessity, care planning the specific catheter size with resident specific interventions, daily catheter care,…

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 residents were free of unnecessary psychotropic medications for one (#87) of five residents reviewed for psychotropic medications out of 49 sample residents. Specifically, the facility failed to attempt a gradual dose reduction (GDR) for Resident #87's use of antidepressant medication, sedative medication and antipsychotic medication or provide substantial documentation by the prescribing physician on why a GDR of the resident's medication was contraindicated. Findings include: I. Facility policy and procedure The Psychotropic Drug Use policy, revised November 2016, was provided by the nursing home administrator (NHA) on 4/10/24 at 4:41 p.m. It read in pertinent part, Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs. Quarterly thereafter, or with any significant change in condition, the residents will…

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 in accordance with accepted professional standards for one of two medication refrigerators and one medication cart. Specifically, the facility failed to; -Ensure controlled medications were in a locked storage container that was permanently affixed to the refrigerator; -Ensure medications were not left in a medication cup on top of the medication cart when not in direct line of sight with the nurse; and, -Ensure that the medication cart was locked when not in direct line of sight of the nurse. Findings include: I. Observations On 4/4/24 at 2:42 p.m., the medication refrigerator was observed with licensed practical nurse (LPN) #2. Six vials of liquid Ativan (a benzodiazepine and a schedule IV controlled substance used to treat anxiety) were in a ziploc bag on the bottom shelf and one bottle of oral Ativan was on the bottom shelf in the refrigerator. -The storage box was being installed in the refrigerator but it was not permanently affixed to the inside of the refrigerator as…

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 manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for two (#57 and #87) of two residents reviewed for pain out of 49 sample residents. Specifically, the facility failed to: -Offer person-centered non-pharmacological pain interventions for Resident #57; and, -Follow physician orders for pain parameters when administering as needed pain medications for Resident #57 and Resident #87. Findings include: I. Facility policy and procedure The Pain Management policy, revised November 2019, was provided by the nursing home administrator (NHA) on 4/10/24 at 4:41 p.m. It read in pertinent part, It is the policy of this facility to provide an environment and programs that assist each resident o attain or maintain the resident's highest practicable physical, mental and psychosocial well being. Residents are provided and receive the care…

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 staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included facility and community based risk assessments, facility resources, types of staff medical practitioners needed, staff training and competency information, and contract and memorandum of understanding information for third party providers in normal and emergency situations. Findings include: I. Record review The facility assessment, reviewed 12/9/22, was received from the nursing home administrator (NHA) on 10/5/23 at 10:50 a.m. The facility assessment failed to include: -The facility-based and community-based risk assessment, utilizing an all-hazards approach; -Identify the facility resources including a 25 bed secure unit and wanderguard system; -Identify the type of staff, health care professionals, medical providers needed to provide care and support 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 interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to resident rights, abuse and neglect, quality of life and quality of care. Findings include: I. Facility policy and procedure The Quality Assurance can Performance improvement (QAPI) policy, revised February 2020, was received from the nursing home administrator (NHA) on 10/9/23 at 9:53 a.m. The policy documented in pertinent part, Provide a means to measure current and potential indicators for outcomes of care and quality of life. The QAPI plan describes a process for identifying and correcting qualified deficiencies. Provide a means to establish and implement performance improvement projects to correct identified…

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 of eight staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA), #13, CNA #14, CNA #15, CNA #9 and CNA #16. Findings include: I. Facility policy The Nurse Aide Qualifications and Training Requirements policy, revised August 2022, was provided by the director of nursing (DON) on 10/9/23 at approximately 1:30 p.m. It revealed in pertinent part, Nurse aides will have a minimum of 12 hours of training in the following areas prior to direct contact with residents: communication and interpersonal skills; infection control, safety/emergency procedures; promoting residents ' independence; respecting residents ' rights; basic nursing skills; personal care skills; mental health and social service needs; care of cognitively…

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 report an allegation of potential abuse to the State Agency in accordance with State law for one (#15) resident of three residents reviewed for abuse out of 22 sample residents. Specifically, the facility leadership failed to report an allegation of verbal abuse of Resident #15 by facility a staff member to the facility administrator, local law enforcement or the State Agency. Findings include: I. Facility policy The Abuse, Neglect, Exploitation and Misappropriation and Prevention Program policy, revised April 2021, was received from the director of nursing (DON) on 9/28/23 at 2:00 p.m. The policy documented in pertinent part, The Abuse, Neglect, Exploitation and Misappropriation and Prevention Program consists of a facility wide commitment and resource allocation to support the following objectives, provide staff orientation and training programs that include topics such as abuse prevention and reporting of abuse, and investigate and report 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 record review, resident and staff interviews, the facility failed to investigate an allegation of abuse for one (#15) of four residents reviewed for abuse out of 22 sample residents. Specifically, the facility failed to thoroughly investigate an allegation of staff to resident physical abuse involving Resident #15. Findings include: I. Facility policy The Abuse, Neglect, Exploitation and Misappropriation and Prevention Program policy, revised April 2021, was received from the director of nursing (DON) on 9/28/23 at 2:00 p.m. The policy documented in pertinent part, The Abuse, Neglect, Exploitation and Misappropriation and Prevention Program consists of a facility wide commitment and resource allocation to support the following objectives,identify and investigate all possible incidents of abuse, neglect mistreatment or misappropriation of resident property. Investigate and report any allegations within time frames required by federal requirements. Protect residents from any further harm during…

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 that the medical record was complete and accurate in keeping with accepted standards of practice for one (#12) out of 22 sample residents. Specifically, the facility failed to contain an accurate representation of incontinence care and meals provided to Resident #12. Findings include: I. Resident #12 A. Resident status Resident #12, age [AGE], admitted on [DATE], readmitted on [DATE] and passed away on 8/30/23. According to the August 2023 computerized physician orders the diagnoses included: neurocognitive disorder with Lewy bodies (dementia), dysphagia (difficulty swallowing), dementia, Parkinson ' s disease (deterioration of the brain), anxiety and depression. The 8/22/23 minimum data set (MDS) assessment revealed she had severe cognitive impairments with short-term and long-term memory deficits according to staff interview. She required extensive assistance of two people for bed mobility, transfers, personal hygiene, walking in her room 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 observations, resident and staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in 15 of 62 resident rooms and on seven of eight hallways. Specifically, the facility failed to ensure: -Walls, ceilings, floors were repaired, painted and properly maintained; -To ensure oxygen concentrators were plugged into electrical outlet instead of a power strip; and, -Comfortable room temperature levels for all rooms in the facility located in the dementia nitunit and dining rooms. Findings include: I. Resident environment A. Initial observations Observations of the resident living environment, conducted on 11/15/22 at 2:15 p.m., revealed: room [ROOM NUMBER]: The tile in front of the resident's restroom had missing floor tiles approximately 24 inches by 24 inches. room [ROOM NUMBER]: The wall in the restroom had six dime sized holes from removal of the grab bar. The wall had an area approximately five feet by four feet which had been repaired but not…

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 prevent resident to resident altercations for six (#35, #59, #74, #99, #70 and #21) of six residents out of 49 residents reviewed. Specifically the facility failed to prevent resident to resident physical abuse altercations between: -Resident #35 and Resident #59; -Resident #74 and Resident #99; and, -Resident #21 and Resident #70. Findings include: I. Facility policy and procedure The Abuse policy, modified on 3/9/19, was received from the nursing home administrator (NHA) on 11/14/22 at 11:47 a.m. It read in pertinent part: Our residents have the right to be free from abuse, neglect, misappropriation of property and exploitation. This includes but is not limited to corporal punishment,involuntary seclusion, verbal, mental, sexual and physical abuse. As part of the resident abuse prevention, the administration will protect our residents from abuse by anyone including other residents, facility staff, volunteer staff, family members or other individuals.…

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 (#15, #95 and #53) of six residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, hygiene, dressing and grooming out of 49 sample residents. Specifically, the facility failed to provide each resident a dignified dining experience with timely feeding assistance, proper positioning, and adaptive equipment as recommended for Resident #15, #95 and #53. Findings include: I. Facility policy and procedure The Meal Assistance policy, dated 2018, was provided by the director of nursing (DON) on 11/17/22 at 6:30 p.m. It read in pertinent part: Residents shall receive assistance with meals in a manner that meets the individual needs of each resident. -Facility Staff will serve resident trays and will help residents who require assistance with eating. -Residents who cannot feed themselves will be fed with attention to safety, comfort and dignity, for example: Not standing over…

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 received necessary respiratory care and services that is in accordance with professional standards of practice, the resident's care plan and the residents choice for three (#96, #90 and #67) of four residents reviewed for oxygen therapy out of 49 sample residents. Specifically, the facility failed to: -Ensure Resident #96, and Resident #90 had complete oxygen orders to include a prescribed liter flow rate; -Ensure Resident #96, and Resident #90 had a person-centered care plan focus for oxygen therapy based upon the resident's assessed needs; and, -Ensure Resident #67's continuous positive airway pressure (CPAP) was cleaned per manufacturer's recommendations. Findings include: I. Facility policy The Oxygen Administration policy, dated 2020, was provided by the nursing home administrator (NHA) on 11/16/22 at 3:15 p.m. It revealed, in pertinent part, Verify that there is a physician's order for this procedure. Review…

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, observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards, for two of four medication rooms. Specifically, the facility failed to discard expired medical supplies and laboratory testing items. Findings include: I. Observations A. Medication room [ROOM NUMBER] On [DATE] at 9:05 a.m., medication room [ROOM NUMBER] was observed with licensed practical nurse (LPN) #1. The following was observed in the clean supply area: -17 vials which were labeled BD Universal Transport for viruses, chlamydia, mycoplasma, ureaplasma, expired on [DATE], which was 139 days prior. B. Medication room [ROOM NUMBER] On [DATE] at 1:30 p.m., medication room [ROOM NUMBER] was observed with registered nurse (RN) #3. The following was observed in the clean supply area: -Seven packaged kits labeled: Wolf Pak dressing change kit with cholera prep on step application, labeled with an hour-glass symbol and expired [DATE], 506…

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 ensure food was prepared, stored, and served under safe and sanitary conditions to prevent the potential contamination of food and the spread of food-borne illness in one of one kitchens and one of two dining rooms. Specifically, the facility failed to: -Ensure food was served in a sanitary manner where staff did not handle resident ready to eat foods with bare unwashed hands; and, -Ensure staff performed proper hand hygiene prior to assisting a resident with their meal. Findings include: I. Professional standards According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19), retrieved online https://drive.google.com/file/d/18-uo0wlxj9xvOoT6Ai4x6ZMYIiuu2v1G/view, 11/28/22; read: Employees are preventing cross-contamination of ready to eat foods with bare hands by properly using suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. II. Facility policy and procedure The Preventing Foodborne Illness - Employee Hygiene 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 and interviews the facility failed to ensure that the personal funds account were managed adequate for one (#39) of one resident reviewed for personal funds out of 49 sample residents. Specifically, the facility failed to ensure Resident #39 was aware of personal funds and was able to access his funds on the weekend. Findings include: I. Resident #39 status Resident #39, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), the diagnoses included hemiplegia and hemiparesis following a cerebrovascular disease affecting the right dominant side (stroke with right sided weakness), protein calorie malnutrition, cognitive communication deficit and heart disease. The 10/16/22 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) with a score of 15 out of 15. He required supervision with transfers and was independent for all other activities of daily living (ADLs). II. 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 record review and interviews, the facility failed to establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf for one (#39) of one reviewed for personal funds out of 49 sample residents. Specifically, the facility failed to ensure quarterly statements were provided for Resident #39. Findings include: I. Facility policy The Resident Trust policy and procedure, undated, was provided by the nursing home administrator (NHA) on 11/16/22 at 3:15 p.m. It revealed, in pertinent part, Quarterly statement shall be mailed to the family, resident and or responsible parties on file with the business office and only to those individuals listed on the Patient Trust Agreement form that is maintained in the business office file for each individual resident. II. Resident #39 status Resident #39, age [AGE], was admitted on [DATE]. 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 record review and interviews, the facility failed to coordinate the appropriate relocation following facility-initiated transfer and discharge for one (#106) of two residents reviewed for discharge out of 49 sample residents. Specifically, the facility failed to ensure Resident #106 was provided: -An updated comprehensive care plan and discharge plan, when the facility issued a facility initiated discharge notice; and, -An effective discharge planning process that focused on the resident's discharge goals. The facility further failed to: -Consider the availability or lack of caregiver/support; and the resident's capacity and capability to perform required care, as part of the identification of discharge needs; -Ensure the resident was discharged to a safe location; -Involve the resident representative medical durable power of attorney (MDPOA) in the development of the discharge plan from the start of the facility-initiated discharge to the final plan for discharge; -Document the resident's interest in…

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 staff reviews, the facility failed to provide notice of discharge to the resident representative and Office of the State Long-term Care Ombudsman at least 30 days before the resident's discharge for one (#106) of two reviewed for discharge out of 49 sample residents. Specifically, the facility failed to: -Ensure the resident was provided an appropriate discharge notice at least 30 days prior to actual discharge date ; -Ensure Resident #106 and the resident representative/medical power of attorney (MDPOA) was provided written notice of transfer/discharge in a language/format the resident could understand; -Ensure the resident and resident representative were fully informed of their appeal rights and how to request and file an appeal to the resident's discharge from the facility; -Provide the resident and resident representative with information about the specific location where the resident would be discharged ; -Provide the resident and resident representative with the mailing 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 and staff interviews, the facility failed to incorporate the recommendations from the PASARR (preadmission screening and resident review) level II determination and evaluation report into the assessment, care planning and transition of care for two (#62 and #21) or four residents reviewed for PASARR out of 49 sample residents. Specifically, the facility failed to: -Take steps to ensure services were provided as recommended in Resident #62 and Resident #21's PASARR level II report; -Ensure the PASSAR recommendations were included in Resident #62 and Resident #21's medical record; and, -Ensure the PASSAR recommendations were included in Resident #62 and Resident #21's care plans. Findings include: I. Resident #62 A. Resident status Resident #62, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO) diagnoses included respiratory failure, paranoid schizophrenia (mental disorder that causes impaired perception of reality) and dementia. The 8/4/22…

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 proper activities of daily living care (ADLs) for two (#21 and #25) of two residents reviewed for ADL care out of 49 sample residents. Specifically, the facility failed to: -Address Resident #21's request for incontinent care in a timely manner; and, -Implement an effective communication system for Resident #25. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADLs): Supporting policy, revised March 2018, provided by the nursing home administrator (NHA) on 11/21/22 at 11:47 a.m., read in pertinent part, residents would be provided with care, treatment and services as appropriate to maintain or improve their ability to carry out ADLs. Residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming, and personal and oral hygiene. II. Resident #21 A. Resident status Resident #21, age [AGE], was admitted 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 resident observations, record reviews, and interviews, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (#82) of two residents reviewed for urinary tract infections of 49 sample residents. Specifically, the facility failed to for Resident #82: -Provide timely nursing assessment of urinary status/condition when the resident experienced a change in condition consistent with a urinary tract infection; and, -Ensure the consistent nursing assessment and catheter care for a placed indwelling urinary catheter to ensure urinary health. Findings include: I. Professional reference According to [NAME], P.A., [NAME], A.G. , et.al. Fundamentals of Nursing, tenthed., 2021, pp. 1155,-1160: Urinary tract infections are the most common hospital acquired infection, accounting for up to 40% of infections reported by acute care hospitals. The major risk factors for catheter-associated urinary tract infection…

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 behavior monitoring was conducted for target behaviors related to the use of a stimulant for one (#62) of five residents reviewed for unnecessary medications of 49 sample residents. Specifically, the facility failed to track and document binge and purge behaviors prior to and after starting a stimulant medication for Resident #62. Findings include: I. Facility policy The Behavioral Assessment, Intervention, and Monitoring policy and procedure, initiated 2018, was provided by the director of nursing (DON) on 11/17/22 at 6:05 p.m. It read, in pertinent part, Behavioral symptoms will be identified using facility-approved behavioral screening tools and the comprehensive assessment. The facility will comply with regulatory requirements related to the use of medications to manage behavior changes. The interdisciplinary team (IDT) will evaluate behavioral symptoms in residents to determine the degree of severity, distress and potential…

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 menus were followed to meet the resident's cultural needs for one (#25) of one resident reviewed for nutrition out of 49 sample residents. Specifically, the facility failed to ensure reasonable efforts to meet the ethnic and cultural food needs of Resident #25. Findings include: I. Facility policy and procedure The Resident Food Preferences policy and procedure, dated September 2017, was provided by the director of nursing (DON) on 11/17/22 at 6:00 p.m. It revealed in pertinent part: Individual food preferences will be assessed upon admission and communicated to the interdisciplinary team. Modifications to diet will only be ordered with the resident's or representative consent. II. Resident #25 A. Resident status Resident #25, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included pulmonary fibrosis, atrial fibrillation, anxiety, adult failure to thrive, dysphagia…

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 the hospice services provided meet professional standards and principles that applied to individuals providing services in the facility for one (#90) of two residents reviewed for hospice services out of 49 sample residents. Specifically, the facility failed to: -Have a written agreement to ensure for Residents #90, a written plan of care included both the most recent hospice plan of care and a description of the services furnished by the long term care (LTC) facility; and, -Ensure that the LTC facility staff provide orientation regarding the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff. Findings include: I. Resident #90 A. Resident status Resident #90, age [AGE], was admitted on [DATE]. According to the November 2022 computerized physician orders (CPO), diagnoses included heart failure, dysphagia (swallowing difficulty), and lack 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.