Southeast Colorado Hospital LTC

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#1) of three residents reviewed for accidents out of three sample residents. Specifically, the facility failed to: -Ensure Resident #1 had an individualized care plan with person-centered interventions to prevent elopement; and, -Ensure Resident #1 was provided with the supervision necessary to prevent an elopement. Findings include: I. Facility policy and procedure The Elopement and Wandering policy and procedure, revised June 2019, was provided by the nursing home administrator (NHA) on 4/22/25 at 3:05 p.m. It read in pertinent part, The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement. Procedure: -Staff will identify residents who are risk for harm because of unsafe wandering; -Staff will assess at-risk residents for potentially correctable risk factors related to unsafe…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection. Specifically, the facility failed to: -Ensure residents were offered hand hygiene prior to eating; -Ensure hand hygiene was performed appropriately while serving meals and assisting residents with eating; -Ensure housekeeping staff disinfected high touch surfaces (call lights, bed controls, hand rails and light switches) in resident rooms; -Ensure gloves were changed and hand hygiene was performed appropriately when needed during the cleaning of residents' rooms. Findings include: I. Failure to ensure residents were offered hand hygiene prior to eating A. Observations During a continuous observation on 11/18/24, beginning at 11:24 a.m. and ending at 12:15 p.m., the following was observed: A hand sanitizing wipe dispenser was located inside the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure the resident's right to receive services in the facility with reasonable accommodation of the resident's needs and preferences for two (#20 and #13) of five residents reviewed for accommodation of needs out of 22 sample residents. Specifically, the facility failed to ensure Resident #20 and Resident #13 were able to self-adjust the water coming out of the faucets in their room sinks to a safe and comfortable temperature for their personal use when completing activities of daily living (ADL), including hand hygiene and grooming tasks. Findings include: I. Professional reference According to the National Institute of Health (NIH) Examining the Impact of Familiarity On Faucet Usability For Older Adults With Dementia, retrieved on 12/2/24 from https://pmc.ncbi.nlm.nih.gov/articles/PMC3716871/, A person's ability to complete ADLs is not only necessary for physical well-being, but is central to one's independence, pride, and dignity. 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 interviews and record review, the facility failed to ensure one (#18) of one resident out of 22 sample residents was kept free from abuse. Specifically, the facility failed to identify a pattern of concerns regarding the care provided by certified nurse aide (CNA) #1 in order to prevent an incident of verbal abuse by CNA #1 toward Resident #18. Findings include: I. Facility policy and procedure The Alleged or Suspected Violations of Patient or Resident Rights policy and procedure, dated September 2022, was provided by the director of nursing (DON) on 11/21/24 at 6:32 p.m. It read in pertinent part, All procedures will follow the elements of the Elder Justice Act which describes the responsibilities for long term care providers, caregivers - paid or volunteer, home health providers or any facility staff who provide direct care to an at-risk elder. Abuse is the willful infliction of injury, unreasonable confinement, intimidation or punishment with resulting physical harm, pain or mental anguish, or…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain proper nutrition and personal hygiene for three (#4 and #21) of three residents reviewed out of 22 sample residents. Specifically, the facility failed to: -Provide Resident #4, a resident assessed to need supervision, cueing, encouragement and occasional physical assistance with meals the necessary assistance to eat and maintain proper nutrition; and, -Provide Resident #21 with timely incontinence care. Findings included: I. Professional reference According to the Alzheimer's Association, Food and Eating, 2024, retrieved on 12/2/24, from https://www.alz.org/help-support/caregiving/daily-care/food-eating Proper nutrition is important to keep the body strong and healthy. For a person with Alzheimer's or dementia, poor nutrition may increase behavioral symptoms and cause weight loss. Possible causes of poor appetite…

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 properly stored and labeled in accordance with professional standards in one of two medication carts and two of two medication storage rooms. Specifically, the facility failed to: -Ensure expired medications were removed from the medication carts and medication storage rooms; and, -Ensure the temperature of the medication storage refrigerator and the vaccine storage refrigerator were checked and recorded daily. Findings include: I. Professional reference The United States Food and Drug Administration (USFDA) (2/8/21) Don't Be Tempted to Use Expired Medicines, was retrieved on 11/25/24 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…

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 stored, prepared and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff; and, -Cutting boards were free from deep scratches and stains. Findings include: I. Improper hand hygiene A. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg. 46-47, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service items and: Before handling or putting on single use gloves for working with food, and between removing soiled gloves and putting on clean gloves. Food employees shall clean their hands and exposed portions of their arms including surrogate prosthetic devices for hands or arms with soap and water for at least 20 seconds and shall use the following cleaning procedure: 1. Vigorous…

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 staff interviews, the facility failed to maintain a sanitary, orderly, and comfortable environment for residents in eight of 35 resident rooms in two hallways. Specifically, the facility failed to ensure walls and doors were properly maintained. Findings include: I. Initial observations Observations of the resident living environment was conducted on 6/14/23 at 2:00 p.m. revealed: room [ROOM NUMBER]: The wall behind the resident's headboard had deep scratches and gouges approximately 12 inches long by one inch wide from the bed being lifted and lowered. room [ROOM NUMBER]: The wall behind the resident's headboard had deep scratches and gouges approximately 11 inches long by one inch wide from the bed being lifted and lowered. room [ROOM NUMBER]: The wall behind the resident's headboard had deep scratches and gouges approximately 12 inches long by one inch wide from the bed being lifted and lowered. The lament in front of the sink was chipped and missing a section approximately four…

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 two (#32 and #29) of five residents out of 21 sample residents. Specifically, the facility failed to: -Evaluate the use of an as needed PRN antipsychotic medication by a physician within 14 days for Resident #38; -Provide non-pharmacological interventions for Resident #38 prior to administration of a PRN antipsychotic medication; -Identify and track behaviors for the use of psychotropic medications for Resident #38 and #29; -Monitor side effects of psychotropic medications for Resident #38 and #29; -Evaluate the use of an as needed PRN psychotropic medication by a physician within 14 days for Resident #29; and, -Provide non-pharmacological interventions for Resident #29 prior to administration of a PRN psychotropic medication. Findings include: I. Facility policy and procedure The Unnecessary Psychotropic Medication policy, revised May 2022, was provided 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 record review and interviews, the facility failed to coordinate assessments with the preadmission screening resident review (PASRR) program for one (#38) of five reviewed for PASRR out of 21 sample residents. Specifically, the facility failed to: -Take steps to ensure services were provided as recommended in the resident's PASRR level II for Resident #38; and, -Notify the State Mental Health Agency that recommendations could not be met for Resident #38. Findings include: I. Resident status Resident #38, age [AGE], was admitted on [DATE]. According to the March 2023 computerized physician orders (CPO), diagnoses included schizophrenia and tobacco use. The 5/29/23 minimum data set (MDS) assessment showed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident was independent with activities of daily living. There were no behaviors noted in the MDS. II. Record review Resident #38's preadmission screening and resident review (PASRR) dated…

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 develop and implement a comprehensive person-centered care plan, consistent resident rights, that included measurable objectives and timeframes to meet medical, nursing, mental and psychosocial needs for one (#27) of five residents reviewed for comprehensive care plans of 21 sample residents. Specifically, the facility failed to have a person-centered, resident-specific, vision care plan for Resident #27. Findings include: I. Resident status Resident #27, age [AGE], was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO), diagnoses included headaches, dizziness and giddiness. The 4/17/23 minimum data set (MDS) assessment revealed the resident had mild cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The MDS assessment identified the resident needed corrective lenses. II. Resident interview Resident #27 was interviewed on 6/13/23 at 9:25 a.m. She said she had glasses on her bed…

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 dependant residents received services necessary to maintain or improve the ability to perform activities of daily living (ADLs) for one (#3) of four residents reviewed for ADLs out of 21 sample residents. Specifically, the facility failed to provide treatment and services for toileting, eating and repositioning consistent with needs and plan of care for Resident #3. Findings include: I. Resident status Resident #3, age of 90, was admitted on [DATE]. According to the June 2023 computerized physician orders (CPO) diagnoses included acute kidney failure, diabetes, dysphagia (difficulty swallowing), aspiration pneumonia (inflammation of the lungs due to food or liquid being breathed into the airways), history of pressure ulcer (stage 3) to sacral region (tailbone), urinary incontinence, stroke and traumatic brain injury. The 4/25/23 minimum data set (MDS) quarterly assessment revealed the resident had severe cognitive impairment with…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure resident care consistent with professional standards of practice, to prevent avoidable pressure ulcers for one (#30) of three residents reviewed out of 20 sample residents. Specifically, the facility failed to ensure the resident did not develop avoidable deep tissue injuries to his bilateral great toes by: -Ensuring the removal of the resident's socks while in bed, to prevent irritation/pressure to the bilateral great toes; -Ensuring the implementation of interventions to keep the resident's bed covers from touching the tips of the resident's bilateral great toes; and, -Updating the resident's care plan to include interventions for the resident's right great toe deep tissue injury. These failures contributed to the resident developing deep tissue injuries to both of his great toes, which increased in size. Additionally, these failures contributed to delayed wound healing. Findings include: I. Professional reference According 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 observations, record review and interviews, the facility failed to ensure residents were as free from unnecessary psychotropic drugs as possible for two (#28, and #33) of five residents out of 20 total sample residents. Specifically, the facility failed to: -Ensure consent was obtained and residents and/or their responsible parties were informed of psychotropic medications with black box warnings (the Food and Drug Administration ' s strictest and most serious type of warning which describes a medication ' s serious or life-threatening side effects or risks) prior to the administration of the medication for Resident #28; -Consistently track behaviors to justify the use of an antipsychotic medication for a resident with dementia for Resident #28 and Resident #33; and, -Attempt a gradual dose reduction (GDR) of an antipsychotic medication for a resident with dementia for Resident #28. Findings include: I. Facility policy and procedures The Unnecessary Drugs policy, last revised 9/2013, was provided by the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.