Trinidad Rehabilitation And Healthcare Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure three (#2, #21, #54) of five residents reviewed for unnecessary medications out of 37 sample residents were free from unnecessary medications. Specifically, the facility failed to: -Ensure Resident #2, Resident #21 and Resident #54 had appropriate non-pharmacological interventions for behaviors initiated; and, -Ensure informed consent, which included the risks associated with taking a psychotropic medication, were obtained from the resident or resident's representative before the resident's use of a psychotropic medication for Resident #2, Resident #21 and Resident #54. Findings include: I. Facility policy The Psychotropic Medication Use policy, revised July 2022, was provided by the nursing home administrator (NHA) on 6/5/24 at 12:00 p.m. It read in pertinent part, Non-pharmacological approaches are used to minimize the need for medications, permit the lowest possible dose, and allow for the discontinuation of medications when possible.…

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 hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#89) of five residents receiving hospice services out of 37 sample residents. Specifically, the facility failed to orient hospice aides to the facility, including the policies and procedures. Findings include: I. Facility policy The Hospice Program policy, revised July 2017, was provided by the nursing home administrator (NHA) on 6/5/24. It read in pertinent part, Ensuring that our facility staff provides orientation on the policies and procedures of the facility, including resident rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to the residents. II. Resident status Resident #89, age [AGE], was admitted on [DATE]. According to the June 2024 computerized physician's orders (CPO), diagnoses included neoplasm of the prostate, chronic kidney disease 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 observation, record review and interviews, the facility failed to ensure freedom from abuse for six (#14, #19, #29, #36, #37 and #66) of six residents reviewed out of 52 sample residents. Specifically, the facility failed to protect Residents #29, #37 and #66 from physical abuse by Resident #36 who was physically aggressive toward others and protect Resident #14 from physical abuse by Resident #19. Cross reference F609 failure to report abuse allegations. Findings include: I. Facility policy and procedure The abuse policy entitled Resident safety dated 5/31/19 was sent via email by the nursing home administrator (NHA) on 2/12/2020. It read, in pertinent part; It is the policy of our facility to maintain a work and living environment that is professional and free from threat and/or occurrence of harassment, abuse (verbal, mental or sexual), neglect, corporal punishment, involuntary seclusion and misappropriation of property; -Our facility promotes an atmosphere of sharing with residents and staff without…

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 to the state survey and certification agency, in accordance with state law, five of five incidents of physical abuse stemming from resident-to-resident altercations in the memory care unit. The facility failure to report alleged abuse involved six (#14, #19, #29, #36, #37 and #66) of six residents reviewed for abuse reporting out of 52 sample residents. Cross-reference F600 Free from Abuse Findings include: I. Facility policy and procedure The abuse policy entitled Resident safety dated 2/1/11 was sent via email by the nursing home administrator (NHA) on 2/12/12020 . It read, in pertinent part; any suspected, observed or reported violation of this resident safety policy will be reported to the supervisor on duty. The supervisor on duty shall report any suspected violations of this resident safety policy immediately to the administrator and to the director of nursing (DON) or their designee(s) as soon as practicable. The state Department 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 provide written notice of the bed hold policy before transfer to the hospital to the residents or their representatives in a sample of four ( #248, #63, #80 and #60) of four out of 52 total sample residents reviewed. Specifically the facility failed to ensure: Resident #248, #63, #80 and # 60 were informed,in writing of the bed hold policy, when they were transferred to the hospital from the facility. Findings include I. Policy The bed hold policy read, residents who were discharged or transferred from the facility to a hospital or other facility upon physician's orders or who leave the facility for any reason, medical or otherwise shall be offered a reservation on their bed at the facility under the following conditions. The policy shall be included in the admissions contract, and must additionally be furnished to the resident at the time of transfer or discharge. II. Resident #248 A. Resident #248, 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.

Based on observations and staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness through proper kitchen sanitation procedures. Specifically, the facility failed to ensure: -Holding temperatures were at appropriate level; -Adequate hand washing occured; -Moisture was not between stacked pans; and, -Health shakes were appropriately dated. Findings include: I. Food temperatures of cold and hot food items were not held at the proper temperature to reduce the risk of food borne illness. A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. It read in pertinent part; The food shall have an initial temperature of 41ºF or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control. B. Main kitchen The evening meal…

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 and identify what resources are necessary to care for its residents appropriately during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which was specific to the residents of the facility. Findings include: The deficiency was cited previously during a recertification survey on 2/7/19. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with the regulatory requirement. I. Record review The facility assessment was last reviewed on 1/10/2020 by the nursing home administrator (NHA). The facility assessment failed to include the following: -Include staff competencies that were necessary to provide the level and types of care needed for the resident population or include the staff training program to ensure any training needs were met for all new and existing staff; -Identify the certified medication technicians job duties…

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 staff, medical director interviews and record review, the facility failed to ensure all responsibilities of the medical director were effectively performed, which had the potential to affect all residents of the facility. Specifically the facility failed to ensure: -The medical director fulfilled his responsibility for the implementation of resident care policies or the coordination of medical care in the facility; and, -Participated in the Quality Assessment and Assurance (QAA) committee or assigned a designee to represent him/her. Findings include: I. Medical director agreement The medical director (MD) independent contract agreement was signed 2/2/11. The agreement documented the medical director shall participate in the development and annual review of written facility policies and procedures as they relate to resident medical and nursing. The MD will serve on the quality assurance committee, infection control committee, pharmacy committee. Review of incident and accident reports as may be requested by the facility nursing home administrator to identify health 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.

Based on record review and staff interview the facility failed to have in effect a written transfer agreement with one or more hospitals approved for participation under Medicare and Medicaid programs in order to reasonably ensure residents would be transferred from the facility to a hospital, and assured of timely admission to the hospital when transfer was medically appropriate. Findings include: Record review The facility was unable to provide a written agreement for the one area hospital. The facility provided a transfer agreement between the area hospital and the facilities prior ownership. The agreement was between the former owner and the area hospital which was dated 8/1/95. Interview The nursing home administrator was interviewed on 2/5/2020 at 8:00 a.m. The NHA said she did not have a written transfer agreement. She provided the version from 1995 and previous owners, as mentioned above. Follow-up The NHA was interviewed a second time on 2/5/2020 at approximately 1:00 p.m. The NHA said she contacted the hospital and an hospital transfer agreement was signed. The agreement…

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, abuse prevention and reporting, kitchen sanitation, staff competencies, meaningful activities, medication administration, facility assessment, unnecessary medications. Findings include: I. Cross-reference citations Cross-reference F600: The facility failed to ensure freedom from abuse. The facility's failure to identify and address quality concerns of abuse resulted in the facility having substandard care. The facility's failure to report all alleged violations of potential abuse was cited at a F level and resulted in substandard care. Cross-reference F609: The facility failed to report alleged violations 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.

Based on record review and staff interview, the facility failed to ensure for three (#25, #82, and #94) of six residents who receive Medicaid benefits were notified out of 52 total sample residents. Specifically, the facility failed to ensure: -Residents/legal representatives were notified when personal funds account reached $200.00 less than resource limit allowed for one person. Findings include: I. Record review The Trial Balance, dated 2/3/2020, revealed three sample Residents (#25, #82 and #94) had a personal needs account (PNA) balance within $200 of the State allowable limit of $2000.00. The medical records for Resident #25, #82 and #94 failed to show any evidence that the family had been contacted and notified of the PNA account was within $200 of the State allowable limit of $2000.00 A. Resident #25 Resident #25 PNA quarterly statements dated 11/1/19 through 1/13/2020 showed an opening balance of $1708.26 and an ending balance of $1963.88. The Resident's account had been within $200 of the State allowable resource limit of $2000.00 for the last two months. The PNA ledger…

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, staff interview, the facility failed to inform two of three sample residents (#18 and #96) of changes in services covered by Medicare, in a timely and appropriate manner. Specifically, the facility failed to demonstrate that residents who previously received skilled nursing facility services (SNF), funded through Medicare benefits, had received timely and appropriate written notice of discontinuation of benefits and notice of liability. Findings include: I. Resident #18 A. Notice of Medicare Provider Non-Coverage Resident #18 The Notice of Medicare Provider Non-Coverage (NOMPNC) for resident #18 was not delivered in a timely manner. According to the facility, the last covered day (LCD) was 10/3/19. However, the NOMPNC showed the notice was not given timely and was given on 10/7/19 which was six days late. B. Liability Notices According to the documentation provided by the facility on 2/5/2020, the Medicare Part A benefits were terminated for resident #18 on 10/3/19 and the resident continued to reside in the facility after the termination of benefits. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure five (#1, #78, #26, #77 and #37) of 10 residents reviewed for activities of 20 sample residents had an ongoing activity program based on comprehensive assessments, care plans and resident preferences. Specifically, the facility failed to provide person centered, meaningful activities that met the interests and needs of Residents #1, #78, #26, #77 and #37. Findings include: I. Facility policy and procedure The Activities in Nursing Home policy, dated 6/9/16, was provided by the medical records director on 2/5/2020 at 11:15 a.m. It revealed in pertinent part, Because absence of meaningful and/or enjoyable activity can lead to mental and physical deterioration in residents, the Activities Department will work as a member of the interdisciplinary team to keep resident functioning at the highest level possible in all dimensions of life, physical, mental, social, emotional and spiritual, encourage independence and pre-institutional…

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 interview, the facility failed to ensure five out of five nurses were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care. Specifically, the facility failed to conduct comprehensive competencies in skills for nurses. Findings include: I. Facility demographics Cross-reference F838 due to the facility assessment failed to include the complete and through competencies for licensed nurses. The January 2020 Census and Condition form was provided by the director of nursing (DON) on 1/27/2020 at 11:00 a.m. It documented 44 residents were on respiratory treatments, two residents had indwelling or external catheters and one resident with colostomy. The Facility Assessment last updated January 2020, was provided by the nursing home administrator (NHA) on 1/27/2020 at 11:00 a.m. It identified nursing staff competencies to provide care needed for the residents were: hand hygiene, meal feeding skills, medication pass and needle skills. The…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, record review and interviews, the facility failed to ensure six (#14, #19, #29, #36, #37 and #66) of six residents reviewed out of 52 sample residents received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. The facility was aware that Resident #36 with a diagnosis of dementia with behavioral disturbance and had physical resident-to-resident altercations with four residents (#29, #36, #66 and #37) when she resided on the secured unit. The facility failed to comprehensively assess and effectively identify person-centered approaches for dementia care for Resident #36 by addressing repeated behavioral issues created an environment where the 16 other residents residing on the secured unit were at risk for harm. The facilities failures to implement appropriate interventions timely for Resident #36 who had documented history of resident-to-resident altercations towards multiple residents contributed 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.

Based on observation, record review and interviews, the facility failed to ensure it was free of a medication error rate of five percent or greater for two (#8 and #96) out of nine residents observed during medication administration. Specifically, the facility failed to: - Ensure the correct strength of Refresh eye drop was administered to Resident #96, - Ensure prescribed medications were administered at the scheduled time for Residents #8 and #96, - Ensure Resident #8's mouth was rinsed after the administration of his inhaler, - Prevent an error rate of 36.67%, resulting from eleven medication errors out of 30 opportunities. Findings include: I. Facility policy The Medication Administration policy dated February 2011, was provided by the director of nursing (DON) on 2/4/2020 at 11:00 a.m. It read in pertinent part, If there is any discrepancy between the medication administration record (MAR) and the label, check physician orders before administering the medication. If mediation is given at a time different from the scheduled time, give reason for change in time in the electronic…

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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to provide assistance with hand hygiene to the residents before meals. Findings include Observations On 1/27/2020, 1/28/2020 and 1/29/2020, prior to the lunch and supper meals, as staff assisted residents into the downstairs dining room, the staff failed to offer and provide hand hygiene assistance before residents ate their meals. On 1/30/2020, prior to the lunch and supper meals, as staff assisted residents into the main dining room, the staff failed to offer and provide hand hygiene assistance before residents ate their meals. Staff interview The director of nursing (DON) was interviewed on 2/5/2020 at 6:06 p.m. She said she was the facility's infection control preventionist. She said all staff were trained on proper hand washing techniques.The process for 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 staff interviews and resident record review, the facility failed to designate a resident representative to advocate for the resident and ensure advance directives matched the resident's current needs and wishes for one (#83) of three residents reviewed out of 52 sample residents. Specifically, the resident was not provided an opportunity to have interested parties attend care plan conferences, and be involved in advanced directives as the resident's health and ability to participate had declined. Findings include: I. Facility policy and procedure The Surrogate Decision Making policy, undated, provided by the nursing home administrator (NHA) on [DATE], revealed in pertinent part: An appropriate surrogate is designated to make decisions on behalf of a resident who is incapable of making decisions for self. -Surrogate decision making because of resident mental incompetence to make personal health care decisions must be supported by court approval or by the observed fact that resident is unresponsible (sic)…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#94) of one out of a total of 52 sampled residents who entered the facility with limited mobility and range of motion received appropriate services and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrated as unavoidable, out of 52 sample residents. Resident #94, who required supervision with ambulation in his room and on the corridor had a decline in his mobility which showed he no longer ambulated in the corridor and required limited assistance in his room. He had an avoidable decline in his walking ability after staff failed to assess for interventions. The staff failed to update the care plan with interventions and to initiate recommendations for walking with the resident. As a result of the facility's failures Resident #94 went from walking with supervision in the corridor to limited assistance and now to the activity not occuring. Findings…

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 ensure residents were free from accidents for two of one residents (#61) out three out of 52 total sampled residents. Specifically the facility failed to ensure: -Resident #61 received appropriate assessments, interventions, and post-fall reviews to ensure further falls were prevented. (Cross-reference to F695). Findings include: I. Facility policy and procedure The Accident/Incident Report policy, undated, provided by the nursing home administrator (NHA) on 2/4/2020, revealed in pertinent part: An accident is defined as any happening, not consistent with the routine operation of the long-term care facility. -All residents who fall or are found on the floor must have their vital signs taken as soon as possible. -Update resident care plan. II. Resident #61 Resident #61 was admitted to the facility 3/9/11, and readmitted on [DATE]. According to the February 2020 medication administration record (MAR), diagnoses include…

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

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews, and record review, the facility failed to ensure appropriate respiratory services were provided for one (#61) of five residents reviewed out of 52 sample residents. Specifically, the facility failed to ensure physician orders were followed and respiratory care was provided per professional standards for Resident #61. Cross-reference to F689, accident hazards Findings include: I. Resident #61 status Resident #61 was admitted on [DATE] and readmitted [DATE]. According to the February 2020 computerized physician orders (CPO), diagnoses included schizoaffective disorder bipolar type, history of falling, chronic kidney disease stage 3, folate deficiency anemia, and low back pain. The 12/30/19 quarterly minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The resident had behaviors, present and fluctuating, of inattention and disorganized thinking. The resident was on oxygen.…

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, interview, and record review, the facility failed to ensure for two (#16 and #248) of six residents reviewed for the use of unnecessary medications out of 52 total residents were free from unnecessary drugs. Specifically, the facility failed to: -Ensure gradual dose reduction was attempted for Resident #16; and -Provide non pharmacological interventions for Resident #248 before administering antipsychotic medications. Findings include: I. Resident #16 A. Resident status Resident #16, under [AGE] years old, was admitted on [DATE]. According to the January 2020 computerized physician orders (CPO) diagnoses included mild intellectual disabilities, type 2 diabetes, hemiplegia from cerebral vascular disease. The 11/15/19 minimum data set (MDS) assessment revealed the resident had not cognitive impairment with a brief interview for mental status (BIMS) of 15 out of 15. The resident exhibited no behaviors, and showed no symptoms of depression. The resident was coded as received an antidepressant…

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 interview, the facility failed to have sufficient staff with the appropriate competencies in skills and techniques necessary to care for residents ' needs, as identified through resident assessments, and described in the plan of care. Cross reference F838-failed to have a completed comprehensive facility assessment Specifically, the facility failed to: -Provide a completed facility assessment and with the lack of skill competencies the facility could not make sure the cares provided were up to professional standards; and, -Document and ensure the above CNAs and CNA-MED had completed competencies in skills and techniques. Findings include: Record review No competencies for staff were found in the files for the CNAs. Interviews CNA #8 was interviewed on 2/7/19 at 9:20 a.m. He said he had not had to demonstrate his skills in order to prove his competency in providing care before providing care. CNA #7 was interviewed on 2/7/19 at 9:42 a.m. She said she had not had to demonstrate her skills in order to prove her competency in providing care before providing…

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 of one kitchens. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff. Findings include: I. Improper hand hygiene A. Professional references A. According to the Centers for Disease Control (CDC), Hand Hygiene in Healthcare Settings, March 2016, https://www.cdc.gov/handhygiene/providers/index.html (January 2018). It read in pertinent part, .When to Perform Hand Hygiene .After contact with inanimate object (including medical equipment) in the immediate vicinity of the patient . B. According to Aurora Health Care, Neutropenic Precautions, May 2016, https://ahc.aurorahealthcare.org/fywb/X31975.pdf (January 2018). It read in pertinent part, . Placing you on neutropenic precautions means that we are taking extra steps to protect you from germs, because you have a lowered ability to fight infections .Read and follow the instructions on the door. Family/visitors may be asked to wear a mask 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.

Based on record review and interview, 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 have a comprehensive facility assessment. I. Findings include The facility assessment (FA) was reviewed and revealed it was not a comprehensive assessment of the facilities resources necessary to provide daily care to the resident population. The FA was developed on 12/29/17 and updated 1/2/19. The facility had a secured unit with 23 residents. The FA did not identify a secured unit. The facility failed to identify the care required by the resident population specifically the secured unit. The FA did not complete the ethnic, cultural, and religious factors to include languages, cultural preferences, and religions within the resident population. The FA did not include a staffing plan to include sufficient staff to meet the needs of the residents at any time. The FA did not identify staff training 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.

Based on observations and staff interviews, the facility failed to provide sufficient support personnel competent to carry out the functions of the dietary service for one of two dining rooms. Specifically, the facility failed to ensure an adequate system was in place to provide meal services in a timely fashion to residents seated in the secured dining room. Findings include: The food was prepared in the main kitchen and transported to the secure unit at all meal times. The meal carts were brought into the secure unit at 11:50 a.m. A. Posted mealtimes The posted meal times for the main dining room were breakfast was scheduled to begin breakfast at 6:30 a.m., lunch at 10:30 a.m. and dinner at 3:30 p.m. B. Lunch observations On 2/4/19 at 11:03 a.m., 14 residents were observed sitting in various locations in the Cokedale dining room. Residents were helped to their respective tables. -At 11:36 a.m., 19 residents were seated in the dining room. -At 11:42 a.m.-11:45 a.m., two certified nurse aide (CNA)'s started taking residents orders and serving drinks to the residents. -At 11:45 a.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 observations, record review and interview, the facility failed to ensure for one (#42) of 34 residents had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility out of 34 sample residents. Specifically, the facility failed to allow Resident #42 a visit with a lawyer for a change of power of attorney (POA). I. Professional reference Shari D Caton, Esq. Colorado Bar association, Power of Attorney, http://www.cobar.org/portals/cobar/repository/SLH/chap23.pdf (2/12/19), .Does a power of attorney take away a principal's rights? A power of attorney does not take away a principal ' s right to make decisions. An agent simply has the power to act along with the principal in accordance with the authorization set forth in the document. Only a court, through a guardianship and/or conservatorship proceeding, can take away a principal ' s rights . Can a principal change his or her mind? A principal may change his or her mind 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, record review and interview, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services and assistance during meals for one (#77) of four residents reviewed for meal assistance of 34 sample residents. Specifically, the facility failed to provide timely assistance during a meal for Resident #77. Findings include: A. Resident status Resident #77, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the February 2019 computerized physician order (CPO), diagnoses included orofacial dystonia and anorexia. The 10/1/18 minimum data set (MDS) assessment revealed, the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of 00 out of 15. No mood or behavior symptoms were noted. No rejection of cares noted. He required total assist with eating. B. Record review The care plan, revised on 10/11/18, identified a nutritional risk with a diagnosis of anorexia. Interventions…

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 staff interviews, the facility failed to provide an ongoing program to support residents in their choice of activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for three (#84, #3 and 58) of eight residents reviewed for activities out of 34 sample residents. Specifically, the facility failed to: -Ensure Resident #84, #3 and #58 were invited and encouraged to attend activities of their preference. Findings include: I. Professional reference According to the University of Rochester Medical Center, Older Adults and the Importance of Social Interaction, 2015, https://www.urmc.rochester.edu/encyclopedia/content.aspx (March 2017), in pertinent part: .Specific health benefits of social interaction in older adults include: Potentially reduced risk for cardiovascular problems, some cancers, osteoporosis, and rheumatoid arthritis. Potentially…

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 and family interviews and record review, the facility failed to ensure the resident received treatment and care in accordance with professional standards of practice, their comprehensive, person centered care plan and the residents choice for one (#55) of five residents reviewed for supplemental oxygen use out of 34 sample residents. Specifically, the facility failed to notify Resident #55s physician of low oxygen saturation levels (SATs); and did not educate or remind the resident when he was found without his oxygen on. Findings include: 1. Resdient status Resident #55, age [AGE], was admitted on [DATE] and readmitted on [DATE]. According to the February 2019 computerized physician order (CPO), diagnoses included congestive schizoaffective disorder, personality disorder, dementia with behaviors and dependence on supplemental oxygen. The 12/19/18 minimum data set (MDS) assessment revealed, the resident had no cognitive impairment with a brief interview for mental status (BIMS) score of 15 out…

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.