Columbine West Health and Rehab LLC

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards in two of four medication storage carts and two of two storage closets. Specifically, the facility failed to: -Ensure medications were labeled with the date they were opened;-Ensure expired medication were removed and discarded from the medication carts; and,-Ensure medications were stored in a secured area.

Inspectors wroteBased on record review and interviews, the facility failed to establish an effective antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one (#30) of five residents reviewed for antibiotic stewardship out of 31 sample residents. Specifically, the facility failed to ensure Resident #30's long term use antibiotic was evaluated for appropriate use.

Inspectors wroteBased on interviews and record review, the facility failed to protect and promote an environment free from resident-to-resident sexual abuse. The facility failure affected four of four residents (#1, #2, #3, and #4) out of seven sample residents and contributed to incidents of abuse by Resident #2 and #4. Residents #1 and #2 resided in the facility's secured unit. Fourteen residents resided in the secured unit: four male (including Resident #2) and 10 female (including Resident #1). Residents #3 and #4 resided in the non-secured unit. Resident #2 had a history of being verbally sexually inappropriate toward female residents and staff. On 2/5/25, staff observed Resident #2 grabbing the breast of female Resident #1 and lifting her shirt. When told to stop, Resident #2 stated, She likes it. Although Resident #2 was placed on one-to-one supervision from 2/5/25 until 2/7/25 at 9:30 a.m. [...]

Inspectors wroteBased 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 freedom from abuse, reporting and investigating that rose to the level of immediate jeopardy and created a situation where a serious adverse outcome occurred and caused harm.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#1) of one resident who were diagnosed with dementia, received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being out of seven sample residents. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #1. Cross reference F600: failure to protect Resident #1 from abuse.

Inspectors wroteBased on observations and interviews, the facility failed to provide a clean, comfortable and homelike environment for residents who resided in 13 of 15 rooms out of a sample of 70 resident rooms. Specifically, the facility failed to ensure resident rooms had safe, comfortable temperatures that did not exceed 81 degrees Fahrenheit (F).

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#30) of four residents reviewed for pressure injuries out of 36 sample residents received care consistent with professional standards of practice to prevent pressure injuries. Resident #30 was admitted on [DATE] for long term care. At the time of the admission, the resident was identified as being at risk for developing pressure injuries. Upon admission, the resident's skin was intact and she did not have any pressure injuries. Resident #30 attended dialysis three times a week. On 10/7/23, a nurse documented Resident #30 developed a deep tissue injury (DTI) on her right heel. Preventative measures to protect the resident's heels were not implemented until after the development of the DTI on 10/7/23. [...]

Inspectors wroteBased on observation and interviews, the facility failed to post, in a form and manner accessible and understandable to residents, information on how to file a complaint with the State Agency. Specifically, the group interview revealed the facility failed to ensure residents knew where the required posting on how to file a complaint with the State Agency was located and that residents were able to easily access and read the information on the posting.

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in one of one kitchen and one of two nourishment rooms. Specifically, the facility failed to: -Ensure holding temperatures were at appropriate temperatures; and, -Ensure food was labeled, dated and disposed of in a timely manner. I. Failure to ensure holding temperatures were at appropriate temperatures. A. Professional reference The Colorado Retail Food Establishment Rules and Regulations, (3/16/24) were retrieved on 4/17/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view and read in pertinent part, The food shall have an initial temperature of 41ºF (fahrenheit) or less when removed from cold holding temperature control or 135°F or greater when removed from hot holding temperature control. B. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to establish a sanitary environment to help prevent the transmission of communicable diseases and infections on three of five units. Specifically, the facility failed to: -Ensure enhanced barrier precautions (EBP) were implemented and followed for residents with wounds and/or indwelling medical devices; and, -Ensure staff used appropriate personal protective equipment (PPE) when entering the room of a COVID-19 positive resident.

Inspectors wroteBased on record review and interviews, the facility failed to take steps to ensure the 15 residents, including Resident #39, who resided in the secure unit were free from potential sexual abuse by Resident #43. Record review revealed Resident #43 had a documented history of sexually inappropriate behavior toward male residents. Record review and interview revealed the facility failed to take timely steps to minimize the potential risks to other residents related to her behavior.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the comprehensive care plan was reviewed and revised timely to include the instructions needed to provide effective and person-centered care for one (#56) of six residents out of 36 sample residents. Specifically, the facility failed to revise Resident #56's care plan to address the resident's pattern of repeated refusals of three physician ordered pain medications. I. Resident #56 A. Resident status Resident #56, age [AGE], was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included dementia, Parkinson's disease, psychotic disturbance, mood disturbance, anxiety, hallucinations, post traumatic stress disorder, depression, pain in right and left knee, stiffness of left knee and chronic pain syndrome. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents received person-centered dementia care that met their needs for one (#43) of five residents reviewed for dementia care out of 36 sample residents. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #43 in order to provide the resident with her highest practicable quality of life and care.

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents were free of unnecessary psychotropic medications for one (# 66) of five residents reviewed for unnecessary medications out of 36 sample residents. Specifically, the facility failed to track and monitor behaviors for Resident #66 who was on four different psychotropic medications.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to prepare, distribute and serve food in a sanitary manner in two of three dining rooms. Specifically, the facility failed to: -Prevent potential cross contamination during meal service and meal delivery; -Ensure drink stations were free of contamination; and -Use proper hand hygiene during meal delivery.

Inspectors wroteBased on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards for two (#82 and #18) of six residents reviewed for non-pressure related skin conditions and physician orders out of 30 sample residents. Specifically, the facility failed to: -Monitor bruising for healing after a fall for Resident #82; and -Follow blood pressure medication physician orders for Resident #18.