Eben Ezer Lutheran Care Center

Inspectors wroteBased on and observations, record review and interviews, the facility failed to ensure six (#1, #2, #3, #4, #5 and #6) of seven residents out of seven sample residents were kept free from abuse. Specifically, the facility failed to:-Ensure Resident #2, Resident #3 and Resident #5 were kept free from physical abuse from Resident #1; -Ensure Resident #1 and Resident #4 were kept free from abuse towards each other; and,-Ensure Resident #6 was kept free from physical abuse by Resident #7.

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen and two of four kitchenettes. Specifically, the facility failed to: -Ensure food was labeled, dated and discarded in a timely manner; -Ensure staff performed hand hygiene before donning (putting on) gloves to serve ready-to-eat food; and, -Ensure food was reheated to the appropriate temperature. I. Failed to ensure food was labeled, dated and disposed of timely A. Professional reference The Colorado Department of Public Health and Environment (2024) The Colorado Retail Food Establishment Rules and Regulations, retrieved on 8/21/24 from https://drive.google.com/file/d/1kEtv4f6YciFXXzLEu6amUc9Anu9uWGYn/view read in pertinent part, A date marking system that meets the criteria may include: [...]

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 two of four hallways. Specifically, the facility failed to: -Ensure housekeeping completed proper hand hygiene when cleaning resident rooms; and, -Ensure nursing followed proper standards of practice during wound care and followed enhanced barrier precautions appropriately.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#26) of six out of 32 sample residents were provided services that met professional standards of quality. Specifically, the facility failed to: -Ensure the physician's orders for Resident #26 contained the dose of the medication the nurse was to administer to the resident.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were provided an environment as free of accident hazards as possible for one (#55) of four residents reviewed for accidents and hazards out of 32 sample residents. Specifically, the facility failed to: -Ensure identified interventions were implemented consistently and monitored for effectiveness; and, -Update and revise Resident #55's care plan with new interventions after each skin injury.

Inspectors wroteBased on observations, record review and interviews, the facility failed to use a person-centered approach when determining the use of bed rails for one (#57) of 15 residents reviewed for bed rails out of 32 sample residents. Specifically, for Resident #57, the facility failed to: -Assess and review what interventions were attempted prior to the use of side rails; -Ensure the resident's comprehensive care plan was person centered; -Ensure assessments of the resident's use of the bed rails were completed regularly after they were installed; and, -Obtain consent that included the risks and benefits for using bed rails from the resident and/or the resident's representative before the bed rail installation.

Inspectors wroteBased 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 one of five certified nurse aides (CNA) reviewed. Specifically, the facility did not provide regular in-service education based on the outcome of the annual performance review for CNA #5.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure two (#58 and #48) of four residents out of 25 sample residents reviewed for abuse were kept free from abuse. Resident #48, with a diagnosis of dementia, had known aggressive and impulsive behaviors to other residents. Resident #48 was walking down the hallway and Resident #58 was walking towards her. Resident #48 pushed Resident #58 and she lost her balance. Resident #58 fell to the ground and fractured her right hip. The facility failed to protect Resident #58 from Resident #48's aggressive behaviors.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide supervision, assistance, services, and implement timely interventions to prevent falls with injuries for two (#29 and #4) of nine residents reviewed for accidents/hazards out of 25 sample residents. Resident #29 had three falls since admission, had severe cognitive impairment, used a wheelchair for ambulation, and required supervision with transfers. Between 9/21/22 and 11/27/22, Resident #29 experienced three falls: one witnessed and two unwitnessed. After the 11/18/22 fall, the resident sustained a left hip fracture. On admission the resident fall risk was 15. The facility failed to initiate a fall care plan with effective interventions to prevent repeated falls. [...]

Inspectors wroteBased 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 one of three medication storage rooms and one of three medication carts. Specifically, the facility failed to discard expired medications and to lock a medication cart, when left unattended.

Inspectors wroteBased on observations, interviews and record review the facility failed to provide adequate supervision and assistance devices to prevent accidents for two (#54 and #2) of six residents reviewed for falls, out of 32 sample residents. Specifically, the facility failed to ensure adequate supervision and effective interventions were in place to prevent multiple falls for Resident #54 and Resident #2, and falls that resulted in multiple injuries to Resident #54. The lack of supervision and effective interventions resulted in seven unwitnessed falls and one witnessed fall since 1/5/21 that caused multiple fractures and injuries to Resident #54's pelvis, right wrist, left hip, left elbow, left hand and head that caused her extreme pain, required trips to the emergency department and resulted in limited mobility.

Inspectors wroteBased on observation, record review and interviews the facility failed to ensure that one (#66) of five residents reviewed out of 32 sample residents were free from unnecessary psychotropic medications. The facility's failed to document and evaluate the effectiveness of non pharmacological behavioral interventions for Resident #66, a person with dementia; alternatively psychotropic medications were prescribed which lead to over-sedation of the resident. The resident resided in a secured memory care unit with other residents and had an alarm system on her door to alert staff when the door opened. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents who were 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 (#66) out of three residents reviewed out of 32 sample residents. Specifically, the facility failed to implement identified person centered interventions for Resident #66, a person with dementia and behavioral disturbances; alternatively the resident was given multiple medications which caused sedation. (cross reference to F758: use of unnecessary psychotropic medications)