Falcon Heights Rehabilitation and Nursing LLC

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents consistently received food prepared by methods that conserved nutritive value and was palatable in taste, texture and temperature. Specifically, the facility failed to ensure the residents' food was palatable in temperature appearance.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were kept free from physical abuse for two (#11 and #7) of eight residents reviewed for abuse out of 11 sample residents. Specifically, the facility failed to: -Protect Resident #7 from physical abuse by Resident #9; and,-Protect Resident #11 from physical abuse by Resident #10.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#1) of four residents were kept free from abuse out of six sample residents. Specifically, the facility failed to ensure Resident #1 was kept free from physical abuse by Resident #2

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#2) of six residents investigated for abuse out of seven sample residents were kept free from physical abuse. Specifically, the facility failed to protect Resident #2 from two physical abuse altercations by Resident #3.

Inspectors wroteBased 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 one (#5) of five residents reviewed for abuse out of 13 sample residents. Specifically, the facility failed to report an allegation of abuse involving Resident #5 to the State Agency.

Inspectors wroteBased on record review and interviews, the facility failed to permit one (#5) of two residents out of 13 sample residents to return to the facility following a facility-initiated transfer to the hospital. Specifically, the facility failed to: -Ensure a facility-initiated transfer to the hospital included an appropriate discharge location for Resident #5; and, -Reassess Resident #5's status at the time the resident sought to return to the facility after a facility-initiated transfer to the hospital, and did not allow the resident to return to the facility based upon his status at the time of his transfer to the hospital.

Inspectors wroteBased on observations, record review and interviews, the facility failed to promote and maintain resident dignity for two (#35 and #51) of three residents reviewed out of 49 sample residents by providing care in a dignified, respectful and individualized manner. Specifically, the facility failed to: -Ensure Resident #35 was provided meal assistance in a dignified manner; and, -Ensure Resident #51 was treated with dignity and respect when asking for assistance.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents consistently receive food prepared by methods that conserved nutritive value and was palatable in taste, texture, appearance and temperature. Specifically, the facility failed to ensure the residents' food was palatable in taste, texture, appearance and temperature.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure food items were stored and served under sanitary conditions in the main kitchen. Specifically, the facility failed to ensure staff correctly and accurately tested for the correct parts per million (ppm) of the dishwasher, chemical sanitizer solution of the three sink compartments and sanitizer buckets.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents on five of five hallways had the right to choose his or her own attending physician. Specifically, the facility failed to allow residents to choose their primary care provider (PCP) when the facility changed medical provider groups.

Inspectors wroteBased on observations and interviews, the facility failed to maintain a safe, comfortable and functional homelike environment for residents, staff and the public on four of five units. Specifically, the facility failed to provide the necessary maintenance services to ensure resident's room doors #205, #304, #306, #404, #405 and #607 were easily able to be opened and closed and damaged floors were repaired.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for three (#35, #43 and #66) of eight residents out of 49 sample residents. Specifically, the facility failed to: -Ensure safe smoking practices were followed, including adequate supervision, for Resident #35; -Ensure a thorough investigation was completed after Resident #35 burned her fingers while smoking; and, -Ensure medications were not left at the bedside without appropriate self-administration assessments for Resident #35, Resident #43 and Resident #66.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in three of five medication carts and one of two medication storage rooms. Specifically, the facility failed to: -Ensure medications were properly labeled with open dates; and, -Ensure expired medications were removed from the medication carts and the medication storage room.

Inspectors wroteBased on observation, 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 hallways. Specifically, the facility failed to: -Ensure nursing staff completed proper hand hygiene during medication pass; and, -Ensure housekeeping completed proper hand hygiene when cleaning resident rooms.

Inspectors wroteBased on observations and interviews, the facility failed to provide adequate ventilation by means of mechanical ventilation for three of four resident shower rooms. Specifically, the facility failed to ensure exhaust fans in resident shower rooms were functioning efficiently.

Inspectors wroteBased on record review and interviews, the facility failed to take steps to protect two (#70 and #28) of two residents reviewed for abuse out of 49 sample residents. Specifically, the facility failed to ensure Resident #70 and Resident #28 were free from physical abuse from each other on two separate occasions.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#65 and #180) of five residents reviewed for assistance with activities of daily living (ADL) received fingernail care out of 49 sample residents. Specifically, the facility failed to: -Ensure Resident #65 received scheduled showers according to his preference; and, -Ensure Resident #180's fingernails were trimmed and cleaned.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#12) of six residents reviewed for activities out of 49 sample residents received an ongoing program of activities designed to meet needs and interests, and promote physical, medical and psychosocial well-being. Specifically, the facility failed to ensure Resident #12 was provided opportunities to participate in one-to-one staff visits or attend small group activities in accordance with his comprehensive plan of care.

Inspectors wroteBased on observations, record review and interview, the facility failed provide treatment and services in accordance with professional standards of practice for one (#9) of one resident out of 49 sample residents. Specifically, the facility failed to ensure Resident #9 received quality care when the on-call physician did not return calls upon Resident #9 experiencing a change of condition.

Inspectors wroteBased on record review and interviews, the facility failed to manage pain for one (#43) of two residents out of 49 sample residents in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences. Specifically, the facility failed to provide pain relieving cream to Resident #43 as ordered by the physician.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure it was free of a medication error rate of five percent (%) or greater. Specifically, the medication administration observation error rate was 8%, or two errors out of 25 opportunities for error.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined the facility failed to ensure diabetes management was provided in accordance with accepted standards of nursing practice and physician's orders for 1 (Resident #66) of 2 sampled residents reviewed for diabetes monitoring. Specifically, the physician's orders for notification of hyperglycemic episodes based on specified blood sugar parameters were not followed for Resident #66, to enable the physician to make modifications to the resident's treatment plan if needed.

Inspectors wroteBased on observation, and interviews the facility failed to follow infection control measures to prevent the potential cross contamination of SARS-CoV-2 COVID-19, during testing procedures while the facility was in outbreak. Observations and interviews revealed the facility failed to follow infection control procedures per Centers for Disease Control (CDC) guidance while performing polymerase chain reaction (PCR) testing for SARS-CoV-2 COVID-19, on both resident and staff. The nurse performing the testing on 11/15/21 failed to: -Wear proper personal protective equipment (PPE), including a National Institute for Occupational Safety and Health (NIOSH) approved N-95 mask, protective gown consistently and properly when collecting SARS-C0V-2 COVID-19 specimen from staff and residents; [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#50) of one out of 32 sample residents received care consistent with professional standards of practice, to prevent the development of pressure ulcers, and to promote healing of pressure injuries. The facility's failure to provide necessary interventions to prevent Resident #50 from developing pressure ulcers, promote healing of the pressure ulcers and prevent worsening of the pressure ulcers. The resident was a significant risk for the development of pressure ulcers based on her compromised health, being treated for current pressure ulcers, and her being dependent on staff for activities of daily living. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that a resident received timely assessment and treatment for severe pain starting after a fall where major injuries resulted for one (#109) of four residents reviewed for falls out of 32 sample residents. Record review and interviews revealed the facility failed to recognize and effectively assess the resident's continued expression of uncontrolled pain as symptoms of major injuries sustained following a fall in the facility. This failure led to the resident experiencing severe pain for 48-hour delay in treatment for injuries. Resident #109 was admitted to the facility after experiencing a decline in ability and weakness in motor skills and functional ability. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents of the entire facility including (#50, #21, #6, and #22) had the right to receive visitors at the time and location of their choosing. Specifically, the facility failed to: -Ensure residents of the facility had the right to receive visitors at the time and location of their choosing prior to the facility being placed on outbreak status; -Ensure the family of Resident #50 was allowed to see the resident for compassionate visits without restrictions such as the requirement to make an appointment 72 hours in advance and not answering the phone when an appointment was attempted to be made by the family and; -Ensure the facility visitation guidance was up to date and communicated to the residents ' families.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure professional standards of practice for administering medications were followed for one (#36) of one resident with an enteral tube feeding out of 32 sample residents. Specifically, the facility failed to: -Crush and administer each prescribed medication one at a time, flushing the percutaneous endoscopic gastrostomy (PEG) tube in between each administered medication, to prevent potential adverse side effects; -Ensure the PEG tube was flushed with purified or sterile water instead of tap water before, after and with medication; -Ensure the medications were fully dissolved prior to administrations; -Ensure all medication was administered without any mediation residue left in the medication cup after the nurse finished administration; [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one out of one facility kitchens and four out of four units. Specifically, the facility failed to ensure: -Hand hygiene was completed prior to handling clean dishes; -Food was not placed in a reach-in refrigerator that was not working; and, -Residents were offered and encouraged to complete hand hygiene prior to meals.

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 infection control practices for: SARS-CoV-2 facility wide testing during an outbreak; aseptic wound care procedures to prevent contamination from pathogens; and environmental disinfection and cleaning in resident rooms and common areas.

Inspectors wroteBased 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 in five out of five units. Specifically, the facility failed to: -Change gloves from dirty to clean and perform hand hygiene during wound care with Resident #50 (Cross reference F686), -Ensure sharps container was not overflowing with contaminates, -Ensure high touch and contaminated surfaces in resident rooms were consistently sanitized, per guidance from the centers for disease control (CDC), and: -Ensure resident tubs were properly sanitized including regular cleaning and maintenance of whirlpool jets.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the self-administration of medications was clinically appropriate for four (#2, #7, #24, and #21) of four out of 32 sample residents Specifically, the facility failed to ensure all four Residents (#2, #7, #24, and #21) were assessed for self administration of medications.

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice for four out of five units and two (#16 and #52) of two out of 32 sample residents. Specifically, the facility failed to: -Ensure respiratory orders were followed for Resident #52 for his tracheostomy, -Obtain physician orders and care plan for oxygen for Resident #16, and, -Clean oxygen equipment and suction machines in four of five units.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the resident had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for one (#27) of five out of 32 total sample residents. Specifically, the facility failed to have an accurate Colorado medical orders for scope of treatment (MOST) form uploaded into the electronic medical record (EMR) for Resident #27. The MOST form uploaded was dated [DATE] as signed by the resident, and dated [DATE] when signed by the physician for- No CPR: Do not attempt resuscitation, however the physician orders in the resident's EMR said-Full code, dated [DATE]. This failure created a conflict with the physician orders. [...]

Inspectors wroteBased on record review and interviews, the facility failed to refer one (#56) of 16 residents reviewed out of 32 sample residents to the appropriate state-designated authority for level II preadmission screening and resident review (PASRR) evaluation and determination for services. Specifically, the facility failed to ensure that Resident #56 with a known psychological disorder was properly assessed on the PASRR level I screen to gain and maintain their highest practicable medical, emotional and psychosocial well-being.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure two (#36, and #35) of four residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good nutrition, hygiene, dressing and grooming, out of 32 total sample residents. Specifically, the facility failed to provide: -Consistent and routine oral care for Resident #36; and, -Timely incontinent and other cares for Residents #35.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the nutritional and hydration needs were consistently met for one (#39) resident out of three reviewed out of 32 sample residents. Specifically, the facility failed to ensure Resident #39, who was on thickened liquids, consistently was offered and encouraged to drink fluids throughout the day.

Inspectors wroteBased on record review and interviews the facility failed to ensure dialysis services were consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for one (#20) of one resident reviewed out of 32 sample residents. Specifically, the facility did not assess Resident #20 post dialysis to ensure there were no complications or concerns related to the resident's dialysis treatments and review the documentation sent back from the dialysis center in a timely manner.