Life Care Center of Aurora

Inspectors wroteBased on record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#2) of three residents reviewed for medication errors out of three sample residents. Specifically, the facility failed to ensure Resident #2 was administered antibiotic medications per physician's orders.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases on three of four units. Specifically, the facility failed to:-Ensure housekeepers cleaned and disinfected the residents' rooms in a hygienic manner;-Ensure housekeepers performed hand hygiene appropriately while cleaning resident rooms;-Ensure chemical dwell times were followed during resident room cleaning;-Ensure resident vital signs equipment was disinfected; and,-Ensure staff followed enhanced barrier precautions (EBP) precautions while providing direct resident care.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement a comprehensive care plan for one (#87) of seven residents reviewed for care plans out of 49 sample residents. -Specifically, the facility failed to ensure individualized, person centered interventions were identified and documented in Resident #87's behavior/mood care plan.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received necessary respiratory care and services per physician orders for one (#77) of two residents reviewed for respiratory care out of 49 sample residents. Specifically, the facility failed to administer Resident #77's supplemental oxygen per physician's orders.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#7 and #123) of seven residents diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to attain the highest practicable mental and psychosocial wellbeing out of 49 sample residents. Specifically, the facility failed to ensure Resident #7 and Resident #123, who had identified indicators of depression were provided with mental health services.

Inspectors wroteBased on observations and interviews, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards of practice for one of three medication administration carts and one of two medication storage rooms. Specifically, the facility failed to ensure medications, such as eye drops, inhalers and insulin pens, were labeled and dated appropriately with the resident's name and the date the medication was opened.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#4 and #80) of four residents reviewed for ancillary services, such as dental services, out of 49 sample residents received routine dental care obtaining routine and 24-hour emergency dental care. Specifically, the facility failed to:-Provide dental services for Resident #4 who had broken and missing teeth; and,-Provide dental services for Resident #80 who had identified dental decay.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the residents' environment remained as free from accident hazards as possible and prevent falls with major injury for two (#46 and #76) of four residents reviewed for falls out of 53 sample residents. Resident #46, who had a known history of falls, had a diagnosis of obesity which required the use of a bariatric (to support substantial weight) bed with extensions to enable the bed frame to be made larger. On 1/29/24, the resident sustained a witnessed fall from her bed when she was being rolled on her side with the assistance of staff during a bed bath. Resident #46 was sent to the hospital for evaluation of left knee pain following the fall where she was discovered to have a fracture of her left femur (thigh bone), which was surgically repaired on 1/30/24. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent. Specifically, the facility had a medication error rate of 14.29%, which was five errors out of 35 opportunities for error.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#40) resident out of 53 sample residents. Specifically, the facility failed to: -Ensure Resident #40 was assessed for the appropriateness and safety of self-administration of topical medications; and, -Ensure there was a physician order for self-administration of topical medications.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for one (#33) of five residents reviewed out of 53 sample residents. Specifically, the facility failed to ensure Resident #33 received her scheduled showers, who was dependent on staff for bathing.

Inspectors wroteBased on observations, interviews and record review, the facility failed to assist residents with making appointments and arranging transportation for one (#89) of three residents reviewed for vision/ancillary services out of 53 sample residents. Specifically, the facility failed to offer and make an appointment for optometry services for resident #89.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure one (#89) of three residents reviewed for ancillary services, such as podiatry services, out of 53 sample residents received proper foot care and treatment according to standards of practice. Specifically, the facility failed to ensure podiatry care was provided timely and as requested by Resident #89.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents with a gastrostomy tube received appropriate treatment and services to prevent complications for one (#18) of three residents reviewed for tube feeding management out of 53 sample residents. Specifically, the facility failed to label Resident #18's tube feeding bag with the date and time the tube feeding bag was hung, the initials of the nurse hanging the tube feeding bag, the type of tube feeding the resident was receiving and the flow rate for the tube feeding administration.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#62 and #68) of four residents who required respiratory care received care consistent with professional standards of practice out of 53 sample residents. Specifically, the facility failed to: -Follow manufacturer recommendations to maintain, clean, sanitize and store Resident #62 and Resident #68's continuous positive airway pressure (CPAP) mask and machine; -Accurately complete section O in the minimum data set (MDS) assessment under respiratory treatments for Resident #62 and Resident #68; -Ensure a care plan was in place to include settings, cleaning, disinfecting and storage of the CPAP for Resident #62; and, -Ensure Resident #68's CPAP mask sealed properly because it was torn.

Inspectors wroteBased on observation and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly on one of four medication carts. Specifically, the facility failed to: -Ensure medication was not left unattended on the medication cart; and, -Ensure tuberculin (medication to test for tuberculosis, a lung bacteria) vials were dated with open dates.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#89) of three residents reviewed for ancillary services, such as dental services, out of 53 sample residents received routine dental care obtaining routine and 24-hour emergency dental care. Specifically, the facility failed to refer Resident #89 to the dentist to replace lost dentures and repair loose fitting dentures.

Inspectors wroteBased on record review and interviews the facility failed to clarify basic life support choices, including cardiopulmonary resuscitation (CPR), prior to the arrival of emergency medical personnel according to the advance directive for one resident (#2) out of three residents reviewed for CPR out of six sample residents. Specifically, the facility failed to: -Follow the advance directive on Resident #2's medical orders for scope of treatment (MOST) form by having emergency medical personnel perform CPR on the resident when her code status was Do Not Resuscitate (DNR); -Assist the roommate and family out of the room while CPR was being performed on Resident #2 until prompted by emergency medical services (EMS); and, -Ensure resident's MOST forms were readily accessible and in the right location.

Inspectors wroteBased on interviews, record review, document review, and facility policy review, the facility failed to ensure a resident was provided with an environment that was free of accident hazards and adequate supervision/assistance to prevent an accident for 1 (Resident #56) of 3 sampled residents reviewed for accidents. Specifically, Certified Nursing Assistant (CNA) #4 transferred Resident #56 on 12/09/2021 using a sit-to-stand lift (a mechanical device utilized to assist a person from a sitting to a standing position) when Resident #56 had not been assessed for the use of the lift. Additionally, CNA #4 performed the transfer without the assistance of a second staff member, when two staff were required for the transfer. Further, the facility failed to complete a thorough investigation to determine the root cause of the incident. [...]

Inspectors wroteBased on observations, interviews, and facility document review, the facility failed to ensure laundry staff wore the necessary personal protective equipment (PPE), including a gown, during, handling/sorting of soiled linens and avoided shaking/agitating soiled linens to the extent possible to prevent potential cross-contamination and spread of infection. The failed practices had the potential to affect all residents who resided in the facility.

Inspectors wroteBased on observations, interviews, and facility policy and document review, the facility failed to store food in accordance with professional standards of food service safety in 1 of 1 warming kitchen (a kitchen on the unit where food was stored and served for residents). Specifically, the facility failed to ensure that food and beverages that were available to residents were labeled, dated, and not expired.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to provide maintenance services necessary to maintain an orderly and comfortable interior for 1 (Resident #8) of 26 sampled residents whose rooms were observed during the initial pool process. Specifically, the facility failed to ensure Resident #8's wheelchair armrests were maintained in good repair.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined that the facility failed to revise the comprehensive care plan to address a newly identified pressure ulcer and abscessed area to the toe for 1 (Resident #52) of 4 sampled residents reviewed for pressure ulcers or other skin conditions.

Inspectors wroteBased on interviews, record review, and facility policy review, it was determined the facility failed to consistently assess and document the status of a pressure ulcer in order to track healing progress and facilitate prompt identification of any potential deterioration for 1 (Resident #52) of 3 sampled residents reviewed for pressure ulcers.