Life Care Center of Pueblo

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure an environment free from risk of accidents and hazardous situations for one (#1) of three residents reviewed for accident hazards out of 19 sample residents. Resident #1 was admitted to the facility on [DATE]. Resident #1's comprehensive care plan revealed the resident was taking an anticoagulant (blood thinner) medication and goals included preventing abnormal bleeding and bruising as a result. On 12/24/25 at approximately 2:40 p.m. Resident #1 was being assisted to an activity in the dining room by the social services director (SSD) in her wheelchair without the foot pedals in place. Resident #1's left leg was bumped on her wheelchair when her leg dropped. At 5:41 p.m. Resident #1 complained of pain to her lower left leg. At 8:52 p.m. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease. Specifically, the facility failed to:-Ensure staff performed appropriate hand hygiene when handling residents' meal trays and water pitchers;-Ensure staff handled residents' drinkware and silverware in a sanitary manner; and,-Ensure staff donned (put on) face masks appropriately during a facility outbreak with COVID-19.

Inspectors wroteBased on record review and interviews the facility failed to ensure residents were treated with dignity and respect for three (#1, #12 and #9) of four residents out of 13 sample residents. Resident #1, who was non-weight bearing on his right leg due to a broken ankle required staff assistance to transfer from his wheelchair to and from the toilet. According to Resident #1, certified nurse aide (CNA) #1 was rude to him when he requested assistance with transferring to the toilet and told him he could use the bathroom himself. CNA #1 did assist the resident onto the toilet, however when Resident #1 requested assistance to transfer back to his wheelchair after using the bathroom, CNA #1 entered the resident's room and refused to assist him. CNA #1 informed the resident we are not doing this again and left the resident's room without assisting him. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents had the right to be free from physical abuse for one (#3) of three residents reviewed for abuse out of 13 sample residents. Resident #3 was admitted to the facility on [DATE] with a diagnosis of constipation. On [DATE], in the early morning hours, Resident #3 called for assistance. The resident told the staff that she was constipated and needed assistance or she wanted to go to the hospital. Registered nurse (RN) #1 came to her room. Certified nurse aide (CNA) #5 assisted Resident #3 to roll over. RN #1 began to insert a suppository and felt a hard stool in the resident's rectum. As RN #1 removed the stool from Resident #3's rectum, the resident was crying and yelling in pain and asking RN #1 to stop. [...]

Inspectors wroteBased on record review and interviews, the facility failed to have evidence that all alleged abuse were thoroughly investigated for one (#3) of three residents reviewed for abuse of 13 sample residents. Specifically, the facility failed to thoroughly investigate an allegation of abuse.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement an effective discharge plan for one (#3) of three residents reviewed for discharge planning out of 13 sample residents. Specifically the facility failed to assist Resident #3 in the development of a safe and appropriate discharge plan.

Inspectors wroteBased on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#3) of three residents reviewed for quality of care out of 13 sample residents. Specifically the facility failed to: -Follow the physician's standing orders for bowel management for Resident #3; -Document the bowel medications that were administered to Resident #3; -Document the nursing medication reassessment; -Document the nursing abdominal and peri-rectal assessment; and, -Document the digital fecal disimpaction (procedure of removing stool from the rectum with a finger) procedure for Resident #3.

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 five of five staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided regular in-service education based on the outcome of the reviews for certified nurse aide (CNA) #1, CNA #2, CNA #3, CNA #4 and CNA #5.

Inspectors wroteBased on record review and interviews, the facility failed to develop a comprehensive care plan for services that were to be provided in order to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being for two (#63 and #6) of five residents reviewed for care planning out of 36 sample residents. Specifically, the facility failed to: -Develop a dementia care plan focus for Resident #63 and Resident #6; and, -Update care plan interventions for falls for Resident #63.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure drugs and biologicals were labeled and stored in accordance with accepted professional standards for two of three medication carts. Specifically, the facility failed to ensure inhalers were dated when opened.

Inspectors wroteIII. Resident #83 A. Resident status Resident #83, age [AGE], was admitted on [DATE] and re-admitted on [DATE]. The January 2020 computerized physician order (CPO) revealed diagnoses of dementia without behavioral disturbance, history of falling and muscle weakness. The 1/9/2020 minimum data set (MDS) revealed the resident had short-term memory problems and moderately impaired cognitive skills for daily decision making. The resident required extensive assistance for transfers, bed mobility, and toileting. B. Record review The director of nursing (DON) provided the fall investigations for falls occurring on 7/5/19, 7/16/19, 7/18/19, 9/1/19, 9/5/19, 9/9/19, 9/10/19, 9/15/19, 9/16/19, 9/17/19, 9/18/19, and 12/24/19 on 1/30/2020 at 2:00 p.m. -On 7/5/19 revealed the resident was found lying on the floor in her room. A contusion was found on her left forehead. [...]

Inspectors wroteBased on observations, 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 qualify of care, quality of life, and resident safety. Specifically, the facility failed to demonstrate that their quality assurance performance improvement (QAPI) program committee effectively identified quality care issues to address concerns related to abuse prevention, accident hazards, resident rights, respiratory care and highest practicable quality of life.

Inspectors wroteBased on record review, observation and staff interview, the facility failed to ensure food was prepared and served in a sanitary and timely manner. Specifically, the facility failed to ensure: -Staff performed adequate hand hygiene while serving foods; -The holding temperatures of the always available foods on the steam table were checked and recorded; and, -Temperatures of foods prepared in the microwave and from the fryer were checked prior to serving to residents.

Inspectors wroteBased on observation, interview and record review the facility failed to treat residents with dignity and respect while providing assistance and care for one (#54) out of one of the 48 sampled residents, as well as, disrespectfully referring to residents who required meal assistance in the dining area as feeders. Specifically, the facility failed: -to ensure Resident #54 was treated with dignity and respect. Resident #54 stated that she felt disrespected by the way certified nurse aide (CNA #14) spoke to her and ignored her request for assistance; -to respectfully refer to residents who required meal assistance.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure five (#289, #17, #111, #83, and #283) of five residents personal and medical information was private and confidential out of 47 sample residents. Specifically, the electronic medication administration record (MAR) for five of five residents (above), was left visible on the computer screen located on top of medication carts in hallways visible to other residents, visitors providers and staff members.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that six (#332, #52, #100, #25, #114, #49) out of ten residents reviewed for respiratory care and treatment received respiratory treatments in a manner of care consistent with professional standards of practice, the resident's care plan, goals and preferences out of 48 sampled residents. Specifically the facility failed to: -Ensure Resident #332 received nebulizer treatment as ordered within a reasonable time frame after returning from the hospital; -To clean, sanitize and store Resident #52 nebulizer equipment in a manner to prevent possible bacterial cross-contamination with respiratory infection; -To have an order to administer Resident #100s CPAP (continuous positive airway pressure) therapy; [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to effectively follow an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease and infection. Specifically, the facility failed to: -Follow proper housekeeping protocols to prevent cross-contamination. -Maintain proper cleaning standards and procedures. -Ensure proper hand sanitation, gloving and disinfection of medical scissors while providing wound care to Resident #5 to prevent cross-contamination; and -Ensure proper hand hygiene was done when handling soiled linen by certified nurse aide (CNA) #10, and in between resident cares by CNA #16.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents were protected from abuse for one (#67) of two residents out of 48 sample residents. Specifically, the facility failed to ensure: -The alleged assailant was relieved from working with residents immediately following Resident #67' s allegation of sexual abuse and prior to the facility' s investigation (see investigation interviews).

Inspectors wroteBased on record review and interviews, the facility failed to develop a comprehensive care plan for two (#119, #43) out of 50 sample residents for services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to: -Implement person centered care plan interventions for Resident #119s to prevent recurring falls with injuries (cross-referenced F689); and, -Implement a person centered care plan intervention for Resident #43s care needs related to a limited range of motion, specifically for splinting assistance.

Inspectors wroteBased 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 (#116) of two resident reviewed for edema of 45 sample residents. Specifically, the facility failed to ensure donning of tubigrips on lower extremities for Resident #116 according to the physician orders and care plan.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#43) of one resident with limited mobility reviewed for range of motion (ROM) received appropriate services, equipment, and assistance to maintain independence and services to prevent further decrease in ROM, out of 48 sample residents reviewed. Specifically, the facility failed to ensure Resident #43 continued to receive assistance for splinting of the right hand to prevent the possibility of worsening of a contracture and to protect skin integrity.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure that the hospice services provided meet professional standards and principles that applied to individuals providing services in the facility for one (#80) of three residents reviewed for hospice services out of 48 sample residents. Specifically, the facility failed to: -Have a written agreement to ensure Resident #80, had a written plan of care which included both the most recent hospice plan of care and a description of the services furnished by the long term care (LTC) facility; and, -Ensure that the LTC facility staff provide orientation regarding the policies and procedures of the facility, including patient rights, appropriate forms, and record keeping requirements, to hospice staff furnishing care to LTC residents.

Inspectors wroteBased on observations and interviews, the facility failed to ensure accepted infection control practices were being implemented by staff while providing patient care. Specifically, the facility failed to -Ensure staff washed their hands in between patient rooms and when in an identified high risk area; -Ensure staff followed accepted hand hygiene practice when performing infusion therapy; and, -Provide residents with an opportunity to wash or sanitize their hands before meals.

Inspectors wroteVI. Resident #85 A. Resident status Resident #85, age [AGE], was admitted on [DATE]. According to the admission face sheet, diagnoses included chronic obstructive pulmonary disease (COPD), pain, severe major depressive episode with psychotic features and type two diabetes mellitus with diabetic neuropathy. The 10/9/18 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required extensive assistance from two persons for transferring and toileting. She was also completely dependent on one person for bed mobility. B. Resident interviews Resident #85 was interviewed on 1/7/19 at 12:28 p.m. The resident said she reported concerns regarding call light response and oxygen use to the facility. She said there was a recent incident where she did not receive assistance for ten minutes with her oxygen. [...]

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure the resident living environment was clean and safe. Specifically, the facility failed to ensure three of six shower rooms were cleaned after each use.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide adequate training for adequate provision of care and services to the behavioral health population for one (#5) of one resident reviewed for behaviors out of 40 sample residents. Specifically, the facility failed to provide required behavior training to facility staff.

Inspectors wroteBased on observations, record review and interviews, the facility failed to investigate a complaint for one (#5) of two residents reviewed for grievances out of 40 sample residents. Specifically, the facility failed to resolve a complaint the resident submitted to administration.

Inspectors wroteBased on record review and interviews, the facility failed to provide notice of transfer to one (#52) of one resident reviewed for hospitalization of 40 sample residents. Specifically, the facility failed to provide Resident #52 with notice of transfer upon being sent to an acute care setting with an emergent condition.

Inspectors wroteBased on record review and interviews, the facility failed to provide notice of the bed hold policy to one (#52) of one resident reviewed for hospitalization of 40 sample residents. Specifically, the facility failed to provide Resident #52 with a notice of the bed hold policy upon emergency transfer to an acute care setting.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide intravenous (IV) care and services in accordance with professional standards of practice for two (#103 and #173) of two residents who received IV care and services out of 40 sample residents. Specifically, the facility failed to ensure nursing staff timed, dated and initialed the IV bags they hung for Residents #103 and #173.

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident who used psychotropic drugs receive behavioral interventions for one (#173) of 19 residents reviewed for anti-anxiety medications out of 40 sample residents. Specifically, the facility failed to identify, document, and utilize behavioral interventions prior to the administration of an as needed (PRN) psychoactive medication.