Malley Transitional Care Center

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#4) of three residents reviewed for accidents out of 18 sample residents remained as free from accidents and hazards as possible. Resident #4, who had diagnoses of multiple sclerosis (a progressive neurological condition), polyneuropathy (a disease featuring weakness, numbness and burning pain) and anxiety disorder (an intense, excessive and persistent worry and fear about everyday situations), was admitted to the facility on [DATE]. Resident #4 was dependent on staff for transfers utilizing a Hoyer lift (mechanical lift). On 4/7/26 staff were transferring Resident #4 using the smaller Hoyer lift. According to the resident's weight, the resident required the larger Hoyer lift. The resident began to fall and was lowered to the ground. On 4/9/26 at 9:00 p.m. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were kept free from abuse for one (#14) of five residents reviewed for abuse out of 18 sample residents. Specifically, the facility failed to protect Resident #14 from physical abuse by Resident #10.

Inspectors wroteBased on observation, record review, interview, and policy review, the facility failed to 1.) maintain a comfortable temperature for residents in their rooms and hallway for two of three units (West unit and the East unit), and 2.) maintain the residents' wheelchairs in a condition that was in good repair. Specifically, the wheelchair arms for seven of 78 residents' wheelchairs (Resident (R) 64, R239, R8, R240, R1, R118, and R117) were cracked and missing vinyl exposing the white material underneath. This failure prevented the cleaning and sanitizing of the wheelchair arm rests.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure allegations of abuse were reported per the federal regulations to the Colorado Department of Public Health and Environment (CDPHE) within two hours of the facility being made aware of the abuse allegations for three of three residents (Residents (R) 61, R237, and R387) reviewed for allegations of abuse out of a total sample of 31.

Inspectors wroteBased on record review and interview, the facility failed to ensure two of two residents and their representatives (R) 86 and R109) reviewed for facility initiated emergent hospital transfer from a total sample of 31 residents were provided with written transfer/discharge notices that contained the required information. This failure had the potential to affect the residents and their Resident Representative (RR) by not having the knowledge of how to appeal the transfer, if desired, and how to notify the State Long-Term Care (LTC) Ombudsman's office.

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change in status Minimum Data Set (MDS) for one of one resident (Resident (R) 121) reviewed for hospice in a total sample of 31 residents. This had the potential to cause unmet care needs for R121.

Inspectors wroteBased on observation, interview, record review, and review of facility policy, the facility failed to secure one of two medication carts on the East Wing when out of the site of the nursing staff. This failure could permit individual unauthorized access to residents' medications.

Inspectors wroteBased on observations, interviews, record reviews, and review of facility policy, the facility failed to 1.) follow current standards of practice related to the use of personal protective equipment (PPE) with transmission-based precautions and/or implement their policy and procedures related to enhanced barrier precautions (EBP) for two of two residents (Resident (R) 107 and R389) reviewed for transmission-based precautions out of a total sample of 31, and 2.) sanitize glucometers in a manner that prevented cross-contamination for one of three residents (R76) observed receiving fingerstick blood glucose tests (FSBG). These failures had the potential to lead to the spread of infection throughout the facility.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#2) of three residents reviewed for accidents remained free from accidents. On 7/7/23 Resident #2 sustained an arm fracture during a transfer by one certified nurse aide (CNA) using a sit to stand lift. Prior to the transfer, Resident #2 was not evaluated and was not deemed safe or appropriate for the use of sit to stand lift. The incident during transfer was not clearly communicated to the nurse and head to toe assessment was not completed. As a result, the resident's arm fracture went unnoticed for the next 48 hours. The next day on 7/8/23 the resident refused to be transferred with a sit to stand lift and stayed in bed more than usual. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible. This was evidenced by hazardous hot water temperatures in resident care areas on two of three units. Water temperatures in resident rooms and two shower rooms exceeded safe temperatures, creating the likelihood for serious harm/injuries if the situation was not corrected immediately.

Inspectors wroteBased on record review and interviews, the facility failed to prevent a significant medication error for one (#85) resident of eight residents reviewed for medication errors out of 47 sample residents. The facility failed to ensure medications were labeled according to the physician's orders to prevent significant medication errors for Resident #85. On 1/6/23, the facility administered 65 mg of Methadone instead of 15 mg ordered on 12/2/22. After the incorrect dose was administered, the resident required Narcan (to treat narcotic overdose) to be administered and was sent to the emergency room. The medication error caused the resident to be upset; he rocked in his wheelchair, hyperventilated, yelled and cursed at staff.

Inspectors wroteBased on observations and staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness. Specifically the facility failed to: -Ensure holding temperatures were at appropriate temperatures; -Ensure proper food handling practices; -Ensure health shakes were dated when thawed; -Ensure artificial nails with polish were not worn by food worker; and, -Ensure meat was thawed correctly.

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 resident safety.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents received notices orally and in writing which included a written description of their legal rights. Specifically, the facility failed to post a list of names, addresses and telephone numbers of the State Agency in the facility.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were provided prompt efforts by the facility to follow up on grievances. Specifically, the facility failed to file and follow up on resient grievances related to: -Missing clothes and items; and, -Call light times.

Inspectors wroteBased on observations and interviews the facility failed to ensure two out of three medication refrigerators stored and secured drugs and biologicals in accordance with accepted professional principles. Specifically, the facility failed to: -Ensure controlled medications were in a locked storage area that was secured to the refrigerator; -Ensure medication room door was locked; -Ensure medication cart was locked when nurse not at the cart; -Ensure alcohol for drinking was not stored with used culture vials; -Ensure batteries and medications were not stored together; and, -Ensure controlled medications for disposal were kept in a double locked area until disposal.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to: -Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas; -Ensure staff used proper hand hygiene; -Ensure residents were provided with an opportunity to participate in hand hygiene prior to meals; and, -Ensure residents' personal property were labeled and stored appropriately.

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for one (#117) of three residents out of 47 sample residents. Specifically, the facility failed to: -Develop and revise a person-centered acute/baseline care plan within 48 hours of admission for Resident #117 that included pertinent healthcare information related to the resident's psychosocial needs, anxiety with depression, and history of trauma for staff to use to prevent potential further anxiety and retraumatization; and, -Review the baseline care plan with the resident or the resident's representative for input into choices and approaches.

Inspectors wroteBased on record review, interviews, and observations the facility failed to develop a comprehensive care plan for two (#75 and #4) out of eight residents out of 47 sample residents for services to attain or maintain the residence highest practical physical, mental, and psychosocial well-being. Specifically, the facility failed to: -Ensure the care plan for Resident #75 reflected activity preferences; and, -Ensure the care plan for Resident #4 reflected dental needs.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure that activities of daily living (ADL) for dependent residents were provided for two (#57 and #87) out of 47 sample residents. Specifically, the facility failed to: -Ensure Resident #57 was provided repositioning and personal hygiene assistance in a timely and consistent manner; and, -Ensure Resident #87 was provided timely incontience care.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two (#57 and #107) out of four residents reviewed for activity programming out of 47 sample residents. Specifically, the facility failed to offer and provide personalized activity programs for Resident #57 and #107 as documented in their care plan.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#87) of three residents out of 47 sample residents with limited mobility reviewed for range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion. Specifically, the facility failed to establish a consistent restorative nursing program for Resident #87.

Inspectors wroteBased on interviews and record review, the facility failed to manage pain in a manner consistent with professional standards of practice for one (#61) out of three residents out of 47 sample residents. Specifically the facility failed to: -Complete a thorough pain assessment for Resident #61 when she experienced an increase in pain; -Ensure the as needed (PRN) pain medication was available for Resident #61; and, -Follow-up on recommendations for Resident #61 from the pain clinic.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that a resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for two (#87 and #117) of four residents reviewed out of 47 sample residents. Specifically, the facility failed to identify Resident #87 and #117 post traumatic stress disorder (PTSD) and identify triggers which may retraumatize them.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure one (#96) resident out of 47 sample residents received the appropriate treatment and services to maintain their highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #96.

Inspectors wroteBased on resident and staff interviews and record review the facility failed to assist a resident to obtain routine or emergency dental services, as needed, for one (#4) out of 47 sample residents. Specifically, the facility failed to provide dental services for Resident #4.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure residents maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, as evidenced by severe or significant weight loss for one (#65) of five residents reviewed for nutrition out of 50 sample residents. Specifically, the facility failed to reassess Resident #65's nutritional status after he removed his gastrostomy tube (G-tube) and experienced a significant weight loss of 19.2% in six months. I. Facility policy and procedure The facility Nutrition Assessment Policy, revised December 2011, was provided by the nursing home administrator (NHA) on 11/12/19. [...]

Inspectors wroteBased on observations and interviews, the facility failed to properly store medications in six of six medication carts. Specifically, the facility failed to - Ensure multi-dose medications were labeled with the date of opening or the proper resident identifier or both; and, - Discard of expired medication from the medication cart. - Discard of discontinued medication from the medication cart.

Inspectors wroteBased on record review and interviews the facility failed to provide sufficient nursing staff to ensure the residents received the care and services they required to achieve their highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed to provide assistance and respond to resident call lights in a timely manner. I. Facility policy and procedure The Answering the Call Light policy, revised October 2010, was provided by the nursing home administrator (NHA) on 11/12/19. It read, in pertinent part, Answer the resident's call as soon as possible. If you have promised the resident you will return with an item or information, do so promptly. If assistance is needed when you enter the room, summon help by using the call signal. A. Resident Interviews A group interview was held on 11/7/19 at 3:30 p.m. [...]