Parker Post Acute

Inspectors wroteBased on record review and interviews, the facility failed to provide emergency basic life support and cardiopulmonary resuscitation (CPR) when needed for one (#1) of three residents reviewed for advance directives out of seven sample residents. Resident #1 was admitted to the facility on [DATE] with a history of acute and chronic respiratory failure and aspiration pneumonia. On [DATE], the power of attorney for Resident #1 completed and signed a Colorado Medical Orders for Scope of Treatment (MOST). The MOST form documented Resident #1 desired to receive CPR with full treatment in the event it was required. On [DATE], a physician's order was entered into Resident #1's electronic medical record (EMR) that identified Resident #1 was a full code and should receive CPR. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans, and resident preferences for one (#64) of three residents out of 62 sample residents. Resident #64, was admitted on [DATE] with a diagnosis including sepsis, acute respiratory failure, congestive heart failure, pneumonia and pressure-induced deep tissue damage of the left ankle. Resident #64 said he experienced pain when the staff were repositioning him. Observations revealed while the staff were repositioning Resident #64, he cried out in pain and asked the staff to stop. The staff continued care despite the resident crying out in pain and did not stop to reassess the resident to ensure he did not suffer from additional pain. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure infection prevention and control programs were maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on three out of three floors. Specifically, the facility failed to: -Ensure staff followed appropriate hand hygiene while performing wound care and don correct PPE (gown) while perform transfers for Resident #6; and,-Ensure staff wore the appropriate personal protective equipment (PPE) when providing care to residents who were on enhanced barrier precautions (EBP); -Ensure staff wore the appropriate PPE when providing care to residents who were on contact precautions;-Ensure contaminated laundry was handled appropriately; and,-Ensure oxygen tubing was handled in a sanitary manner.

Inspectors wroteBased on observations, record review and interviews, the facility failed to honor residents' choices for two (#58 and #42) of three residents out of 62 sample residents. Specifically, the facility failed to:-Facilitate and honor a wheelchair preference for Resident #58; and,-Ensure Resident #42's call light was within reach.

Inspectors wroteBased on record review and interviews, the facility failed to investigate and report an alleged violation of potential abuse to the State Survey and Certification Agency in accordance with state law for two (#56 and #102) of five residents reviewed for abuse out of 62 sample residents. Specifically, the facility failed to timely report an incident of potential sexual abuse involving Resident #56 and Resident #102 to the State Agency.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for one (#36) of three residents reviewed for hearing problems of 62 sample residents. Specifically, the facility failed to ensure Resident #36`s pocket audio device was regularly charged for the resident`s use.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure an environment free of accident hazards for one (#46) of two of five residents reviewed for accident hazards out of sample residents reviewed for accident hazards. Specifically the facility failed to ensure fall interventions were implemented for Resident #46 as written in the care plan.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice and the comprehensive person-centered care plan for one (#21) of one resident reviewed for respiratory care out of 62 sample residents. Specifically, the facility failed to ensure that Resident #21 received oxygen therapy in accordance with their physician's orders.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#56) of three residents reviewed for dementia care received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being out of 62 sample residents Specifically, the facility failed to assess Resident #56 to determine if she was able to consent to a romantic relationship with a diagnosis of dementia.

Inspectors wroteBased on observations, record review and interviews, the facility failed to assess, arrange, and document discharge services for one (#1) of one resident reviewed out of three sample residents. Specifically, for Resident #1, the facility failed to: -Assess oxygen therapy discharge needs for the resident; and, -Ensure home health services were confirmed for the resident prior to discharge.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure two (#7 and #4) of four residents reviewed for accidents out of 13 sample residents received adequate supervision to prevent accidents. Resident #7, who had diagnoses of unspecified dementia, a history of falling and muscle wasting, was admitted to the facility on [DATE]. Between 6/14/24 and 7/21/24, the resident experienced six falls. The facility failed to put effective fall interventions into place after each fall. On 8/7/24, Resident #7 experienced a seventh fall and sustained a laceration on her forehead which resulted in the resident being transferred to the hospital for sutures to the laceration. Upon the resident's return from the hospital, a fall mat and instructions to keep the resident's bed in the low position were added to the resident's care plan as fall interventions. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#5) of four residents had an effective pain management regimen in a manner consistent with professional standards of practice out of 13 sample residents. Resident #5 was admitted to the facility on [DATE] with a diagnosis of low back pain and dementia. The resident was on a scheduled pain regimen, which consisted of Tylenol 1000 milligrams (mg) three times a day and Aspercreme 1% (topical pain medication) to be applied to the resident's right shoulder twice a day. On 1/23/25 at 3:40 a.m. the resident began complaining of excruciating pain to her shoulder, back of both thighs, both knees, calves and hips. The facility failed to address Resident #5's reports of excruciating pain for three and a half hours until the nurse obtained a physician's order to administer Valium (muscle relaxer medication).

Inspectors wroteBased on record review and interviews, the facility failed to develop and implement a baseline care plan which included the instructions needed to provide effective and person-centered care for two (#2 and #6) of three residents reviewed for baseline care plans out of 13 sample residents. Specifically, the facility failed to ensure pertinent medical information was included on Resident #2 and Resident #6's baseline care plans within 48 hours of admission.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (#2) of three residents reviewed out of eight sample residents. Specifically, the facility failed to ensure transportation services were provided for Resident #2 which resulted in the resident missing an appointment with her oncologist and several chemotherapy infusion appointments.

Inspectors wroteBased on observation and interviews, the facility failed to ensure medications and biologics were stored and labeled properly on three of five medication carts and one of two medication storage rooms. Specifically, the facility failed to ensure: -Ensure medications were not stored in staff pockets; -Insulin (medication for diabetes) pen injection devices, were labeled appropriately with open dates; -Ensure inhaler medications were stored and labeled appropriately with open dates; -Ensure expired medications were removed from the medication rooms; and, -Ensure food items were not stored in the medication carts.

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 development and transmission of diseases and infection for two out of three units in the facility. Specifically, the facility failed to: -Ensure high touch areas were cleaned appropriately by the housekeeping staff; -Ensure the housekeeping staff used proper surface disinfectant times; -Ensure appropriate cleaning products were used in resident areas; and, -Ensure the housekeeping staff cleaned from cleaner to dirtier areas.

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 one (#46) of three sample residents for incontinence care out of 48 sample residents. Specifically, the facility failed to ensure Resident #46 was offered incontinence care timely.

Inspectors wroteBased on record review and staff interviews, the facility failed to clarify resuscitation choices and document them accurately in the medical record for two (#51 and #89) of 24 residents reviewed for advance directives out of 48 sample residents. Specifically, the facility failed to ensure the medical orders for scope of treatment forms (MOST) forms matched the physician's orders for Resident #51 and #89.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#99) of three residents who entered the facility with limited mobility and range of motion received appropriate services and assistance to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility was demonstrated as unavoidable out of 48 sample residents. Specifically, the facility failed to ensure Resident #99 received restorative services to prevent potential worsening of functional ability.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#37 and #170) of seven residents who required respiratory care received the care consistent with professional standards of practice out of 48 sample residents. Specifically, for the facility failed to: -Ensure a care plan was in place to include for oxygen therapy to include oxygen route, frequency, and liters required for Resident #37; -Ensure a physician's order was in place for oxygen therapy for Resident #37; -Ensure a physician's order was in place to include the appropriate care of a continuous positive airway pressure (CPAP) machine for Resident #37 and Resident #170; -Follow manufacturer recommendations to maintain, clean, sanitize, and store Resident #170 and Resident #37's CPAP; [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents were free of unnecessary psychotropic medications for one (#90) of five residents reviewed for unnecessary medications out of 48 sample residents. Specifically, the facility failed to: -Ensure an as needed (PRN) psychoactive medication were discontinued after 14 days for Resident #90; -Provide documentation and rationale to justify the continued use of a PRN psychotropic medication for Resident #90; and, -Provide non-pharmacological interventions prior to the administration of a PRN psychotropic medication for Resident #90.

Inspectors wroteBased on observations, interviews, record review, and document and policy review, the facility failed to ensure care and services were provided to prevent new pressure ulcer development for one (Resident #98) of three residents reviewed for pressure ulcers. Specifically, the facility failed to monitor the resident's skin under a knee brace and foot boot every shift as ordered, and the resident developed a stage 3 pressure ulcer to the right calf.

Inspectors wroteBased on observations, interviews, and document and facility policy review, the facility failed to follow the prepared menu for four (Residents #26, 42, 69, 83) of four residents who received a pureed diet from the facility kitchen. Specifically, the facility failed to serve the correct portion size for pureed foods during the lunch meal on 09/27/2022.

Inspectors wroteBased on interviews, record review, document review, and facility policy review, the facility failed to report 1 of 2 incidents of resident-to-resident abuse reviewed. Specifically, the facility investigated, but did not report to the state survey agency (SSA), a resident-to-resident altercation in which Resident #247 grabbed the arm of Resident #73 and would not let go.

Inspectors wroteBased on interviews, record review, and facility policy review, the facility failed to ensure a resident was allowed to return to the facility after being transferred to the hospital emergency room for 1 (Resident #247) of 2 sampled residents reviewed for transfer/discharge.

Inspectors wroteBased on observation, interviews, record review, and facility policy review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately completed for 2 (Resident #9 and Resident #21) of 22 residents reviewed for MDS accuracy. Specifically, the facility failed to ensure information regarding the resident's medication regimen was accurately completed for Resident #9 and failed to ensure information regarding limitation in range of motion was accurately completed for Resident #21.

Inspectors wroteBased on observations, interviews, record review, and facility policy review, the facility failed to develop and implement a comprehensive person-centered care plan for one (Resident #51) of 22 residents whose comprehensive care plans were reviewed. Specifically, the facility failed to ensure Resident #51's limited range of motion (ROM) was addressed in the care plan to prevent any further decreases in ROM.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure residents with limited range of motion (ROM) received care and services to prevent any further decrease in ROM for one (Resident #51) of three residents reviewed for position/mobility.