Pikes Peak Post Acute

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure three (#2, #3 and #5) of three residents were kept free from abuse out of nine sample residents. Specifically, the facility failed to:-Protect Resident #2 and Resident #3 from being physically abused by Resident #1; and,-Protect Resident #5 from being physically abused by Resident #4.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#3) of seven residents who were diagnosed with dementia, received the appropriate treatment and services to attain or maintain the highest practicable physical, mental and psychosocial well-being out of nine sample residents. Specifically, the facility failed to effectively identify person-centered approaches for dementia care for Resident #3.

Inspectors wroteBased on observations, record review,and interviews, the facility failed to maintain a system of documenting grievances and demonstrating prompt action for residents for four (#135, #40, #37 and #51) residents out of seven residents reviewed for grievances out of 53 sample residents. Specifically, the facility failed to effectively address, resolve and demonstrate the facility's response to individual grievances for Resident #135, Resident #40, Resident #37 and Resident #51.

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 three of three certified nurse aides (CNA). Specifically, the facility failed to complete annual performance reviews and/or provide regular in-service education based on the outcome of the reviews for CNA #4, CNA #5 and CNA #6.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide reasonable accommodations necessary to accommodate mobility and accessibility in the resident's environment for one (#26) of one resident reviewed for accommodation of needs out of 53 sample residents. Specifically, the facility failed to ensure Resident #26's bed side rails were installed as requested by the resident and as recommended by the rehabilitation services department staff.

Inspectors wroteBased on record review and interviews, the facility failed to honor resident choices for one (#30) of one resident reviewed for self-determination out of 53 sample residents. Specifically, the facility failed to promote, facilitate and support a room change for Resident #30, per her preference.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were free from abuse for two (#88 and #54) of four residents reviewed for abuse out of 53 sample residents. Specifically, the facility failed to protect Resident #88 and Resident #54 from physical abuse from Resident #144.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received the necessary services and assistance for bathing for two (#48 and #77) of four residents reviewed out of 53 sample residents. Specifically, the facility failed to provide complete grooming with shower/bed bath for Resident #48 and Resident #77 in order to maintain personal hygiene, including shaving of beard, washing of hair and trimming of fingernails.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure proper treatment and services to maintain vision abilities for one (#137) of three residents reviewed for vision services out of 53 sample residents. Specifically, the facility failed to ensure Resident #137's new eyeglasses were obtained in a timely manner.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#4) of three residents out of 53 sample residents. Specifically, the facility failed to ensure staff were aware of and following the care planned interventions for Resident #4 in order to prevent further falls.

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 possible development and transmission of infectious disease on three of nine units. Specifically, the facility failed to: -Ensure housekeeping staff wore gloves and performed appropriate hand hygiene while cleaning residents' rooms; -Ensure housekeeping staff wore masks appropriately while the facility was in a flu outbreak; and, -Ensure staff sanitized dining tables and the floor prior to the next meal.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide a safe, sanitary, functional and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure necessary kitchen equipment was maintained in a safe, sanitary and working condition.

Inspectors wroteBased on record review and interviews, the facility failed to ensure four (#2, #9, #10 and #8) of four resident reviewed for abuse out of 10 sample residents were kept free from abuse. Specifically, the facility failed to ensure multiple residents, including Resident #2 and Resident #8, were kept free from physical abuse by addressing Resident #1's physically aggressive behavior. Resident #1 physically assaulted Resident #2 on four occasions and continuously targeted Resident #2. The facility was aware Resident #1 was territorial over his space and did not like to be touched. Facility staff failed to intervene timely on multiple occasions to prevent multiple physical abuse incidents by Resident #1 toward Resident #2. [...]

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 three (#1, #9 and #2) of four residents reviewed for abuse out of 10 sample residents. Specifically, the facility failed to report incidents of physical abuse involving Resident #1 to the State Survey Agency (SSA).

Inspectors wroteBased on record review, the facility failed to investigate incidents of physical aggression involving one (#1) of four residents reviewied out of 10 sample residents. Specifically, the facility failed to conduct investigations of physical abuse involving Resident #1.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents received necessary respiratory care and services per physician orders for four (#2, #10, #12 and #13) of four residents reviewed for respiratory care out of 13 sample residents. Specifically, the facility failed to: -Ensure physician's orders for oxygen were obtained for Resident #2 and Resident #10 prior to administering oxygen; -Ensure oxygen saturation levels (SpO2) were being monitored consistently for Resident #2, Resident #10 and Resident #12; -Ensure Resident #12's physician's order for oxygen accurately identified the correct oxygen flow rate; and, -Ensure staff were providing the correct flow rate of oxygen per the physician's order to Resident #13. I. [...]

Inspectors wroteBased on record review and interviews, the facility failed to revise the care plan for one resident (#1) out of three residents reviewed, to reflect, respond, and alert staff to the resident's behaviors that placed Resident #3 and others at risk for harm. Record review revealed on 10/13/23 at approximately 5:30 a.m., a certified nurse aide (CNA) entered Resident #1's room and found Resident #1 sitting in his chair next to the bed of his roommate, Resident #3. Resident #1 was holding a foot pedal to his wheelchair and his roommate had injuries to his face and body. Further record review revealed two days earlier, on 10/11/23, Resident #1 had transferred to the memory unit and into a room with Resident #3 who used a continuous positive airway pressure (CPAP) machine and oxygen at night. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure the resident's responsible party was notified when a change in medication occurred for one (#2) out of three residents reviewed for notification out of 13 sample residents. Specifically the facility failed to: -Ensure the responsible party was notified when a psychotropic medication was ordered and administered for Resident #2.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide written notification of room changes and roommate changes for two (#3 and #1) of three residents reviewed for notifications out of 13 sample residents. Specifically, the facility failed to provide timely written and/or verbal notification of room and/or roommate changes to Resident #3 and Resident #1 and/or their representatives.

Inspectors wroteV. Resident #111 A. Resident status Resident #111, age [AGE], was admitted on [DATE]. According to the August 2023 CPO, the resident's diagnoses included unspecified dementia, unspecified severity, without behavioral disturbance, psychotic disturbance, mood disturbance and anxiety. The 7/12/23 MDS assessment revealed the resident was severely impaired with a brief interview for mental status score of zero out of 15. He required extensive assistance with dressing, toileting, and personal hygiene. He required supervision oversight, encouragement and cuing with eating. -It did not indicate the resident experienced weight loss. B. Observations On 8/14/23 at 2:18 p.m. Resident #111 ate 100% of his lunch of oven fried chicken, buttered parslied noodles, green beans with a dinner roll and fresh fruit cup. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure menus were followed to meet the residents' nutritional needs. Specifically, the facility failed to: -Follow the correct portion sizes to ensure adequate nutrition was provided to the residents; and, -Ensure the correct items were served in accordance with the posted menu. I. Facility policy and procedure The Food Service Quality Indicators policy, dated 5/1/23, was provided by the nursing home administrator (NHA) on 8/17/23 at 1:15 p.m. It revealed in pertinent part, Portion sizes of foods served are correct according to the written menu for each diet. Meals are served according to the Diet Guides: recipes are followed, portion sizes are correct, all items are present non-specified items are included and preferences are honored if not contraindicated by diet restriction. II. [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen, the north serving kitchen and four out of four nourishment rooms. Specifically, the facility failed to: -Ensure food was labeled and dated and disposed of timely in the walk-in refrigerators, dry storage and reach-in refrigerator in the main kitchen and in four nourishment rooms; -Ensure the main kitchen and four unit nourishment rooms were clean and sanitary; -Ensure garbage was covered and disposed of in the main kitchen; -Ensure appropriate hand hygiene when staff were assisting residents with meals; -Ensure temperatures were taken of refrigerators in the main kitchens and the nourishment rooms; -Have a system in place to monitor the internal temperature of the dishwasher to ensure the functioning of the dishwasher; [...]

Inspectors wroteBased on record review and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment which included all resources, staff education, staff competencies and facility based risk assessments.

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 develop and implement effective action plans to address repeat deficiencies and ensure systemic and lasting improvement for quality of care issues.

Inspectors wroteBased on interviews and record review, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to follow up with residents' concerns regarding meals that were brought up by the food committee.

Inspectors wroteBased on record review and interviews the facility failed to ensure that the personal funds accounts were managed adequate for seven (#21, #92, #65, #79, #34, #12 and #97) of seven residents reviewed for personal funds out of 70 sample residents. Specifically the facility failed to: -Ensure Resident #21 was assisted in applying for financial benefits and setting up an account so he could access money; and, -Ensure Resident #92, #65, #79, #34, #12 and #97 were notified and assisted in spending down their bank accounts.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide an environment as free of accident hazards as possible and ensure residents received adequate supervision and assistance devices to prevent accidents for eight (#285, #297, #286, #295, #296, #125, #25 and #130) of nine residents reviewed for accident hazards out of 70 sample residents. Specifically, the facility failed to: -Identify elopement/wander risk, implement wander guard and develop a comprehensive wander risk care plan based on knowledge of previous secure placement and elopement evaluations for Resident #285, #297, #286, #295, #296 and #125; and, -Ensure timely interventions were put into place following falls for Resident #25 and #130.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure a resident diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being for three (#64, #52 and #116) of four residents reviewed for dementia care out of 70 sample residents. Specifically, the facility failed to: -Provide a person-centered approach, individualized approach and treatment to Resident #116's dementia care to address her increased confusion prior to moving her to a new room within facility; -Provide a person-centered approach to Resident #64 and Resident #52's dementia care services to address their physically aggressive behavior in order to prevent physical altercations with each other and; [...]

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 32% or 18 errors out of 56 opportunities for error.

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, in five of five medication carts reviewed out of nine medication carts and two of two medication rooms reviewed out of five medication rooms. Specifically, the facility failed to: -Label and date insulin when opened; -Dispose of medications beyond the manufacturer use by date once opened; and, -Ensure medications and vaccines were not stored with resident food.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to maintain an infection control program designed to prevent the spread of infection for one of three neighborhoods. Specifically, the facility failed to perform appropriate hand hygiene during medication administration.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the antibiotic stewardship program included antibiotic use protocols addressing documentation of the indication and duration of the antibiotic and a system to monitor antibiotic use for prophylactic antibiotics for five (#52, #74, #43, #45 and #76) of five residents reviewed for antibiotic use out of 70 sample residents. Specifically, the facility failed to evaluate and monitor the use of current prophylactic antibiotic usage for Residents #52, #74, #43, #45 and #76.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#13) of three out of 70 sample residents. Specifically, the facility failed to ensure Resident #13 was assessed for clinical appropriateness of self administration of medication and medications left at the bedside were secured.

Inspectors wroteBased on interviews and record review, the facility failed to ensure three (#56, #64 and #52) out of 70 sample residents were kept free from abuse. Specifically, the facility failed to: -Ensure Resident #56 was kept free from physical abuse by Resident #188; and, -Ensure resident to resident altercation, which started with yelling, did not result in physical abuse with Resident #64 and Resident #52.

Inspectors wroteBased on observations and interviews, the facility failed to provide services in accordance with currently accepted professional principles. Specifically, the facility failed to ensure medications were not dispensed and stored in medication cups in the top drawer of the medication cart.

Inspectors wroteBased on record review, observations, and interviews the facility failed to ensure one resident (#63) reviewed for activities of daily living (ADLs) received the necessary care and services to maintain their abilities in ADLs out of 70 sample residents. Specifically, the facility failed to provide language communication tools in order for Resident #63 to effectively communicate her needs, requests, opinions and participate in social conversation.

Inspectors wroteBased on observations, record review and interviews, the facility facile to ensure activities designed to support residents physical, mental and psychosocial well-being were provided for two (#21 and #335) of 10 residents reviewed for activities out of 70 sample residents. Specifically, the facility failed to ensure Resident #21 and #335 were provided activities and developed a comprehensive care plan which addressed each resident's socialization and activity needs.

Inspectors wroteBased on record review, observations and interviews, the facility failed to provide the necessary treatment and services to treat and prevent pressure injuries from occurring for two (#1 and #335) of two residents out of 70 sample residents. Specifically, the facility failed to: -Ensure timely identification of a stage 2 pressure injury, notify the physician, receive a treatment order and update the comprehensive care plan for Resident #335; -Ensure treatment orders were in place from a licensed medical provider before a treatment was applied for Resident #335; and, -Ensure timely identification of Stage 1 deep tissue injury (DTI) for Resident #1.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure one (#62) of four residents reviewed were provided with services or treatments to prevent the reduction in range of motion out of 70 sample residents. Specifically, the facility failed to ensure Resident #62 was provided with preventative measures for his contracture.

Inspectors wroteBased on record review and interviews, the facility failed to have scheduled physician visits for two residents (#297 and #295) out of five newly admitted residents reviewed for physician visits out of 65 sample residents. Specifically, the facility failed to ensure the physician evaluated Resident #297 and Resident #295 timely upon admission.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide each resident with a nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the allergens and preferences of each resident for two (#118 and #14) of two residents out of 70 sample residents. Specifically, the facility failed to: -Ensure Resident #118's allergen to gluten was not served to her; and, -Ensure Resident #14 requests, preferences, and options for a vegetarian diet were served to her. I. Facility policy and procedure The Selective Menus policy, dated 5/1/23, was provided by the nursing home administrator (NHA) on 8/17/23 at 1:15 p.m. It revealed in pertinent part, Personal Choice Menus are distributed to the residents based on the facility plan. [...]

Inspectors wroteBased on document review, record review, observations, interviews, and facility policy review, the facility failed to prevent potential accidents by failing to: 1. ensure hot water temperatures were maintained at safe temperatures between 105 - 115 degrees Fahrenheit (F) in 1 (700 Hall; secured memory care unit) of 8 halls in the facility. 2. complete a smoking assessment for one (Resident #260) of one newly admitted residents who smoked tobacco products and required such an assessment prior to smoking.

Inspectors wroteBased on record review and interview, the facility failed to ensure a Preadmission Screening and Resident Review (PASARR) Level I screening was completed within thirty days of admission for one (Resident #89) of one residents reviewed for PASARR.

Inspectors wrote2. A review of Resident #32's admission Record revealed the facility admitted the resident on 02/28/2020 with diagnoses which included chronic obstructive pulmonary disease (COPD) and vascular dementia without behavioral disturbance. A review of Resident #32's annual Minimum Data Set (MDS), dated [DATE], indicated the resident was cognitively intact as evidenced by a Brief Interview for Mental Status (BIMS) score of 15 out of 15. A review of Resident #32's care plan, dated 03/21/2021, revealed the resident exhibited or was at risk for respiratory complications related to COPD, with goals that the resident would have no sign/symptoms of respiratory distress during this treatment period. The interventions included to monitor and report oxygen (O2) saturation levels via pulse oximetry as ordered and prn (pro re nata; as needed) and administer O2 as ordered via nasal cannula. [...]

Inspectors wroteBased on observation, interviews, record review, and review of the facility policy, the facility failed to provide appropriate treatment and care for 1 of 2 residents (Resident #96) with alterations in skin integrity. Specifically, Resident #96 had a rough patch of skin with open cracks in the skin that had not been identified by the facility.

Inspectors wroteBased on record review, observation, interviews, and policy review, the facility failed to ensure an indwelling urinary catheter was utilized with adequate justification for one (Resident #103) of three residents sampled with indwelling urinary catheters.

Inspectors wroteBased on observations, interviews, policy review, and record review, it was determined the facility failed to maintain an infection control program to help prevent the transmission of communicable diseases for two (Resident #154 and Resident #159) of 32 sampled residents. Observations revealed staff did not wear appropriate personal protective equipment (PPE) when entering the rooms of Resident #154 and Resident #159 and there was not appropriate signage posted on the residents' doors about infection prevention precautions.