Pueblo Springs Rehabilitation Center

Inspectors wroteBased on clinical record review, interviews, and review of facility policies, the facility failed to ensure that medications were available as ordered for one resident (resident #5). The deficient practice could result in residents not receiving medications that are physician ordered and necessary.

Inspectors wroteBased on observations, staff interviews and review of policies and procedures, the facility failed to ensure that food was labeled, stored and plated in accordance with professional standards, and that personal items were not located on food preparation counters. The deficient practices could result in food-borne illnesses.

Inspectors wroteBased on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure that medical record were complete and accurate for four residents (#27, #16, #14, and #30). The deficient practice could lead to care team members not being aware of a resident's status, and could lead to missed or services rendered.

Inspectors wroteBased on review of the clinical record, interviews, and observations the facility failed to ensure a Preadmission Screening and Resident Review (PASRR) was updated to accurately reflect changes in the condition of resident #88. The deficient practice can result in a resident not receiving recommended services to promote and attain the highest level of well-being. Resident #88, was re-admitted to the facility on [DATE] with diagnoses that include alcoholic cirrhosis of the liver, major depressive disorder-recurrent, insomnia, and history of a myocardial infarction. An order for Mirtazapine 7.5 mg by mouth at bedtime for depression was discontinued on September 19, 2023. Review of a progress note dated March 4, 2024 revealed the resident had an altercation with another resident, and had to be separated for safety. [...]

Inspectors wroteBased on observations, clinical record reviews, resident and staff interviews, facility documentation and policy review, the facility failed to ensure that nutritional status was accurately assessed and documented in accordance to professional standards for one resident (#30). The deficient practice can result in additional residents experiencing weight loss, without adequate interventions.

Inspectors wroteBased on clinical record reviews, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure that one resident (#284) was free from physical abuse from other residents (resident #15). The deficient practice could result in further incidents of resident to resident abuse.

Inspectors wroteBased on observation, interviews, review of records, and review of facility policy and procedure, the facility failed to ensure that staff follows appropriate infection control practices. The deficient practice could result in a spread of preventable illness to residents and staff.

Inspectors wroteBased on clinical record reviews, facility documentation, staff interviews, and policy review, the facility failed to implement written policies and procedures that prevent the misappropriation of the property of one resident (Resident #299). The deficient practice can result in the lack of prevention for future occurrences.

Inspectors wroteBased on clinical records, resident and staff interviews, and facility documents, the facility failed to ensure that residents are not abused by staff. -Resident #61 was admitted on [DATE] with diagnoses of paraplegia. A care plan dated 11/10/17 included that this resident had an ADL Self Care Performance Deficit related to paraplegia, disease process, limited mobility and included that this resident requires staff participation to use the toilet, with transfers, and to reposition and turn in bed and to encourage to use bell to call for assistance. Review of the clinical did not find notes regarding this incident. Review of the Medication Administration Record (MAR) included that medications were provided by a Licensed Practical Nurse (LPN/staff #126) during the time of the incident. [...]

Inspectors wroteBased on clinical records and staff interviews, the facility failed to ensure that a resident was free from preventable accidents (#4).

Inspectors wroteBased on clinical record review, staff interviews, and facility policy and procedures, the facility failed to ensure level I PASRR (preadmission screening and resident review) was completed for three residents (#8, #48 and #45). This deficient practice could result in residents not receiving the appropriate level of care.

Inspectors wrote-Resident #45 was admitted on [DATE] with diagnoses of schizoaffective disorder, depression, and anemia. The care plan dated July 5, 2022 revealed the resident had potential for acute/chronic pain. Intervention included to administer analgesia medication as per orders and to follow pain scale. The physician order dated November 4, 2022 included for oxycodone (narcotic analgesic) 5 mg (milligrams) and to give 5 mg by mouth every 6 hours as needed for a pain scale of 4-10. This order was transcribed onto the MAR (medication administration record) for February, March and April 2023 However, review of the MAR for February, March and April 2023 revealed that there were multiple days that oxycodone was documented as administered for documented pain scales between 0 and 3. [...]

Inspectors wroteBased on clinical record review, interviews, and review of facility policies, the facility failed to ensure that medications were available for use one resident (#28). The deficient practice could result in resident not receiving necessary medications ordered by the physician.

Inspectors wroteBased on clinical record review, observation, resident and staff interviews, and review of policy and procedures, the facility failed to ensure routine medications were consistently available for one resident (#58). The sample size was 7. The deficient practice could result in medications not being available for residents.

Inspectors wroteBased on observations, clinical record reviews, staff interviews, and review of policy and procedures, the facility failed to ensure one resident (#58) was assessed for self-administration of medications. The sample size was 19. The deficient practice could result in residents unsafely administering medications.

Inspectors wroteBased on clinical record review, staff interviews, and review of policies and procedures, the facility failed to ensure a physician was notified of a high blood sugar level for one resident (#58). The sample size was 19. The deficient practice could result in residents not receiving treatment for high blood sugar levels.

Inspectors wroteBased on observations, clinical record review, facility documentation, resident and staff interviews, and policy review, the facility failed to ensure a pull cord light switch was replaced in one resident's (#46) room. The deficient practice prevented the resident room from having a homelike environment. The sample size was 19.

Inspectors wroteBased on observations, clinical record review, staff interviews, and review of policy and procedures, the facility failed to ensure one resident (#58) had a physician order for an eye-drop. The sample size was 19. The deficient practice could result in residents receiving medications without an order.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, and policy reviews, the facility failed to ensure that one sampled resident (#60) received the necessary services to maintain good grooming and personal hygiene. The deficient practice could result in grooming and personal hygiene needs not being met for residents.

Inspectors wroteBased on observations, clinical record review, resident and staff interviews, facility documentation and policy reviews, the facility failed to ensure one two sampled residents (#60) was provided treatment for contractures, as ordered by the physician. The deficient practice could result in residents not being provided treatment and services to increase, maintain, or prevent further decrease in range of motion (ROM).

Inspectors wroteBased on observations, clinical record review, staff interviews, and policy review, the facility failed to ensure one sampled resident (#58) had an order for PRN (as needed) use of oxygen. The deficient practice could result in residents receiving oxygen without a physician order.