Red Rocks Care Center

Inspectors wroteBased on observation and interview, the facility failed to ensure residents had a safe and functional environment throughout the facility and for 18 (RM's # 20, 22, 27, 41, 43, 46, 49, 50, 51, 54, 64, 65, 66, 67, 68, 70, 71, and 76) of 19 (RM's #4, 20, 22, 27, 41, 43, 46, 49, 50, 51, 54, 64, 65, 66, 67, 68, 70, 71, and 76) rooms observed when the facility failed to: Ensure the facility entrance wall was even and pain all facility walls that were unpainted. Repair broken trim around the heating/cooling unit and damaged floor tiles between resident beds, in room [ROOM NUMBER], 66. Repair seal around heating/cooling unit in room [ROOM NUMBER],66. Repair broken and uneven floor tiles in rooms 22, 41, 43, 45, 49, 50 and 51. Repair bathroom door frame trim in rooms 50, 54, 67, 68, 70 and 71. Repair baseboards in room [ROOM NUMBER]. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the Preadmission Screening and Resident Review (PASRR; a federal requirement to help ensure individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care) was accurate for 5 (R #5, R #27, R #55, R #66, and R #94) of 5 (R #5, R #27, R #55, R #66, and R #94) residents reviewed for PASRR accuracy. This deficient practice is likely to result in the facility not providing the services needed by residents who are identified in the screening process for additional care and services.

Inspectors wroteBased on record review and interviews, the facility failed to revise the plan of care following a confirmed change in condition for 1 (R #77) of 1 (R #77) resident reviewed for care plan revision when:R #77's care plan was not updated to include an orthopedic follow-up (evaluation and ongoing management by a bone and joint specialist to assess healing, treatment needs, and potential complications) and monitoring for safety and pain after R #77 returned from the hospital with a documented fracture requiring immobilization. This deficient practice likely to result in staff not having instructions to direct care, monitor changes, or implement safety interventions after a resident's injury or change in condition.

Inspectors wroteBased on observation, and interviews, the facility failed to properly store medications in the facility medication cart and storage room by not: Ensuring the medication refrigerator (fridge) temperature log is being monitored routinely. Ensuring insulin (insulin is a natural hormone that turns food into energy and manages your blood sugar level) pens are dated when they are first used and dated 28 days after first use. These deficient practices are likely to result in expired medications and medical supplies being used in resident care resulting in residents being at risk of possible infections and not receiving the full benefits of medication.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 4 (R #3, R #55, R #71, and R #84) of 4 (R #3, R #55, R #71, and R #84) residents reviewed for infection control when: The facility failed to ensure staff performed hand hygiene during medication administration. The facility failed to ensure urinary catheter tubing remained off the floor to prevent contamination. The facility did not implement Enhanced Barrier Precautions (EBP) as required for residents with indwelling devices (inside the body) and wounds. The facility did not have biohazard bins or trash cans available for staff to discard used/soiled PPE (personal protective equipment). [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident or their representative were aware of a medication taken by the resident, which included the risks and benefits associated with that medication for 1 (R #14) of 1 (R #14) resident reviewed for unnecessary medications. If residents and/or their representative is not informed of the risks and benefits of each medication, then they are likely not able to make informed decisions.

Inspectors wroteBased on record review and interviews, the facility failed to submit the required five-day follow-up investigation results to the State Agency (SA) for 1 (R #77) of 1 (R #77) resident reviewed for incidents. If the facility is not submitting the summary of the facility's investigation to the State Agency, then the State Agency is unable to appropriately triage (review) the allegation for further investigation.

Inspectors wroteBased on record review and interview, the facility failed to complete a thorough investigation for injuries of unknown origin and report the investigation findings within five working days for 1 (R #77) of 1 (R #77) resident reviewed for incidents. If the facility is not completing an accurate and thorough investigation and submitting the summary of the facility's investigation to the State Agency, then the State Agency (SA) is unable to appropriately triage (review) the allegation for further investigation.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure the Minimum Data Set (MDS; a federally mandated comprehensive assessment of a resident's functional, medical, psychosocial and cognitive assessment completed by facility staff) was accurate for 1 (R #4) of 1 (R #4) resident reviewed for MDS assessments. This deficient practice is likely to result in the facilities failure to provide adequate care and treatment of the resident's needs.

Inspectors wroteBased on record review and interview, the facility failed to develop and implement an adequate baseline care plan (minimum healthcare information necessary to properly care for a resident immediately upon their admission to the facility) for 2 (R #1 and #42) of 3 (R #1, #42 and #48) residents reviewed for baseline care plans, when: R #1's baseline care plan was incomplete and inaccurate due to the baseline care plan failing to include multiple diagnoses with interventions for R #1. A baseline care plan was not developed within 48 hours of admission for R #42. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure an environment free from accident hazards and failed to provide adequate supervision to prevent accidents for 2 (R #5 and R #38) of 2 (R #5 and R #38) residents reviewed for accidents and supervision when: The facility did not ensure staff maintained a safe room temperature, exposing R #5 and R #38 to 32-degree Fahrenheit (F) outside temperatures, when staff opened a window without consent and left the window open for an extended period of time. This deficient practice is likely to lead to residents experiencing avoidable accidents and/or injuries.

Inspectors wroteBased on record review and interviews, the facility failed to ensure ongoing communication and coordination with the resident's dialysis provider for 1 (R #4) of 1 (R #4) residents reviewed for dialysis. If the facility does not ensure consistent two-way communication with the dialysis center for every dialysis treatment, then the facility cannot ensure appropriate monitoring of the resident's dialysis-related condition, recognition of complications, or implementation of timely interventions.

Inspectors wroteBased on interviews and record review, the facility failed to provide a diet in accordance with physician orders for 1 (R #4) of 1 (R #4) resident reviewed for nutrition when:The facility did not ensure therapeutic dysphagia care (the clinical treatment of swallowing disorders using rehabilitative and compensatory interventions to improve swallowing function and reduce the risk of aspiration) was followed and sent R #4 to dialysis with food items (sandwich) inconsistent with his ordered renal/dysphagia advanced diet. Dietary staff and nursing leadership lacked awareness of and oversight over the contents of dialysis sack lunches, placing the resident at risk for aspiration and inadequate nutritional management. These deficient practices are likely to negatively impact a resident's ability to eat, causing difficulty with swallowing during mealtimes.

Inspectors wroteBased on record review and interview, the facility failed to maintain accurate resident records for 5 of (R #'s 8, 37, 42, 90 and 95) of 5 (R #'s 8, 37, 42, 90 and 95) residents reviewed for accuracy of records by not: Ensuring weights were accurately documented for R #'s 8, 37, 42, and 90. Ensuring discharge documentation was updated and accurate for R #95. This deficient practice is likely to result in staff not having the information they need to provide competent, comprehensive care, and services to residents.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure there was a functioning call light system that allowed residents to call for assistance for 5 (1B, 25A, 26A, 27A, and 29A) of 5 (1B, 25A, 26A, 27A, and 29A) resident rooms observed for call light functionality. If the facility does not have a functioning communication system, then residents are unlikely to get their immediate needs met by facility staff.

Inspectors wroteBased on observation and interview, the facility failed to safeguard residents' personal health information when the facility mailed a notice of involuntary discharge to an unauthorized entity for 2 (R #3 and #4) of 3 (R #3, #4 and #7) residents. If the facility fails to ensure the confidentiality, security, and proper management of resident records, then residents are at risk of unauthorized persons accessing their personal and medical information.

Inspectors wroteBased on record review and interview, the facility failed to complete and submit a Five Day Report (a report sent to the State Survey Agency which includes the results of the facility's investigation into alleged violations) to the State Agency regarding allegations of neglect (the failure of the facility, its employees, or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress) for 1 (R #5) of 1 (R #5) residents. If the facility does not submit follow-up reports, then the State Agency cannot assure the residents are safe and free of neglect.

Inspectors wroteBased on record review and staff interview, the facility failed to provide a copy of the planned Involuntary Discharge Notice to the State Long-Term Care Ombudsman for 2 (R #3 and #4) of 3 (R #3, #4 and #7) residents. This deficient practice could result in residents being discharged without necessary advocacy or support from the Ombudsman's office.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents or the guardians were aware of and understood the reason they took a medication, the risks, and the benefits of the medication for 2 (R #19 and R #66) of 2 (R #19, R #66) residents reviewed for unnecessary medications. If the residents or their guardians are not informed of the risks of benefits of the medication, they are not able to make informed decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a homelike environment for 4 (R # 21, 63, 67 and 201) out of 4 (R # 21, 63, 67 and 201) residents reviewed when staff failed to replace the shower bed mattress that had a large hole all the way through the mattress which exposed the white pipe frame; to replace the curtain rods for multiple rooms; and to fix a broken door into the shower room. If residents do not have a homelike environment, they may become depressed and anxious about things in disrepair.

Inspectors wroteBased on record review and interview, the facility failed to ensure comprehensive Minimum Data Set (MDS; a federally mandated assessment instrument completed by facility staff) assessments were accurate for 2 (R #70 and #84) of 2 (R #70 and #84) residents reviewed for accurate MDS Assessments. If resident assessments are not complete and accurate, the facility could misidentify clinical complications and fail to provide adequate care to treat the resident's medical condition.

Inspectors wroteBased on interview and record review, the facility failed to ensure two (R #11 and R #66) of two (R #11 and R #66) residents had complete comprehensive care plans for their care, when staff failed to: 1. Include hospice on R #11's care plan. 2. Ensure R #66's care plans for delirium (a serious change in mental abilities that causes confused thinking and lack of awareness of surroundings), oral health, and use of psychotropic drugs (drugs that affect a person's mental state) were complete and included time frames. This failure had the potential to adversely affect staff's ability to implement preventative measures for the residents' health and well-being.

Inspectors wroteBased on observation, record review, and interview the facility failed to maintain proper infection prevention measures when the facility failed to ensure the shower bed was free of a hole and several other cuts that exposed the foam for 4 (R #21, 63, 67 and 201) of 4 ( R # 21, 63, 67 and 201) residents that used the shower bed. Failure to replace items that required cleaning multiple times per day for infection control purposes could likely cause the spread of infections and illness to the residents who use the shower bed equipment.

Inspectors wroteBased on record review, and interview, the facility failed to provide pressure ulcer interventions as ordered for R #10. This deficient practice could likely result in the resident not receiving appropriate and timely pressure ulcer relieving interventions, which could result in wounds becoming worse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide podiatry (the medical care and treatment of the human foot) services for 1 (R #65) of 1 ( R #65) resident reviewed for toenail care. This deficient practice could likely result in functional decline, pain, and infections.

Inspectors wroteBased on observation and interview, the facility failed to put a resident in her bed when she was asleep, and the resident slumped forward in her wheelchair for 1 (R #13) of 1 (R #13) resident viewed during random observation. This deficient practice could likely cause the resident to fall forward out of her wheelchair and get hurt.

Inspectors wroteBased on observation and interview, the facility failed to provide a sanitary and comfortable environment for all 93 residents, as identified by the facility census provided by the Administrator In Training (AIT) on 12/26/23, by failing to maintain and replace water damaged and stained ceiling tiles. This deficient practice is likely to cause all residents in this facility to be exposed to environmental hazards and to not feel comfortable, which could likely affect their psychosocial well-being.

Inspectors wroteBased on observation and interview, the facility failed to maintain a homelike environment in good condition for 2 (R #101 and R #102) of 4 (R #101, R #102, R #104, and R #105) residents reviewed for homelike environment. This deficient practice could likely cause residents to feel they are not living in a comfortable environment, and they are not valued.

Inspectors wroteBased on record review and interview, the facility failed to ensure the care plan was revised and updated for 1 (R #101) of 5 (R #101, R #102, R #103, R #104, R #105) residents reviewed for revised care plans. This deficient practice is likely to result in residents' care and needs not being addressed if care plans are not updated.

Inspectors wroteBased on record review and interview, the facility failed to ensure medical records were complete and accurate for 3 (R #101, R #102, and #103) of 3 (R #101, R #102 and R #103) residents reviewed for accuracy of documentation. This deficient practice has the potential to negatively impact the care staff provide to meet resident needs due to missing or inaccurate records.

Inspectors wroteBased on record review and interview, the facility failed to provide Foley catheter (a flexible tube inserted into the bladder and anchored by a balloon to allow the free flow of urine into an attached bag) care for 2 (R #1 and 2) of 3 (R #s 1, 2 and 3) residents found to have an indwelling (fixed in a person's body for a long time) Foley catheter. This deficient practice is likely to result in a resident's catheter becoming unclean and unsanitary leading to urinary tract infections (an infection in any part of the urinary system) and other diseases.

Inspectors wroteBased on record review, observation, and interviews, the facility failed to deliver consistently, and timely (to be prompt, be on time, and follow the times provided to the facility) lunch meals to 89 residents that receive trays in the dining rooms, and room trays, as identified on the facility matrix provided by Center Executive Director on 05/01/23. This deficient practice could potentially lead to resident frustration and hunger.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1. Follow policy procedure for sanitizing (method of reducing or eliminating pathogenic agents, such as bacteria, on the surfaces of something) food preparation areas and; 2. Serve a room tray at safe food temperatures (hot foods should be held and served at 135 degrees Fahrenheit) These deficient practices could likely result in residents receiving food that may be contaminated due to unsanitized prep surfaces and poor handling/serving of food trays served in resident rooms.

Inspectors wroteBased on record review and interview, the facility failed to update a residents care plan to reflect new diagnosis and treatment plans for 2 (R #15 & R #92) of 2 (R #15 & R #92) residents reviewed for comprehensive care plans. This deficient practice could likely result in resident care not being closely monitored and managed to meet the needs of the resident.

Inspectors wroteBased on record review and interview the facility failed to ensure residents maintained personal grooming for 2 (R #13 and 23) of 3 (R #13, 23 and 34) residents reviewed for Activities of Daily Living (ADLs)/nail grooming. These deficient practices could likely affect the health of the residents, causing pain in their feet and issues with their shoes not being comfortable.

Inspectors wroteBased on record review and interview, the facility failed to notify the physician that nursing staff did not obtain and administer medications for 2 (R #48 and #92) of 3 (R #15, #48, #92) residents reviewed for medication regimen. This deficient practice could likely result in residents not receiving medication as ordered for treatment of infection and disease.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure that 1 [R #195] of 2 [R #74 and 195] residents reviewed for falls were free from accident hazards by not providing sufficient supervision for one resident. This deficient practice could likely result in injuries or hospitalizations.

Inspectors wroteBased on record review and interview, the facility failed to conduct a urinary and bowel incontinence assessment for 1 (R #15) of 1 (R #15) residents reviewed for falls. This deficient practice could likely result in denying the resident of assessment and services that might restore normal bladder function and allow the resident to return to the highest practicable well being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to properly document the administration of a narcotic medication (a drug that produces analgesia, narcosis, and addiction. It is also known to produce euphoria in some people) for 1 resident (R #81) of 1(R #81) residents record of compliance of record keeping in the controlled substance log (A book that allows on coming nurses to count narcotics medications in the nursing cart). If the facility is not ensuring that controlled drugs are not appropriately documented at the time of administration, it could cause a narcotic medication discrepancy.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the the pharmacist recommendations, which were documented as responded to by the Center Nursing Executive (CNE) were followed through for 1 (R #74) of 3 (R #s 74, 94 and 197) residents sampled for drug (medication) regimen review (thorough evaluation of the medication regimen of a resident, with the goal of promoting positive outcomes and minimizing adverse consequences [undesirable effects of medication]) by not completing a lab screening for INR levels (blood test that that determines how well a person is responding to Warfarin - a blood thinning medication). This deficient practice could likely result in residents receiving medications that may have adverse consequences, receiving medications longer than needed or at a higher or incorrect dose.

Inspectors wroteBased on observation and interviews, the facility failed to: 1) Ensure that opened and accessed (if [NAME]-dose vial has been opened or accessed {e.g needle puntered} the vial should be dated with the last date that the product should be used {expiration date} and discarded with in 28 days unless the manufacturer specifies a different use by date) multi-use vials (a vial of liquid medication that contains more than one dose of the medication) were dated as to when they were initially opened/assessed, by nursing staff. 2) Ensure that expired medications were not stored with unexpired medications, that were readily available for resident use; and 3) Ensure that treatment carts are kept locked when not in use. [...]