South Platte Rehabilitation and Nursing LLC

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received necessary respiratory care and services per professional standards of practice for one (#2) of five sample residents reviewed for respiratory care out of 12 sample residents. Resident #2, who was admitted to the facility on [DATE], had a history of chronic obstructive pulmonary disease (COPD - air flow blockage) and required continuous oxygen. On [DATE] at approximately 8:30 a.m. the facility experienced a 45-minute electrical power outage and the backup generator failed to turn on. The social services director (SSD), who was also a certified nurse aide (CNA), transitioned two residents, including Resident #2, from their oxygen concentrators to their portable oxygen canisters when the power went out. On [DATE] at 10:15 p.m. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received services from qualified individuals who had the skills, experience, knowledge and proper licensure to meet the residents' needs for one (#1) of four residents out of 12 sample residents. Specifically, the facility failed to ensure a qualified and licensed nurse received shift report, evaluated the resident condition, obtained physician's orders for Resident #1.

Inspectors wroteBased on record review and interviews, the facility failed to provide catheter care in accordance with standards of professional practice for one (#3) of three residents out of 12 sample residents. Specifically, the facility failed to ensure the urinary catheter was changed timely for Resident #3.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure two (#5 and #6) of two residents reviewed for abuse out of eight sample residents were kept free from physical abuse. Resident #4 was admitted to the facility on [DATE] with diagnoses which included alcohol abuse and encephalopathy (brain disease that affects brain function). The resident had a mood problem related to being quick tempered, had poor coping skills and could exhibit verbally aggressive outbursts towards others when he disagreed with them. On 10/21/24, certified nurse aide (CNA) #1 witnessed Resident #4, who was coming inside from the smoking area, purposefully run his wheelchair into Resident #5, who was in the hallway in her wheelchair waiting to go outside to the smoking area. [...]

Inspectors wroteBased upon observations, record review and interviews, the facility failed to ensure that two (#4 and #5) of two residents out of eight sample residents, received the appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being. Resident #4 was admitted to the facility on [DATE] with diagnoses of alcohol abuse and encephalopathy (brain disease that affects brain function). The resident had a mood problem related to being quick tempered, had poor coping skills and could exhibit verbally aggressive outbursts towards others when he disagreed with them. The facility failed to implement effective interventions for Resident #4 and appropriately address Resident #4's abuse behaviors towards other residents. The facility failed to protect residents from continued verbal and mental abuse from Resident #4. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure resident assessments were provided by qualified persons for three (#8, #3 and #5) of eight residents out of eight sample residents. Specifically, the facility failed to: -Ensure Resident #8 and Resident #3, who experienced unwitnessed falls, were assessed by a registered nurse (RN) before they were assisted from the floor; and, -Ensure Resident #5, who was the victim of resident-to-resident physical abuse, was assessed by a RN following the resident-to-resident altercation.

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents had the right to a safe, clean and comfortable homelike environment on two of three hallways Specifically, the facility did not facilitate the necessary maintenance services to maintain resident rooms in a sanitary, safe and comfortable manner.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in one of two medication carts and one of two medication storage rooms. Specifically, the facility failed to ensure expired medications were removed from the medication carts and medication storage rooms.

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of three hallways. Specifically, the facility failed to: -Ensure appropriate infection control practices were followed during wound care; and, -Ensure housekeeping staff followed appropriate hand hygiene practices when cleaning resident's rooms.

Inspectors wroteBased on observations, record review and interviews, the facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for two (#10 and #12) of three residents reviewed for pain out of 25 sample residents. Specifically, the facility failed to: -Ensure adequate pain management for Resident #10 and Resident #12; -Ensure a pain care plan was initiated for Resident #12; and, -Ensure pain medications were reconciled upon readmission for Resident #12.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food with professional standards for food service safety. Specifically, the facility failed to: -Ensure proper refrigerator temperatures were maintained, and food was properly dated and discarded by the use by date in two out of two unit refrigerators; and, -Ensure sanitary conditions in the dish room.

Inspectors wroteBased on record review and interviews, the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his/her authority, the resident's representative when there was a change of condition for one (#23) of two residents out of 23 sample residents. Specifically, the facility failed to notify the Resident #23's legal representative related to the resident's sudden excessive increase in weight and then subsequently sudden excessive weight loss.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were free from abuse for one (#39) out of four residents reviewed for abuse out of 23 sample residents. Specifically, the facility failed to prevent incidents of physical abuse by Resident #31 toward Resident #39.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a resident who displayed or was 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 one ( #39) out of four residents reviewed for abuse out of 23 sample residents. Specifically, the facility failed to for Resident #39, effectively identify person-centered approaches for dementia care to prevent resident-to-resident altercations.

Inspectors wroteBased on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption for two residents (#25 and #23) out of 23 sample residents. Specifically, the facility failed to: -Ensure Resident #25's refrigerator temperatures were monitored for refrigerated food storage; and, -Ensure sanitary food storage for Resident #25 and Resident #23's personal refrigerators.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for two of three halls where residents lived. Specifically, the facility failed to ensure hot water temperatures were monitored and maintained at safe and comfortable levels in the east hall (secure unit) and east central hall (directly outside of the secure unit).

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure each resident had the right to and the facility promoted and facilitated a resident's self-determination through support of each resident's right to make choices about aspects of their life that was significant to the resident for one (#63) of 10 residents reviewed of 37 sample residents. Specifically, the facility failed to ensure Resident #63 received a minimum of two showers a week in accordance with resident choice.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure an allegation of abuse, neglect, exploitation or mistreatment was reported and thoroughly investigated in a timely manner for one (#63) of two residents reviewed out of 37 sample residents. Specifically, the facility failed to ensure Resident #63's allegation of verbal abuse by a staff member was thoroughly investigated in a timely manner after the resident had discussed and completed a concern form with the activity assistant (AA).