The Healthcare Resort of Colorado Springs

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen. Specifically, the facility failed to: -Thaw meat in a safe manner; and, -Ensure jewelry was not worn during food preparation and meal service.

Inspectors wroteBased on record review and interviews, the facility failed to honor resident choices for residents residing on three of four units of the facility. Specifically, the facility failed to ensure residents could choose to eat in the dining room at dinner time and on the weekends.

Inspectors wroteBased on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards in two of four medications carts and one of one vaccine storage refrigerators. Specifically, the facility failed to: -Ensure vaccinations were not stored in dormitory style refrigerator; -Ensure expired vaccines were removed from refrigerators; -Ensure Tubersol (used to test for tuberculosis) vials were dated upon opening; -Ensure medication carts were clean from loose pills; and, -Ensure medications were stored according to route.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services and assistance for bathing for two (#144 and #146) of three residents reviewed for ADLs out of 39 sample residents. Specifically, the facility failed to: -Provide bathing for Resident #144 to maintain the resident's personal hygiene; and, -Provide the necessary shower assistance for Resident #146, according to the resident's care plan.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#76) of three residents reviewed for activities out of 39 sample residents received an ongoing program of activities designed to meet the needs and interests, and promote physical, medical and psychosocial well-being. Specifically, the facility failed to ensure group were available for Resident #76 on the weekends per her preference.

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 two (#60 and #74) of three residents reviewed for respiratory care out of 39 sample residents. Specifically, the facility failed to ensure that Resident #60 and Resident #74 received oxygen therapy in accordance with their physician's orders.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%). Specifically, the facility had a medication error rate of 7.14%, which was two errors out of 28 opportunities for error.

Inspectors wroteBased on record review and interviews, the facility failed to ensure physician ordered laboratory services were provided in a timely manner for one (#12) of two residents reviewed for laboratory services out of 39 sample residents. Specifically, the facility failed to ensure timely follow-up for Resident #12's urine sample, which was sent to the laboratory (lab) without being labeled with the resident's identifying information.

Inspectors wroteIV. Resident #60 A. Resident status Resident #60, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia, hyperlipidemia, anxiety disorder and depression. The [DATE] MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required set-up assistance with eating, moderate assistance with personal hygiene, maximum assistance with transfers, and toileting. The resident was receiving oxygen therapy. The assessment indicated the resident was not receiving hospice services. B. Record review Review of the [DATE] CPO revealed Resident #60 was admitted to hospice services related to her diagnosis of COPD on [DATE]. [...]

Inspectors wroteBased on record review and interview, the facility failed to create an environment that protected six (#8, #4, #15, #87, #253, and #254) of eight out of 42 sample residents from mental and verbal abuse, contributing to residents experiencing, among other emotions, night terrors, anxiety, fear, and humiliation. In interviews with Residents #8, #15, and #253, the residents stated certified nurse aide (CNA) #1 slammed and dropped food trays on their tables and slammed their doors shut, mocked them, yelled at them, made them feel like an idiot, and feel anxious, frightened, and humiliated. Resident #4 had tears in her eyes when CNA #1's name was mentioned; when asked if she could talk further about him, she shook her head no and appeared sad. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents received notices in a written description of their legal rights. Specifically, the facility failed to post a sign with how to file a complaint to the State Survey Agency.

Inspectors wroteBased on interviews and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse and/or mistreatment of facility residents. Specifically, the facility failed to post a conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency and who the abuse coordinator was for the facility.

Inspectors wroteBased on interviews and record review, the facility failed to timely report incidents of potential abuse to the proper authorities, including the state survey agency. This involved four residents (#4, #15, #87, #253) out of eight residents reviewed from a total sample of 42 residents. Specifically, the facility leadership failed to ensure four incidents of potential verbal and/or mental abuse by a staff member, certified nurse aide (CNA) #1, were timely reported to authorities, including the state survey agency. Cross-reference F600 (abuse) and F610 (investigation of potential abuse)

Inspectors wroteBased on record review and interviews with residents and staff interviews, the facility failed to ensure incidents of potential abuse involving five residents (#8, #4, #15, #87, and #253) out of a total sample of 42 residents were thoroughly investigated. Cross-reference F600 (abuse) and F609 (reporting abuse).

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 identify and address concerns related to freedom from abuse, reporting and investigating that rose to the level of immediate jeopardy and caused a pattern of psychosocial harm.

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 four units in the facility. Specifically, the facility failed to: -Ensure housekeeping staff cleaned high touch areas were cleaned appropriately; -Ensure housekeeping staff used proper surface disinfectant times; -Ensure housekeeping staff cleaned from cleaner to dirtier areas; -Ensure housekeeping staff changed gloves and performed hand hygiene between bathroom and bedroom; -Ensure housekeeping staff changed mop heads between bathroom and bedroom; -Ensure housekeeping staff changed cleaning cloths between bathroom and bedroom; [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure essential equipment was in proper working order. Specifically, the facility failed to ensure the pellet base heating elements were in safe condition.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the residents had access to the results of the facility's most recent survey conducted by Federal or State surveyors over the past three years of survey, to include survey findings and any plan of correction, in a place readily accessible to to residents, family members and legal representatives of residents. Specifically, the facility failed to make survey results accessible.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to provide wound care as ordered by the physician for 1 (Resident #36) of 1 resident reviewed for treatments.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure a medication error rate of less than 5% for 2 (Resident #28 and Resident #67) of 4 residents observed during medication administration. Observations during medication administration revealed there were two medication errors out of 25 opportunities, which resulted in an 8.00% medication error rate.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure licensed nursing staff did not document wound care treatment that had not been provided for 1 (Resident #36) of 1 resident sampled with a non-pressure related skin wound.