The Lodge at Red Rocks

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate and complete medical records for four (#1, #8, #15 and #16) of six residents reviewed out of 16 sample residents. Specifically, the facility failed to ensure that Resident #1, Resident #8, Resident #15 and Resident #16's medications were documented promptly in the residents' medication administration record (MAR) at the time the medications were administered.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure food wasprepared, distributed and served under sanitary conditions in the main kitchen. Specifically, the facility failed to:-Ensure ready-to-eat foods were handled in a sanitary manner to prevent cross-contamination; and,-Ensure safe and appropriate storage of food items in the main kitchen walk-in refrigerator.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure garbageand refuse was properly disposed of and the dumpster lid was closed to prevent harborage topests and insects. Specifically, the facility failed to:-Ensure all dumpster lids were closed and not overflowing with garbage; and,-Ensure garbage was cleaned up around and under the dumpsters.

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 infections. Specifically, the facility failed to: -Ensure proper infection control practices were followed for wound care;-Ensure housekeepers cleaned and disinfected the residents' rooms in a hygienic manner; -Ensure housekeepers performed hand hygiene while cleaning resident rooms; and, -Ensure catheters were not stored on the floor.

Inspectors wroteBased on observations, record review and interviews the facility failed to provide the necessaryservices to maintain personal hygiene for one (#17) of two residents reviewed for services tomaintain the highest practicable quality of life out of 47 sample residents. Specifically, the facility failed to ensure Resident #17 received timely incontinence care.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide services in accordance with accepted professional standards for one (#2) of five residents reviewed for medication management out of 47 sampled residents. Specifically the facility failed to ensure:-Acetaminophen (pain medication) was administered to Resident #2 were given within pain level parameters; and,-Oxycodone (pain medication) was administered to Resident #2 were given within pain level parameters.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#90) of seven residents out of 47 sample residents. Specifically, the facility failed to ensure staff provided appropriate supervision and implemented care-planned interventions for Resident #90 while smoking.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one resident (#7) of two reviewed for dialysis care, out of 47 sample residents, received dialysis services consistent with professional standards of practice. Specifically, the facility failed to:-Ensure the dialysis communication forms were consistently sent with Resident #7 to the dialysis center; and, -Ensure post-dialysis assessments on Resident #7 were completed and documented per professional standards.

Inspectors wroteBased on observations, record review and interviews, the facility failed to act upon the pharmacist's recommendations in a timely manner for two (#17 and #2) of five residents out of 47 sample residents. Specifically the facility failed to: -Ensure a pain scale was added to Resident #17's morphine order to exclude its use for mild pain per pharmacist recommendation;-Ensure Resident #2's monthly medication reviews (MMR) were reviewed by the physician; and,-Act upon the the pharmacist's recommendations for amitriptyline (antidepressant), sertraline (antidepressant) and an echocardiogram (EKG) for Resident #2.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#94) of three residents reviewed received food and fluids prepared in a form designed to meet his or her needs out of 47 sample residents. Specifically, the facility failed to ensure Residents #94 was served a mechanically altered diet per physician's orders.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents maintained adequate hydration for one (#17) of three residents reviewed for hydration out of 47 sample residents. Specifically, the facility failed to encourage fluid intake for Resident #17.

Inspectors wroteBased on observations, record review and interviews, the facility failed to protect three (#7, #3 and #5) of seven residents reviewed for abuse out of 10 sample residents. Resident #8 was admitted to the facility on [DATE] and was moderately cognitively impaired. He had a history of traumatic brain injury, dementia and diabetes. Resident #7 was admitted to the facility on [DATE] and had a history of dementia, was dependent on staff for all cares and was non-verbal. On 9/29/25 the facility was looking for Resident #8, who was identified as missing. The facility located Resident #8 in Resident #7's room by staff. Resident #8 was found lying on top of Resident #7 with his pants and incontinence brief pulled down below his knees and hips directly over the face of Resident #7. Resident #7 and Resident #8 were separated by staff and police. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents had adequate supervision to prevent accidents for one (#2) of three residents reviewed for accident hazards out of 10 sample residents. Specifically the facility failed to provide adequate supervision to prevent an elopement for Resident #2 after he informed staff he was not staying at the facility on the day he was admitted to the facility. Resident #2, who had diagnoses of dementia, Alzheimer's disease and history of a traumatic brain injury, was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on record review and interviews, the facility failed to develop, implement and maintain an effective training program for staff based on the facility assessment and resident population for four of five certified nurse aides (CNA) reviewed. Specifically the facility failed to:-Ensure CNA #6 and CNA #7 had dementia training;-Ensure CNA #6, CNA #7 and CNA #8 had behavioral health management training;-Ensure CNA #5 and CNA #7 had resident rights training;-Ensure CNA #5 and CNA #7 had infection control training;-Ensure CNA #5, CNA #6 and CNA #7 had quality assurance performance improvement (QAPI) training; and,-Ensure CNA #7 had effective communication.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#5 and #12) of 14 residents were free from verbal abuse out of 27 sample residents. Resident #5 was admitted to the facility's secured unit with diagnoses of frontal temporal neurocognitive disorder (type of dementia that leads to changes in personality, behavior and language), Huntington's disease (progressive breakdown of the nerve cells in the brain), dementia with behavioral disturbances, tremors, and depression on 6/25/25. Despite the prison referral paperwork that identified Resident #5 had aggressive behaviors, the facility admitted the resident to the secured unit from prison. The resident had spent the majority of his life in prison or homeless. The prison's physician recommended that the resident have a one-on-one caregiver for an adjustment period. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#1) of three residents reviewed for medications errors out of 27 sample residents. Specifically, the facility failed to ensure Resident #1 received intravenous (IV) vancomycin (an antibiotic used to treat bacterial infections) for a diagnosis of staphylococcus hominis bacteremia (a bloodstream infection) per physician's orders.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure supervision, and monitor assistive devices and interventions to prevent accidents for three (#1, #8 and #9) of 10 residents reviewed for accidents out of 12 sample residents. Resident #1 was admitted to the facility for long term care on 9/13/23 with a diagnosis of dementia and repeated falls. The resident's care plan directed the staff to utilize a hoyer lift (mechanical lift) for transfers. On 2/25/25 Resident #1 was noticed to have an injury of unknown origin which was discovered to be a fractured ankle. The facility investigation revealed the staff had not been utilizing a hoyer lift to transfer Resident #1, which was indicated on the resident's plan of care and physician's orders. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#3) of three residents reviewed out of 15 sampled resident representatives were immediately informed of an accident involving the resident. Specifically, the facility failed to notify Resident #3's representative following the resident's low blood pressures that created a change of condition ultimately resulting in the resident being transferred out to an acute care hospital.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents who required dialysis services received such services consistent with professional standards of practice for one (#2) of two residents reviewed for dialysis out of 15 sample residents. Specifically, the facility failed to consistently and thoroughly complete the dialysis communication forms between the facility and the dialysis center for Resident #2.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure temperatures in five of 14 resident rooms and the resident's activity room were within the safe range of 71 degrees F (Fahrenheit) to 81 degrees F.

Inspectors wroteBased on observations, record review and interviews, the facility failed to maintain an effective pest control program so the facility was free from pests and rodents on two of four units. Specifically, the facility failed to keep the resident's rooms free from mice.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure nine (#7, #9, #6, #1, #12, #13, #14, #15 and #16) of nine residents out of 17 sample residents were provided prompt efforts by the facility to resolve any grievances. Specifically, the facility failed to: -Ensure concerns from the group regarding Resident #10 wandering into residents' room were followed up timely with a satisfactory resolution; -Ensure Resident #7's personal concern regarding Resident #10 entering his room without permission was followed up timely with a resolution that was satisfactory to Resident #7; and, -Ensure the resident council president was appointed based on the majority vote of the residents.

Inspectors wroteBased on record review and interviews, the facility failed to create an environment that protected residents from physical abuse for one (#5) of three residents out of 17 sample residents. Specifically, the facility failed to ensure Resident #5 was protected from abuse by Resident #4.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure effective pain management for one (#82) of two out of 66 sample residents. Resident #82 experienced an exacerbation of pemphigus, an autoimmune disease in which the immune system mistakenly attacks cells in the top layer of the skin (epidermis) and the mucous membranes in the skin and the inside of the mouth, nose, throat, eyes and genitals. Typical symptoms begin with painful blisters in the mouth that could spread to other mucous membranes. Oral blisters in the mouth or throat making it hard to swallow and eat. The resident had been complaining of blisters and oral pain for over a month and rather than seeking specialized assessment to determine the root cause of the resident's pain and oral blisters the resident was treated with over the counter symptom management. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a clean, comfortable and homelike environment for residents. Specifically, the facility failed to ensure: -Residents were not subjected to foul odors in their rooms and common hallways of the units; -Residents were not subject to trash piling up in their rooms and in common areas contributing to odors throughout the building; -Residents were not subject to mice running around their rooms, getting into their beds and belongings; and running around the building (cross-reference to F925 failure to maintain effective pest control); -Ensure that residents could eat their meals in the dining room without having to look at and smell the piled-up dirty dishes with uneaten food scraps on them left over from the prior meal; -Residents were provided with clean unstained face washcloths and hand towels; [...]

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: -Implement policies and procedures to inform staff of their responsibility to report abuse and neglect and the right to not be retaliated against for not reporting allegations of abuse and neglect (cross-reference F609 for reporting and F610 for investigating allegations of abuse); and, -Assure that reporters were free from retaliation or reprisal by posting a conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency if they believed the facility had retaliated against an employee or individual who reported a suspected crime with details of how to file such a complaint.

Inspectors wroteBased on observations, record review and interviews, they failed to employ sufficient dietary and food and nutrition staff to carry out the functions of the food and nutrition services. Specifically, the facility failed to: -Provide sufficient numbers of adequately trained food and nutrition staff which contributed to prolonged wait times for meals and overall decreased resident satisfaction with the dining experience; and, -Clean trays from the day before and had them stacked up in the dining area and hallway.

Inspectors wroteBased on observations, interviews and record review the facility failed to store, prepare, distribute and serve food in a sanitary manner in the kitchen. Specifically, the facility failed to: -Ensure foods were held at appropriate temperatures; -Ensure proper hand hygiene; -Ensure the refrigerators had thermometers; and, -Ensure the wall near the fruit drink machine had a cleanable surface after repair.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure garbage and refuse was properly disposed of and the dumpster lid was closed to prevent harborage to pests and insects. Specifically, the facility failed to: -Ensure all dumpster lids were closed and not overflowing with garbage; and, -Ensure garbage was cleaned up around and under dumpsters.

Inspectors wroteBased on interviews and record review, the facility was not administered in a manner that enabled it to use its resources efficiently and effectively to attain and maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, the resources of the facility were not effectively and efficiently utilized as evidenced by findings that revealed in part conditions of immediate jeopardy for failure to investigate an allegation of abuse of two residents by one facility staff(cross-reference to F610); and other systemic failures. (Cross-reference to F600, F609, F607, F584, F802, F812, F867 and F925)

Inspectors wroteBased on record review, and staff interviews, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies. Specifically, the facility failed to develop a facility assessment that included all resources, staff education, staff competencies, an updated staff list 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 identify and address concerns related to quality of life, freedom from abuse, quality of care, administration and infection control.

Inspectors wroteBased on observations, record review and interviews the facility failed to maintain an effective pest control program so the facility was free from pests and rodents. Specifically, the facility failed to keep all areas of the facility free from mice.

Inspectors wroteBased on record review and interviews, the facility failed to report alleged violations of potential abuse/neglect to the proper authority, including the police and state oversight agency in accordance with state law for three alleged violations out of five reported violations for abuse of a resident (#28, #10 and #111) by staff out of 66 sample residents. Specifically, the facility leadership failed to report three separate allegations of resident abuse by a staff member to the facility administrator, local law enforcement, or the State Agency; and staff failed to report suspicion of abuse and or neglect to leadership in a timely manner: -Allegation of verbal and physical abuse of Resident #28 by facility staff; and, -Allegation of verbal abuse of Resident #110 and #10 by facility staff. Cross-reference F610, failure to investigate/prevent/correct alleged violation.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the minimum data set assessment (MDS) accurately reflected residents' status based on the criteria outlined in the resident assessment instrument (RAI) for five (#20, #29, #105, #111 and #107) residents out of seven out of 66 sample residents. Specifically, the facility failed to appropriately assess and accurately document the resident status for: -Resident #107 and Resident #29 the MDS assessment did not accurately document the residents had level II preadmission screening and resident review (PASRR) conditions; and, -Resident #20, #105, #107, #111 immunizations history was not accurately documented.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to consistently provide activities of daily living (ADL) support for three (#78, #90 and #29) of five dependent residents reviewed for ADLs out of 66 sample residents. Specifically, the facility failed to provide consistent ADL assistance to provide: -Assistance with grooming (fingernail care) for Residents #78 and #90; -Incontinent care and repositioning assistance to maintain Resident #78 skin integrity; and, -Assistance, cueing and supervision throughout the meal for Resident #29.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to provide an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for four (#23, #81, #112 and #105) residents out of eight reviewed for activity programming out of 66 sample residents. Specifically, the facility failed to: -Offer and provide personalized activity programs for Resident #23, #81 and #112 on secure unit and Resident #105 on the non-secure unit; and, -Conduct activity assessments for Resident #81, #112 and #23.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the residents' environment remained as free from accident hazards as possible for high water temperatures throughout the facility and for two (#324 and #8) of two dependent residents reviewed for smoking out of 66 sample residents. Specifically, the facility failed to ensure: -Appropriate interventions were in place to prevent potential smoking hazards for Resident #324 and Resident #8; and, -Facility water temperatures were safe for resident use.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals used in the facility were properly stored in one out of four medication carts. Specifically, the facility failed to ensure medication carts were locked when left unattended.

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: -Ensure the menu was followed; and, -Ensure food items were omitted without substitutions being made of the same nutritional value.

Inspectors wroteBased on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, texture, temperature and appearance.

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 three units at the facility. Specifically, the facility failed to: -Ensure residents' personal toiletry items were labeled appropriately; -Ensure residents were provided with an opportunity to participate in hand hygiene before and after meals; and; -Ensure the hand hygiene was performed appropriately by staff.

Inspectors wroteBased on record review and staff interviews, the facility failed to implement policies and procedures related to pneumococcal immunizations for nine (#17, #20, #23, #25, #29, #67, #72, #82, #104 and #105) of 10 residents reviewed for immunizations out of 66 sample residents. Specifically, the facility failed to: -Offer Resident #25, #82 and #105 the pneumococcal vaccine upon admission; -determine which pneumococcal vaccine was given to Resident #17, Resident #23 and Resident #29 and offer additional doses as needed; and, -Offer additional doses of the pneumococcal vaccine to Resident #20, #67 and #104.

Inspectors wroteBased on observation, interview, and record review the facility failed to promote dignity and respect for one (#67) of one resident out of 66 sample residents. Specifically, the facility failed to promote dignity and respect for Resident #67 by allowing the resident to be present and participate while staff were cleaning, rearranging and disposing of contaminated belongings in the resident's room.

Inspectors wroteBased on record review and interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision and hearing abilities for two (#82 and #67) of three residents reviewed for visual problems of 66 sample residents. Specifically the facility failed to: -Ensure the Resident #67's had access to glasses (corrective lenses) for visual deficits; -Follow through with getting post eligibility treatment income (PETI) to pay for the residents glasses for Resident #67; and, -Ensure that after Resident #82's family declined to pay for hearing aids, Resident #82 was provided with an alternative to help the resident hear effectively.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one (#111) of two residents who required respiratory care received care consistent with professional standards of practice out of 66 sample residents. Specifically, for Resident #111 the facility failed to: -Ensure a physician's order was in place to include the appropriate administration of a continuous positive airway pressure (CPAP) machine with oxygen therapy including machine settings, frequency and duration of use, method of delivery, machine and oxygen settings, device maintenance and cleaning of equipment; -Follow manufacturer recommendations to maintain, clean, sanitize and store the resident's CPAP equipment; -Ensure a care plan focus was in place to include oxygen therapy to include orders for use/administration, equipment maintenance and machine storage; [...]

Inspectors wroteBased on record review and resident and staff interviews, the facility failed to provide the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental, and psychosocial well-being for two (#67 and #4) of two residents reviewed for psychosocial well-being out of 66 sample residents. Specifically, the facility failed to ensure appropriate behavioral health services to: -Identify, address, and/or obtain necessary services for the behavioral health care needs of Resident #67 and Resident #4; -Develop and implement a person-centered care plan that includes and supports the behavioral health care needs, identified in the comprehensive assessment; -Develop individualized interventions related to the resident's diagnosed conditions; and, -Review and revise behavioral health care plans that have not been effective.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#58) of eleven residents reviewed for medication administration out of 66 sample residents. Specifically, the facility failed to ensure Resident #58 was administered the correct dose of insulin by properly priming the insulin pen before insulin administration.

Inspectors wroteBased on interviews and record review the facility failed to provide or obtain dental services for one resident (#8) of one out of 66 sample residents. Specifically, the facility failed to assist Resident #8 with making an appointment for dental services when the resident complained that her dentures did not fit and was causing her pain when she wore them.

Inspectors wroteBased on observation and staff interview, the facility failed to ensure essential equipment was in proper working order for the facility's kitchen. Specifically, the facility failed to ensure the kitchen equipment was repaired which included the walk-in freezer's fan system that was not working properly causing condensation and icicles.

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 residents, family members and legal representatives of residents. Specifically, the facility failed to make accessible survey results of the previous recertification survey of 9/25/19 and all complaint surveys since the last recertification survey through the last complaint survey conducted 5/18/23.

Inspectors wroteBased on record review and staff interviews, the facility failed to thoroughly investigate allegations that certified nurse aide (CNA) #1 physically and verbally abused two of four residents (#28 and #111) reviewed for abuse out of 66 sample residents. Staff interview revealed allegations of abuse involving CNA #1. Staff stated that during care, Resident #28, although severely cognitively impaired, pointed to CNA #1, stating the staff member had pulled her hair. When interviewed during the survey on 9/11/23, Resident #28, who was appropriately responsive to questions, said she was grabbed, shaken, and her hair pulled by a staff member, hurting the back of her head. Staff interviews further revealed Resident #111, who was moderately cognitively impaired, alleged CNA #1 had verbally abused her. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure that all residents were free from abuse, neglect, and exploitation, for two resident victims (#12 and #106) from being physically abused (#53 and #174) resident in a resident to resident physical altercation in four resident to resident abuse allegations out of 66 sample residents. The facility failed to provide adequate supervision and effective interventions to prevent two separate incidents of resident or resident altercations resulting in one or more residents being injured. On 9/1/23 at 12:00 p.m. Resident #12 was physically abused by Resident #53. Resident #12 sustained deep scratches and cuts to his right arm from the physical attack on his person by Resident #53 which required ongoing medical treatment by a wound care physician and nursing staff. [...]

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent development and worsening of pressure injuries for two (#29 and #8) of three residents reviewed for pressure injuries out of 66 sample residents. Resident #29 who required extensive assistance with activities of daily living (ADL) from staff members for bed mobility, positioning, transfers, toileting and dressing, was known to be at risk for skin impairment due to impaired mobility and had inability to self reposition and relieve pressure points. [...]

Inspectors wroteBased on record review and interviews the facility failed make immediate notification to the resident representative when the resident had a significant change in condition requiring a need to alter treatment; initiate a resident's transfer or discharge from the facility; or when the resident was involved in an accident with an injury for one (#72) of four residents out of 66 sample residents. Specifically, the facility failed to immediately inform the Resident #72's representative when the resident was transferred to the hospital for emergency medical care.

Inspectors wroteBased on observations, record review and interviews, the facility failed to develop a comprehensive person-centered care plan for three (#76, # 335, and #336) of 32 residents reviewed for person-centered care plans out of 53 sample residents. Specifically the facility failed to: -Care plan the use of antipsychotic medications and pain for Resident #76; -Care plan pain and falls for Resident #335; and -Care plan a stage III pressure injury for Resident #336.

Inspectors wroteBased on observations and interviews, the facility failed to ensure two of three medication carts had drugs and biologicals stored and labeled in accordance with accepted professional principles. Specifically, the facility failed to: -Remove expired medications from medication carts to prevent the use of expired medications; -Properly label prescription medications with the residents' names; -Date insulin when opened; and -Store medication in original packaging

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one (#109) of two residents reviewed for dignity out of 53 sample residents were treated with respect and dignity and in a manner and in an environment that promoted the enhancement of quality of life. Specifically, the facility failed to redirect Resident #109 in a respectful manner, causing him to feel embarrassment with his peers. A. Resident status Resident #109, age [AGE], was admitted on [DATE]. According to the September 2019 computerized physician orders (CPO), diagnoses included depressive disorder, chronic pain end stage renal disease. The 9/19/19 minimum data set (MDS) assessment revealed the resident's cognitive status was intact with a brief interview for mental status (BIMS) score of 14 out of 15. The resident utilized a wheelchair. B. [...]

Inspectors wroteBased on observation, record review and interviews, the facility failed to provide an ongoing program of activities to meet the interests of and support the wellbeing of one (#67) of three residents reviewed for activities out of 53 sample residents. Specifically, the facility failed to engage in a process to identify and provide individualized and independent activities to meet the recreational interests of Resident #67.

Inspectors wroteBased on observation, record review and interviews, the facility failed to provide treatment and care in accordance with professional standards, the care plan and resident choice for one (#67) of two residents reviewed for non-pressure related skin conditions out of 53 sample residents. Specifically, the facility failed to implement physician ordered interventions and follow the resident's care plan to protect the skin to Resident #67's lower legs.

Inspectors wroteBased on observation record review and interviews the facility failed to ensure the resident environment was as free from accident hazards as possible and to provide supervision and assistive devices to prevent avoidable accidents for three (#109, #13, #9) of 28 residents who smoked. Specifically, the facility failed to ensure: - Resident #13, #9 and #109 followed safe smoking practices; and, - Assess Resident #109 for safe smoking at the time of his admission to the facility.

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure two (#108 and #121) of three residents who required respiratory care were provided such care in accordance with professional standards of practice out of 53 sample residents. Specifically, the facility failed to: -Obtain oxygen orders for Resident #108; and -Follow physician oxygen orders for Resident #121.

Inspectors wroteBased on record review and staff interviews, the facility failed to ensure pharmacy recommendations were acted upon in a timely manner for two (#31 and #124) of six residents reviewed for drug regimen review out of 53 sample residents. Specifically, the facility failed to ensure pharmacy recommendations were reviewed by the attending physician for Residents #31 and #124.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure two (#76 and #31) of six residents reviewed for medications of 53 sample residents were free from unnecessary drugs. Specifically the facility failed to: -Track target behaviors, assess the resident for other causes of behavior, use non pharmacological approaches, care plan and document that Resident #76 or their representative were advised of the risks and benefits of an antipsychotic medication; and -Discontinue a PRN (as needed) antipsychotic medication after 14 days for Resident #31.