Village Care and Rehabilitation Center, the

Inspectors wroteBased on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe and sanitary environment to prevent the development and transmission of disease and infection. Specifically, the facility failed to ensure glucometers were sanitized appropriately.

Inspectors wroteBased on observations, record review and interviews, the facility failed to implement an activities program that met the interests of and supported the physical, mental, and psychosocial well-being of each resident for one (#32) of two residents reviewed for activities out of 29 sample residents. Specifically, the facility failed to invite Resident #32 to group activities and meet the socialization needs for the resident.

Inspectors wroteBased on record review and interviews, the facility failed to ensure two (#42 and #45) of two residents out of 29 sample residents were free of significant medication errors. Specifically, the facility failed to: -Ensure Resident #45 was administered his schizoaffective disorder medication per the physician orders; and, -Ensure Resident #42 was administered his diabetes medication per the physician orders.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one (#1) of three residents reviewed for falls (#1) out of four sample residents received adequate supervision and assistance to prevent falls with injury. Resident #1 was admitted to the facility on [DATE] for rehabilitation therapy after undergoing surgical repair for a fractured right femur. The facility was aware upon the resident's admission for skilled nursing services that she had several falls in her prior living setting which resulted in the need for surgical repair after the resident fell and fractured her right femur. The facility also was aware that the resident needed to maintain non-weight-bearing status of her fractured leg. The resident was in the facility for two days when she fell on 7/17/24 at the bedside. Following this first fall, the resident fell an additional four times. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to develop and implement person-centered care plans consistent with professional standards of practice and the residents goals and preferences for four (#23, #26, #34 and #35) of six residents out of 13 sample residents who were prescribed anticoagulant medication. Specifically, the facility failed to ensure Resident's #23, #26, #34 and #35 were provided a comprehensive care plan focus for anticoagulant therapy. Where the care focus included measurable objectives, interventions and timeframes in line with the resident's medical condition, goals and preferences for anticoagulant therapy; in order for staff to meet the resident's care needs.

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 housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touched areas (call lights, door handles and hand rails); -Ensure surface disinfectant times were followed; and, -Ensure residents were offered an opportunity for hand hygiene prior to dining.

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 or her authority, the resident representative(s) when there was a need to alter treatment significantly for one resident (#41) of two residents reviewed out of 35 sample residents. Specifically, the facility failed to make a timely notify Resident #41, the resident's representative and the prescribing physician (wound specialist) that the interdisciplinary team (IDT) made a decision to not start the resident on antibiotic treatment prescribed by the wound care physician (WP).

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure one (#17) of one resident reviewed for activities of daily living of 35 sample residents were provided the necessary care and services to maintain or improve their level of functioning. Specifically, the facility failed to ensure that Resident #17 received timely incontinent care after the resident had an episode of involuntary leakage of urine and feces.

Inspectors wroteBased on record review and interviews, the facility failed to consistently provide pain management services for one (#14) of two residents reviewed for pain management out of a 35 sample residents. Specifically, the facility failed to notify the hospice provider in a timely manner for effective care and treatment to keep Resident #14 comfortable and free of pain at the end of her life.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that the medical record was complete and accurate in keeping with accepted standards of practice for one (#41) out of 35 sample residents. Specifically, the facility failed to ensure Resident #41's medical record regarding the clinical justification for why a prescribed treatment for wound care treatment, antibiotic medication was not provided was documented and documented accurately. Cross-reference F580, timely notification to the resident prescribing physician, the attending physician and the resident representative.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure food was stored, prepared and served under sanitary conditions. Specifically, the facility failed to ensure staff did not touch the inside of plates and bowls with bare hands or soiled hot mitt when food was served on the memory care unit. I. Professional reference The Colorado Retail Food Establishment Rules and Regulations (CRFERR), revised January 2019, read in pertinent part, .Employees prevent bare hand contact with ready-to-eat food by properly using suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment. If used, single-use gloves shall be used for only one task, such as working with ready-to-eat food. Single-use gloves shall be used for no other purpose, and discarded when damaged, when interruptions occur in the operation, or when the task is completed. [...]

Inspectors wroteBased on observations and staff interviews, the facility failed to provide adequate space for a home-like dining experience in one (the memory care unit) out of three dining areas, in order to accommodate residents during meal times. Specifically, the facility failed to ensure: -Sufficient space to allow Resident #46 to move in and out of the dining room independently and accommodate all of the residents in the secure unit; and -Residents already seated at the table would not have to be moved in order to make space for additional residents entering and exiting the dining area. A. Resident status Resident #46, age [AGE], was admitted on [DATE]. According to the August 2019 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbances, obsessive compulsive disorder, major depressive disorder and anxiety disorder. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure four out of five employees required in-service training for nurse aides, no less than 12 hours per year was calculated by the employment date, and included dementia management and resident abuse prevention training. Specifically, the facility failed to ensure four (#4, #5, #6 and #7) out of five certified nurse aides' (CNAs) in-service training record reviewed, received at least 12 hours of annual training.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure quarterly assessments were completed in the required time frame for two (#46 and #1) of two out of 33 sampled residents. Specifically, the facility failed to ensure the quarterly review assessments were submitted timely as specified in the Resident Assessment Instrument (RAI).

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive care plan for two (#31 and #40) out of 33 sampled residents. Specifically, the facility failed to ensure Resident #31 and #40 had a care plan for elopement/wandering behaviors with interventions and failed to include the use of a wander guard.