Wheatridge Park Care Center

Inspectors wroteThe facility identified a census of 40 residents, with 12 residents sampled, and one resident reviewed for pressure ulcers (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). Based on observations, interviews, and record review, the facility failed to provide a pressure reducing device on the bed to prevent a pressure injury for Resident (R) 2. On 07/11/24 the facility noted R2's previous pressure injuries were all closed. On 07/12/24, R2 was moved to a different room and the facility failed to move his air mattress for his bed to the new room. On 07/24/24, R2's left heal pressure injury re-opened and was identified as a stage three pressure injury (full thickness pressure injury extending through the skin into the tissue below). [...]

Inspectors wroteThe facility identified a census of 40 residents, which included 12 residents sampled and three reviewed for accidents and accident hazards. Based on interviews, observations, and record review, the facility failed to provide an environment free of accident hazards for the residents of the facility when the facility failed to properly store chemicals in an unlocked cabinet in an unlocked room and when the facility stored chemicals along a rail in the hallway. Additionally, the facility failed to ensure R26, who was identified by the facility as confused and independently mobile with aggressive and wandering behaviors, remained free of accident hazards when R26 put scissors in his pocket and wandered inside the facility. [...]

Inspectors wroteThe facility reported a census of 40 residents. Based on interview and record review, the facility failed to complete an annual performance review at least once every 12 months for five Certified Nurse Aides (CNAs) reviewed, to ensure adequate appropriate cares and services provided to the residents of the facility. The facility identified five CNAs employed over 12 the month period.

Inspectors wroteThe facility census totaled 40 residents on three halls with a commons area where residents gathered for meals and activities. The facility had one medication cart and one nurse treatment cart that services the facility. Based on observation, interview, and record review, the facility failed to provide a safe environment by the failure to ensure a nurse treatment cart that contained insulin (a medication used to treat diabetes [a disease when the body cannot use glucose, not enough insulin made or the body cannot respond to the insulin]), topical ointments and creams, and narcotics that were in a locked box within the nurse's treatment cart, remained locked when not in direct line of vision of the nurse, in an area where residents could access it.

Inspectors wroteThe facility reported a census of 40 residents. Based on observation, interview, and record review, the facility failed to provide sanitary conditions for food storage and dishes to prevent the spread of food borne illness to the residents of the facility.

Inspectors wroteThe facility reported a census 40 residents. Based on observation, interview, and record review, the facility failed to maintain and/or dispose of garbage and refuse properly in a sanitary condition to prevent the harborage and feeding of pests.

Inspectors wroteThe facility identified a census of 40 residents. Based on observations, record reviews, and interviews, the facility failed to put in place an effective administration who ensured the facility was administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident who resided at the facility. The outcome of these failures caused harm to Resident (R)2 and R8.

Inspectors wroteThe facility reported a census of 40 residents. Based on observation, interview, and record review, the facility failed to ensure the kitchen's double-door oven was in safe operating condition.

Inspectors wroteThe facility reported a census of 40 residents. Based on interview and record review, the facility failed to develop, implement, and permanently maintain an in-service training program for Certified Nurse Aide (CNAs) with the required topics and no less than 12 hours per year. Two of the five nurse aides sampled lacked the required training topics. Two of five nurse aides sampled lacked the required 12 hours per year of in-service training.

Inspectors wroteThe facility reported a census of 40 residents, with 12 residents sampled, including review for advanced directives (a written document which indicated the medical decisions for health care professionals when the person could not make their own decisions). Based on interview and record review, the facility failed to ensure four residents had accurately completed advanced directives. Resident (R)2 had a Do Not Resuscitate (DNR- or no code, a legal document or order that means the person does not desire cardiopulmonary resuscitation [CPR is an emergency lifesaving procedure performed when the heart stops beating] in the event of cardiac arrest), only signed by a physician. R8 had two DNR's; one signed by the guardian only and the other one signed only by the physician. R10's DNR was not signed by a witness and R 20's DNR was only signed by a physician.

Inspectors wroteThe facility identified a census of 40 residents which included 12 residents sampled, that included five residents reviewed for notification of discharge to residents' representative and the Office of the State Long-Term Care Ombudsman. The facility failed to provide written notification to the representatives of Resident (R) 8, R26, R2, R10 and R21. Additionally, the facility also failed to notify the Office of the Long-Term Care Ombudsman (LTCO-a public official who works to resolve resident issues in nursing facilities). These deficient practices placed the residents at risk for impaired rights and uninformed care choices and had the potential to lead to uncommunicated needs related to continuity of care across the healthcare spectrum.

Inspectors wroteThe facility had a census of 40 residents. The sample included 12 residents with five residents reviewed for hospitalization. Based on observation, interview, and record review, the facility failed to provide a bed hold notice to Residents, (R)2, R10, R21 and R26 and/or their representative with a written notice specifying the duration of the bed-hold policy, at the time of the residents' transfers to the hospital.

Inspectors wroteThe facility reported a census of 40 residents. The sample included 12 residents. Based on record review and interviews, the facility failed to complete Care Area Assessments that addressed the individual underlying causes, contributing factors and risk factors for five residents. Resident (R)7 and R21 had incomplete and repetitive documentation, Additionally R8 all the CAA notes documented R8 was deceased , when R8 was still a resident in facility on [DATE]. R144 had no CAA notes for two triggered categories.

Inspectors wroteThe facility reported a census of 40 residents with 12 residents sampled, including five residents reviewed for respiratory care. Based on observations, record reviews, and interviews, the facility failed to properly clean, label and store the nebulizer (a device for administering inhaled medications) for Resident (R)7 in accordance with the standards of care and failed to follow up on a bilevel positive airway pressure (BiPAP-medical device which helps with breathing) physician order. In addition, the facility failed to date the oxygen tubing for R144. R7, R21, R22 and R144.

Inspectors wroteThe facility reported 40 residents with 12 residents included in the sample. Based on observation, interview, and record review the facility failed to use Enhanced Barrier Precautions (EBP is a risk -based approach to use protective personal equipment to reduce the spread of multidrug resistant organism, consisting of gown and gloves). for Resident (R)39 during wound care and R26 during urinary catheter care. This placed the residents at risk for infection. Findings Included: - R39's Electronic Medical Record (EMR) recorded the following diagnosis: acquired absence of left leg below the knee (BTKA), infection of the amputation stump of the left lower extremity, and Methicillin Resistant Staphylococcus Aureus Infection (MRSA, bacteria that is resistant to many treatments and can cause very serious and life-threatening infections). [...]

Inspectors wroteThe facility reported a census of 40 residents. The sample included 12 residents. Based on interview and record review, the facility failed to provide Resident (R)10 care in a dignified manner during colostomy care. R10 was left lying in his bed for 40 minutes with his door open, undressed waist up and no colostomy (surgical creation of an artificial opening on the stomach wall to excrete feces from the body) bag covered his stoma. This deficient practice placed the resident at risk for decreased psychosocial well-being.

Inspectors wroteThe facility reported a census of 40 residents. The sample included 12 residents. Based on observation, interview, and record review, the facility failed to include Resident (R)7 for the development and continued planning of the resident's care plan quarterly. This deficient practice placed the residents at risk for impaired care and services. This practice had the potential to lead to negative psychosocial effects related to safety and uncommunicated needs.

Inspectors wroteThe facility reported a census of 40 residents. The sample included 12 residents. Based on interview and record review, the facility failed to ensure Resident (R)7 received his monthly benefits when he requested the funds.

Inspectors wroteThe facility reported a census of 40 residents. The sample included 12 residents. Based on interview and record review, the facility failed to ensure the correct and complete Beneficiary Protection Notification forms were issued to one of three residents reviewed, Resident (R)146.

Inspectors wroteThe facility reported a census of 40 residents with 12 residents selected for review. Based on observation, interview, and record review, the facility failed to accurately complete the [NAME] Data Set for two residents, Resident (R)7 and R8 related to falls. Additionally, R7 for dentition (the arrangement or condition of the teeth). This placed the resident at risk for uncommunicated care needs.

Inspectors wroteThe facility identified a census of 40 residents, which included 12 residents sampled. Based on interviews, observations, and record review, the facility failed to review and revise the care plans with appropriate interventions for four of the sampled residents; Resident (R) 20 related to physician ordered interventions, R2 related to treatment of an area of pressure ulcer/injury, R22 and R8 related to development and implementation of appropriate interventions to prevent multiple falls for R22 related to continued use of a powered lift chair, or develop any new interventions for R8. These deficient practices resulted in uncommunicated care needs.

Inspectors wroteThe facility identified a census of 40 residents, with 12 residents sampled, and one resident reviewed for discharge planning. The facility failed to implement a discharge plan for Resident (R)144 being discharged from the facility. The discharge planner failed to involve R144 with the discharge planning process.

Inspectors wroteThe facility reported a census of 40 residents. The sample included 12 residents, with five reviewed for immunizations. The facility failed to provide proper documentation of vaccination or declination of vaccines for COVID-19 (vaccines designed to prevent COVID-19 [highly contagious respiratory virus]) or pneumococcal (vaccines designed to prevent pneumonia [inflammation of the lungs which can be debilitating or lethal in the elderly]) for one of the five residents reviewed, Resident (R)5.

Inspectors wroteThe facility reported a census of 40 residents. Based on observation, interview, and record review, the facility failed to display accurate and identifiable staffing formation daily, for the 40 residents in the facility.

Inspectors wroteThe facility reported a census of 41 residents and identified 11 cognitive impaired females. The sample included three residents reviewed for abuse. Based on interviews, observations, and record review, the facility failed to provide a safe environment when staff did not provide adequate supervision to prevent resident-to-resident sexual abuse. On 12/10/23 staff found cognitively intact, independent Resident (R )1 kissing R2, a resident with severe cognitive impairment who lacked the ability to consent. Staff reported R1 had his hand inside of R2's shirt, and R2 had her hand inside of R1's pants. The staff separated the residents. This deficient practiced placed R2 in immediate jeopardy.

Inspectors wroteThe facility reported a census of 36, with 18 residents sampled for review. Based on observation, interview, and record review, the facility failed to review and revise the plan of care for five of the 18 sampled residents including; Resident (R )22 and R135 for shaving assistance; R2 and R16 for fall interventions; and R18 for leg/foot support while in the wheelchair.

Inspectors wroteThe facility reported a census of 36 residents with 18 selected for review which included seven residents reviewed for accidents. Based on observation, interview and record review, the facility failed to ensure safety to prevent accidents for four of the seven residents reviewed which included two Residents (R)30 and R18 with inadequate foot support on their wheelchairs to prevent accidents and two R2 and R16 with failure to determine the root cause of falls and timely develop immediate interventions to prevent further falls.

Inspectors wroteThe facility reported a census of 36 residents with 18 residents sampled, including two residents reviewed for privacy. Based on interview, record review and observation, the facility failed to provide privacy for two Residents (R)16, regarding resident being partially exposed in the doorway of her room and R 22, regarding staff not closing the door to his room while cares were being given.

Inspectors wroteThe facility reported a census of 36 residents with 18 selected for review. Based on observation, interview and record review, the facility failed to ensure the development of a comprehensive care plan to include urinary catheter use for one Resident (R)16 of the 18 residents reviewed.

Inspectors wroteThe facility reported a census of 36 residents with 18 residents sampled, including three residents reviewed for Activities of Daily Living (ADLs). Based on interview, record review and observation, the facility failed to provide appropriate ADL cares for two dependent Resident's (R)22 and R 135, regarding shaving of facial hair.

Inspectors wroteThe facility reported a census of 36 residents with 18 selected for review which included two residents reviewed for urinary catheter. Based on observation, interview and record review, the facility failed to ensure sanitary care of two Resident's (R)16 and 21's urinary catheters to prevent urinary tract infections.

Inspectors wroteThe facility reported a census of 36 residents with 18 selected for review which included four residents reviewed for nutrition. Based on observation, interview and record review, the facility failed to obtain weekly weights as recommended by the registered dietician (RD) and ordered by the physician, to monitor one of the four sampled Residents (R)7 for weight loss.

Inspectors wroteThe facility reported a census of 36 residents. Based on observation, interview and record review, the facility failed to display accurate publicly accessible and identifiable staffing information, on a daily basis on, the Daily Nurse Staffing with the resident census number indicated and the actual hours worked as required for the 36 residents that reside in the facility.

Inspectors wroteThe facility reported a census of 45 with 12 residents in the sample. Based on observation, interview, and record review the facility failed to provide Resident (R)21 and R5 with bathing assistance to maintain good grooming and personal hygiene.