Allison Care Center

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Nursing and Physician Services Deficiencies

Observe each nurse aide's job performance and give regular training.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Resident Assessment and Care Planning Deficiencies

Ensure necessary information is communicated to the resident, and receiving health care provider at the time of a planned discharge.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Egress Deficiencies

Keep aisles, corridors, and exits free of obstruction in case of emergency.

Based on a record review and staff interview it was determined that the the fire alarm system components and devices were not maintained in accordance with the Life Safety Code Section 9.6 and NFPA 72.1. Fire Alarm reports state that batteries are at the end of their lifespan2.No documentation of semi-annual visual inspection for FA devices available for review3. Facility resident spas do not have notifications installed NFPA 101, Section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.NFPA 72- 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. (15). Alarm notification appliances (a) Audible: Test shall be performed in accordance with the manufacturer ' s published instructions. Appliance locations shall be verified to be per approved layout, and it shall be confirmed that no floor plan changes affect the approved layout. It shall be verified that the candela rating marking agrees with the approved drawing. It shall be confirmed that each appliance flashes.14.3 Inspection.14.3.1* Unless otherwise permitted by 14.3.2 visual inspections shall be performed in accordance with the schedules in Table 14.3.1 or more often if required by the authority having jurisdiction.These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance at the exit conference. The Colorado Department of Public Health and Environment conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a).The initial comments (ID Prefix Tag #K000) are informational only, and are a representation of the facility' s general characteristics.This facility is a Type II (000), two-story structure with a partial basement and licensed for 85 beds. The sensus on the day of the survey was 78. The partial basement, which has controlled access, and therefore not utilized by residents, houses the laundry facilities, boiler room, maintenance office, and storage area. The structure is equipped with a National Fire Protection Association (NFPA) 13 automatic fire suppression system. This survey, conducted April 10,2025, included an inspection for compliance with the fire safety requirements of the 2012 edition of the National Fire Protection Association Life Safety Code, (NFPA-101), Chapter 19, "Existing Health Care Occupancies." The surveyor discussed all deficiencies with the Maintenance Supervisor and staff members throughout the course of the survey, and concluded the survey with a discussion of the deficiencies with the Administrator and the Maintenance Supervisor.

A licensure survey was completed on 3/10/25 to 3/13/25. Two deficiencies were cited. Based on observations, record review and interviews, the facility failed to ensure three (#44, #59 and #13) of six residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being out of 39 sample residents.Resident #44 was admitted to the facility for long term care on 9/2/22. It was identified that Resident #44 was at risk for weight loss and nutritional decline due to Alzheimer' s disease, previous history of weight loss and hyperthyroidism (increased metabolism due to an overactive thyroid gland).On 10/8/24, Resident #44 weighed 146.5 pounds (lbs). On 12/5/24, Resident #44 weighed 136 lbs, which indicated the resident had lost 10.5 lbs in two months. In December 2024 the facility increased the resident' s Med Pass (oral nutritional supplement). The resident was evaluated by speech therapy (ST) and it was recommended to downgrade the resident' s diet to pureed on 12/25/24. The resident' s comprehensive care plan indicated the resident needed to be weighed weekly to monitor the resident' s nutritional status since she was at risk for weight loss. The facility failed to consistently weigh the resident weekly as directed on the care plan. On 1/8/25 the resident weighed 134.8 lbs, which indicated the resident had lost 8 percent (%) (11.7 lbs) in three months, which was considered severe. The facility fai.. This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.

A recertification survey with Incident #39400, Incident #39427 and Incident #39428 was completed on 3/10/25 to 3/13/25. Six deficiencies were cited. An Emergency Preparedness survey was conducted from 3/10/25 to 3/13/25. No deficiencies were cited. Based on observations, record review and interviews the facility failed to provide the necessary services to maintain personal hygiene for one (#37) of three residents reviewed for services to maintain highest practicable quality of life out of 39 sample residents.Specifically, the facility failed to ensure Resident #37 consistently received assistance to maintain oral hygiene.Findings include:I. Facility policy and procedureThe Supporting Activities of Daily Living policy and procedure, revised March 2018, was received from the nursing home administrator (NHA) on 3/10/25 at 10:46 a... Based on observations, record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases.Specifically, the facility failed to:-Ensure the staff followed proper infection control procedures for a resident on enhanced barrier precautions (EBP);-Ensure resident rooms were cleaned in a sanitary manner; and,-Ensure medications were handled in a sanitary manner.Findings include:I. Failure to follow EB.. Based on observations, record review and interviews, the facility failed to use a person-centered approach when determining the use of a grab bar/bed rail for one (#37) of one resident reviewed for grab bars/bed rails out of 39 sample residents.Specifically, for Resident #37, the facility failed to:-Identify alternatives to using grab bars/bed rails prior to installing grab bars/bed rails; and,-Conduct routine assessments and maintenance of the resident' s grab bar/bed rail to evaluate the continued safety and/or the continued need for the grab bar/bed rail.Findings include:I... Based on record review and interviews, the facility failed to prevent physical abuse for one (#274) of three residents reviewed for abuse out of 39 sample residents.Specifically, the facility failed to protect Resident #274 from physical abuse by Resident #276.Findings include:I. Facility policy and procedureThe Abuse policy, dated 5/3/23, was provided by the nursing home administrator (NHA) on 3/10/25 at 11:47 a.m. The policy revealed the facility did not condone resident abuse and would take every precaution possible to prevent resident abuse by anyone, including staff membe.. This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.