Arvada Care and Rehabilitation Center

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Egress Deficiencies

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

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Resident Rights Deficiencies

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

Resident Assessment and Care Planning Deficiencies

Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Quality of Life and Care Deficiencies

Provide safe, appropriate pain management for a resident who requires such services.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

Quality of Life and Care Deficiencies

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

A survey for Incident #1932318 and Incident #1932320 was conducted on 8/19/25 to 8/20/25. One deficiency was cited. Based on record review and interviews, the facility failed to ensure residents had the right to refuse to participate in occupational therapy activities for one (#2) resident reviewed for resident rights out of 12 sample residents.Specifically, the facility failed to ensure Resident #2 was allowed to refuse occupational therapy services. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation from 8/19/25 to 8/20/25, resulting in the deficiency being cited as past noncompliance with a correction date of 6/12/25.I. Facility policy and procedureThe Resident Rights policy and procedure, undated, was provided by the corporate consultant (CC) on 8/26/25 at 10:26 a.m. It read in pertinent part, “As a resident of this nursing facility, you have the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility. You have the right to exercise your rights without interference, coercion, discrimination, or reprisal from the facility. “Planning and Implementing Care. You have the right to be informed of, and participate in, your treatment, including the right to request, refuse, and/ or discontinue treatment.”II. Resident #2A. Resident statusResident #2, age 90, was admitted to the facility on 2/7/17. According to the August 2025 computerized physician orders (CPO), diagnoses included hemiplegia and hemiparesis (weakness or paralysis on one side of the body), following cerebral infarction (blood flow to the brain is interrupted, leading to brain tissue damage) affecting the right dominant side, aphasia (impairment in ability to communicate) and hypertension (high blood pressure).The 8/7/25 minimum data set (MDS) assessment documented the resident was unable to answer questions to complete the brief interview for mental status (BIMS) assessment. Staff assessment of the resident revealed the resident had severely impaired cognition and no behavioral issues. The resident had functi..

INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics.This survey conducted was in accordance with the Federal Register at Section 42 CFR 483.70(a).This survey conducted on March 24, 2025, was for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies."This structure is a one (1) story, Type V (111) (VA) construction with a partial basement. The partial basement is used for support services only and has no resident access. This facility, constructed in 1961, is licensed for 54 beds. The facility is fully protected throughout by National Fire Protection Association (NFPA) 13 automatic wet-pipe and dry-pipe fire sprinkler systems. The wet-pipe system protects the main level, and the dry-pipe sprinkler system protects the main entrance canopy and attic spaces. The facility is classified as fully sprinkled. The survey results were discussed with the maintenance director during th.. STANDARD is not met, as evidenced by the observation and staff interview during the course of the survey. It was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3. The doors protecting the corridor leading to the Physical Therapy room are missing essential hardware components and are not effectively keeping the door closed.The Life Safety Code Section 19.3.6.3.2 requires that corridor doors be provided with the means suitable for keeping the door closed that is acceptable to the authority having jurisdiction. Doors must be unobstructed from closing and positively latching into the doorframe. Section 19.3.6.3.1, This deficient practice could affect all residents within the smoke compartments should the egress become untenable due to smoke and heat transfer via the non-latching corridor doors.The Director of Maintenance acknowledges the corridor door condition during the facility tour. STANDARD needs to be met, as evidenced by the observation and staff interview during the survey. It was determined that the facility failed to maintain the marking of means of egress per Life Safety Section 7.10. Exit signs are not provided at all doors from the kitchen. 7.10.1.3 Exit Door Tactile Signage. Tactile signage shall be provided to meet all of the following criteria unless otherwise provided in 7.10.1.4: (1) Tactile signage shall be located at each exit door requiring an exit sign. (2) Tactile signage shall read as follows: EXIT. (3) Tactile signage shall comply with ICC/ANSI A117.1, American National Standard for Accessible and Usable Buildings and Facilities.If code-compliant exit signage is not provided for building egress, this deficient practice could affect all residents, staff, and visitors in the building.The Maintenance Director acknowledged the deficiency of the exit signage during the facility tour. STANDARD not met as evidenced by: Based on observation and staff interview during the survey; it was determined that the facility failed to arrange the exit access so that exits are readily accessible at all times by Life Safety Code 101 Section 19.2.2.2.4, 7.2.1.5.3. The kitchen and administrator office doors were equipped with locking/latching devices, and two releasing operations were required to operate the door. Life Safety Code 101 Section 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side unless otherwise permitted by one of the following:(1) Locks complying with 19.2.2.2.5 shall be permitted. (2)*Delayed-egress locks complying with 7.2.1.6.1 shall be permitted. (3)*Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.(4) Elevator lobby exit access door loc..

A recertification survey with complaint #CO39257 and #CO39389 was conducted on 3/5/25 to 3/12/25. Five deficiencies were cited. An Emergency Preparedness survey was conducted from 3/5/25 to 3/12/25. No deficiencies were cited. Based on observations and interviews, the facility failed to post, in a form and manner accessible and understandable to residents, information on how to file a complaint with the State Agency.Specifically, the group interview revealed the facility failed to: -Ensure residents knew where the required posting on how to file a complaint with the State Agency was located;-Ensure all required information was included on the posting; and, -Ensure that residents were able to easily access and read the information on the posting.Findings include:I. ObservationsOn 3/10/25 at 8:28 a.m.. Based on observations, interviews and record review, 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 disease on two of two units.Specifically, the facility failed to:-Ensure enhanced barrier precautions (EBP) were followed during wound care;-Ensure high touch surfaces in resident rooms were cleaned; and,-Ensure residents' personal hygiene items in shared bathrooms were labeled and stored in a sanitary manner.Findings include:I. EBP fail.. Based on observations, record review and interviews, the facility failed to ensure one (#40) of four residents who required respiratory care received care consistent with professional standards of practice out of 32 sample residents.Specifically, the facility failed to maintain, clean, sanitize and properly store Resident #40' s bilevel positive airway pressure (BiPAP) mask and machine.Finings include:I. Facility policy and procedureThe Non Invasive Respiratory policy, revised November 2024, was provided by the nursing home administrator (NHA) on 3/10/25 at 6:18 p.m. It re.. Based on observations, record review and interviews, the facility failed to ensure one (#201) of two residents reviewed for pain out of 32 sample residents had an effective pain management regimen in a manner consistent with professional standards of practice, resident-centered care plans and resident preferences.Specifically, the facility failed to ensure Resident #201' s pain was managed appropriately and consistently to meet the resident' s stated level of acceptable pain.Findings include:I. Facility policy and procedureThe Pain Assessment and Management policy, revise.. Based on record review, observations and interviews, the facility failed to develop and implement a baseline care plan which included the instructions needed to provide effective and person-centered care for four (#9, #24, #201 and #39) of five residents reviewed for baseline care plans out of 32 sample residents.Specifically, the facility failed to ensure pertinent medical information was included on Resident #9, Resident #24, Resident #201 and Resident #39' s baseline care plans within 48 hours of admission.Findings include:I. Resident #9A. Resident statusResident #9, age 78, was ad..

A complaint survey, prompted by #CO36728, #CO36790, #CO36793, #CO37090 and #CO37105 was conducted on 8/12/24 to 8/14/24. One deficiency was cited. Based on record review and interviews, the facility failed to ensure each resident had the right to formulate an advanced directive for one (#1) of three residents reviewed for advanced directives out of 10 sample residents. Upon Resident #1' s admission to the facility on 6/4/24, a licensed practical nurse (LPN) #3 interviewed Resident #1 and filled out the advanced directive paper form with the necessary information indicating the resident chose to be a DNR (do not resuscitate) status. LPN #1 did not record the resident' s DNR status in Resident #1' s electronic medical records (EMR) as he was required to do. On 6/5/24 the medical provider discussed the decision to be a DNR status with Resident #1 and her family. The nurse practitioner (NP) signed the advanced directives paper form and returned the form to the nurse' s station where the forms were kept for the facility staff to follow-up. On 6/10/24 (seven days after the resident was admitted to the facility) Resident #1 had a cardiac arrest (a medical emergency where the heart suddenly stops beating, preventing blood from flowing to the brain and other vital organs) in her room. On 6/10/24 the nursing staff could not locate the advanced directives form that designated Resident #1' s wished to be a DNR status. The nursing staff called the emergency medical technicians (EMT). When the EMTs entered the facility, the facility nursing staff told the EMTs that the resident' s directives were to receive cardiopulmonary resuscitation (CPR). The EMTs performed CPR, inserted an intubation tube down Resident #1' s trachea (windpipe) and transported the resident to a local hospital.The local hospital documented Resident #1 had a cardiac arrest and was a DNR status but an intubation had occurred in the field.According to Resident #1' s family member, the hospital physician asked the family, due to the fact that Resident #1 had already been intubated, if the family would like to see if Resident #1 would recover over the next 24 to 48 hours. The resident' s family agreed, however, after 24 hours ..