Aviva at Fitzsimons

Quality of Life and Care Deficiencies

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

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Gas, Vacuum, and Electrical Systems Deficiencies

Have a battery powered remote alarm panel in a location accessible by operating personnel.

Administration Deficiencies

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Nursing and Physician Services Deficiencies

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

Nutrition and Dietary Deficiencies

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

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Nutrition and Dietary Deficiencies

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Services Deficiencies

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

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Environmental Deficiencies

Keep all essential equipment working safely.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

Quality of Life and Care Deficiencies

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

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

A survey prompted by #CO38420, #CO38541, #CO38826 and Incident #38424 was conducted on 12/30/24 to 1/2/25. One deficiency was cited. Based on record review and interviews the facility failed to provide services for one (#3) of three residents out of seven sample residents according to professional standards of practice.Specifically, the facility failed to:-Ensure Resident #3 was consistently monitored when having a change in condition; -Follow the physician' s orders; and, -Call the provider when Resident #3' s blood pressure and heart rate dropped. Findings include:I. Facility policy and procedureThe Change in Resident Condition policy, dated 2/29/24, was provided by the regional clinical resource (RCR) on 12/30/24 at 2:59 p.m. It read in pertinent part, "A facility must immediately inform the resident; consult with the resident' s provider; and if known, notify the resident' s legal representative or an interested family member when there is a significant change in the resident' s physical, mental, or psychological status (deterioration in health in life threatening conditions)."Immediate notification to the provider would include but not limited to: a fall resulting in significant injury, critical lab values, respiratory arrest, acute changes in respiratory status, acute changes in cardiac status, significant change in wound status, significant changes to vital signs, sudden cognitive changes, or any life threatening episode."Document in the resident' s medical record the date and time of change of condition, who (physician/family member/responsible party) was notified regarding the condition change, information communicated, response and/or orders received, assessment of resident condition and ongoing monitoring of resident condition, care provided, document the time emergency personnel arrived and took over the care of the resident, if applicable and update the care plan as needed.The Verbal Orders policy, revised February 2014, was provided by the RCR on 12/30/24 at 2:59 p.m. It read in pertinent part, "Verbal orders shall only be given in an emergency or when the attending physician is not immediately available to write or sign the order. Verbal orders will always be based on ver..

A Comparative Federal Monitoring Survey was conducted on 12/3/24, following a State Agency Annual Survey on 10/31/24, in accordance with Title 42, Code of Federal Regulations, 483.73 et seq. (Emergency Preparedness). During this Comparative Federal Monitoring Survey, the facility was found to be in compliance with the Requirements for Participation in Medicare and Medicaid. Based on observation and interview, the facility failed to separate the transfilling area from any portion of a facility wherein patients are housed, examined, or treated by a fire barrier of 1 hour fire-resistive construction. The deficient practice affected 1 of 6 smoke compartments. The facility had a capacity for 100 beds with a census of 32 on the day of the survey.The findings include:Observation during the building inspection tour revealed first floor oxygen transfilling room was not separated from the rest of the facility by a fire barrier of 1 hour fire-resistive construction due to lack of a minimum 45 min fire rated door.An interview with the Maintenance Director revealed that facility was not aware of this requirement.The census of 32 was verified by the Administrator. The findings were acknowledged by the Administrator and the Maintenance Director during the exit interview. The facility was found to be in compliance with Title 42, Code of Federal Regulations, 483.73 et seq. (Emergency Preparedness). Two (2) story, Type II(111) construction. The building has complete coverage by an automatic sprinkler system.A Comparative Federal Monitoring Survey was conducted on 12/3/24, following a State Agency Annual Survey on 10/31/24, in accordance with 42 Code of Federal Regulations, Part 483: Requirements for Long Term Care Facilities. During this Comparative Federal Monitoring Survey, the facility was found not to be in compliance with the Requirements for Participation in Medicare and Medicaid.The findings that follow demonstrate noncompliance with Title 42, Code of Federal Regulations, 483.90 (a) et seq. (Life Safety from Fire).

INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The facility is a two-story building Type II (000) construction without a basement. It is fully protected by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system, which includes a wet fire sprinkler system. This survey was conducted on October 31, 2024, to ensure compliance with the National Fire Protection Association (NFPA) 101 Life Safety Code (2012), Chapter 18 "New Health Care Occupancies", as well as the adopted portions of NFPA 99, Health Care Facilities Code (2012), and other referenced standards. STANDARD not met as evidenced by: Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system per National Fire Protection Association (NFPA) Standard 13 and Standard 25. This deficient practice could affect all residents, staff, and visitors should the automatic sprinkler system fail to operate promptly and effectively due to non-code-compliant maintenance. The pendent sprinkler in 1 North Hall shows signs of foreign materials around the working parts of the head.NFPA 101 2012 Edition Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating conditions and are installed, inspected, and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5The Director of Maintenance ac.. STANDARD not met: Based on observation and staff interviews during the survey, it was determined that the facility needed to maintain the trans-filling of oxygen storage room ventilation per NFPA 99 - Health Care Facilities, 9.3.7.2 and NFPA 55 Compressed Gases and Cryogenic Fluids Code. This deficient practice could affect all residents and staff within the facility should a emergency occur. The following evidenced this:The oxygen trans-filling room is not mechanically ventilated correctly to maintain a negative pressure per NFPA 99 and NFPA 55. The exhaust is vented into the attic space rather than directly to the outside.2012 NFPA 999.3.7.4 Transfilling area shall be provided with ventilation in accordance with NFPA 55, Compressed Gases and Cryogenic Fluids Code.9.3.7.5.3.1Mechanical exhaust.. STANDARD was not met based on observation and staff interviews regarding the emergency lighting. The facility failed to maintain the battery-powered emergency lights per 7.9.3 and 19.2.9.1. This deficiency could affect all residents and staff throughout the facility during primary power loss. This was evidenced by the following:No documentation was available during the record review of the facility-required testing of the battery-powered emergency lighting system at 30-day intervals for not less than 30 seconds monthly or annually for not less than 1 ½ hours .2012 Life Safety Code 101-7.9.3 Periodic Testing of Emergency Lighting Equipment. A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test s.. STANDARD was not met, as evidenced by observation and staff interviews during the survey. It was determined that the facility failed to maintain sprinkler-protected hazardous areas per Life Safety Section 19.3.2.1. This deficient practice could affect all residents and staff in the main smoke compartment should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidenced by the following.The door to the Physical Therapy Gym serving as protection for hazardous areas that require a 1-hour separation from the main corridor. The self-closing device have been removed.Life Safety Code Section 19.3.2.1 requires that sprinkler-protected hazardous areas be separated from other spaces by smoke-resisting construction. Doors in..