Cedars Healthcare Center

Quality of Life and Care Deficiencies

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

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.

Quality of Life and Care Deficiencies

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

Smoke Deficiencies

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

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Install properly constructed and protected linen or trash chutes.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Provide properly protected cooking facilities.

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.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

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 care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Provide care or services that was trauma informed and/or culturally competent.

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 residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

A complaint survey, prompted by #CO1933634 and #CO1935920 was conducted on 7/10/25 to 7/16/25. Two deficiencies were cited. Based on record review and interviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices for two (#1 and #2) of six residents out of seven sample residents.Specifically, the facility failed to accurately document the administration of scheduled medications for Resident #1 and Resident #2. Findings include:I. Facility policy and procedureThe Administering Medications policy, dated April 2019, was provided by the director of nursing (DON) on 7/15/25 at 10:06 a.m. The policy read in pertinent part,“Medications are administered in a safe and timely manner, and as prescribed. Only persons licensed or permitted may prepare, administer, and document the administration of medications.“The director of nursing services (DON) supervises and directs all personnel who administer medications and/or have related functions.“Medications are administered by prescriber orders, including any required time frame.“Medication administration times are determined by resident need and benefit, not staff convenience. Factors that are considered include: - Enhancing the optimal therapeutic effect of the medication; -Preventing potential medication or food interactions; and-Honoring resident choices and preferences, consistent with their care plan.“The individual administering the medication checks the label three (3) .. 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 complaint survey, prompted by #CO36721, #CO36900 and Incident #CO36973 was conducted from 8/19/24 to 8/20/24. One deficiency was cited. Based on record review and interviews, the facility failed to ensure one (#1) of three residents out of five sample residents received treatment and care for optimal skin condition of a contracted hand, in accordance with professional standards of practice. Specifically, the facility did not provide adequate skin care to prevent skin breakdown in Resident #1' s contracted hands and between the resident' s fingers and the thumb. Findings include: I. Professional referenceAccording to the Oxford Health NHS Foundation Trust Hand Contractures, February 2022, retrieved on 8/28/24, from https://www.oxfordhealth.nhs.uk/wp-content/uploads/sites/24/2023/06/1.6.3-Hand- Contractures-Advice-Sheet-for-Care-Homes.pdf,"It is vital to adequately manage this condition in order to prevent pressure sores and skin breakdown in the palm and fingers. "Once a hand contracture is present it can become very painful. Movements can be uncomfortable, but it is essential to maintain adequate hand hygiene;"Hand hygiene is essential management of hand contractures. This should be achieved by regular washing and drying of the hand at least two to three times a day. It is especially important to ensure the skin is properly dry. If the skin is wet/sweaty this increases the changes to the normal skin barrier and can lead to breakdown, sores and infections. Allowing a little time to dry the hand will prevent skin from breaking down and prevent odor, which can become offensive. Also, ensure nails are regularly cut to prevent digging into the hand."II. Facility policy and procedureOn 8/20/24 a request was made to the director of nursing (DON) for the facility' s policy on contracture management and skin integrity management.-The facility did not provide any policies by the end of the survey on 8/20/24. III. Resident #1A. Resident statusResident #1, age less than 65, was admitted to the facility on 4/22/24. According to the computerized physician' s orders (CPO), diagnoses included quadriplegia (paralysis of all four limbs), traumatic brain injury and mus..

Based on a record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code 101 and NFPA 72. The fire alarm system has a trouble signal on the main panel that indicates ground fault. 2012 Life Safety Code 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 CodeThis deficien.. Based on observation during the course of the survey it was determined the facility failed to maintain a hazardous area in accordance with NFPA 99. This was evidenced by the following:Oxygen Transfill rooms need a vent 12" of the floorNFPA 556.15.7 Inlets to the Exhaust System.6.15.7.1 The exhaust ventilation system design shall take into account the density of the potential gases released.6.15.7.2 For gases that are heavier than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the floor.6.15.7.3 For gases that are lighter than air, exhaust shall be taken from a.. Based on observation it was determined the facility failed to maintain corridor doors in accordance with NFPA 101.1.Room door do not resist the passage of smoke room numbers (420, 435, 324)NFPA 80 5.2.1* Fire door assemblies shall be inspected and tested not less than annually, and a written record of the inspection shall be signed and kept for inspection by the AHJ.NFPA 101, 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be doors constructed to resist the passage of.. Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011.Wires strapped onto sprinkler pipe main telephone rm2.Storage rm near rm 420 painted sprinkler head and storage across the hall, 330 2 painted sprinkler heads 3283.Damaged Fire sprinkler head head dietary officeNFPA 25 5.2.1.1.2 Any sprinkler that shows signs of any of the following shall be replaced: (1) Leakage, (2) Corrosion, (3) Physical damage, (4) Loss of.. During the tour of the facility with the staff, it was determined that the facility failed to provide proper coverage of the Wet Chemical Extinguishing System as required in NFPA 17A 7.2.2. Tamper Bar missing from Ansul Pull StationWet Chemical Extinguishing System as required in NFPA 17A 7.2.2. On a minimum, this "quick check" or inspection shall include verification of the following:(3) The tamper indicators and seals are intact.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were disc.. K161/#000 Tag: 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).This survey was conducted on April 9, 2024 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) construction. This original facility was constructed in 1925. The facility has a full basement and utilizes .. Through observation during the survey, it was determined that the facility failed to meet the rubbish chutes, incinerators, and laundry chute requirements in accordance with NFPA 101, This was evidenced by:Upper door laundry chute not original needs to be UL listedNFPA 82 (2009) 10.2.2 "Waste and linen chutes and transport systems including chute loading and discharge doors shall be inspected and maintained not less than annually in accordance with manufacturers' instructions." Life Safety Code Section 19.5.4.1 Existing rubbish chutes or linen chutes, including pneu..

A recertification survey with complaint #CO35255 was completed on 3/13/24 to 3/19/24. Seven deficiencies were cited. An Emergency Preparedness survey was conducted from 3/13/24 to 3/19/24. No deficiencies were cited. Based on observation and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly on one of two medication carts and one medication storage room of two medication storage rooms.Specifically the facility failed to:-Ensure insulin (medications used for glucose control) pens and vials were labeled with open dates; and,-Ensure expired or discontinued medications were removed from the medication room .. Based 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 on two of three units.Specifically, the facility failed to:-Ensure housekeeping staff were following the proper cleaning techniques for cleaning resident rooms and disinfecting high frequency touch areas (call lights, door handles.. Based on observations, record review and interviews, the facility failed to ensure residents were free from physical restraints for two (#180 and #40) of six residents out of 34 sample residents. Specifically the facility failed to:-Ensure Resident #180 was evaluated on admission for use of a restraint;-Ensure a consent was signed for use of a restraint for Resident #180 and #40;-Ensure there was a physician' s order for restraints for resident #180 and #4; and, -Ensure ther.. Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for one (#64) of three residents reviewed out of 34 sample residents.Specifically, the facility failed to ensure Resident #64, who was dependent on staff for bathing, received her scheduled showers. Findings include:I. Facility policyThe Activi.. Based on record review and interviews, the facility failed to conduct a preadmission screening resident review (PASRR) for individuals remaining in a facility 30 days past provisional admission approval for one (#56) of one resident reviewed for PASRR out of 34 sample residents. Specifically, the facility failed to submit a new PASRR level I once an automatically approved provisional admission from a hospital had expired for Resident #56 after she had resi.. Based on record review and interviews, the facility failed to ensure residents with indwelling catheters received the appropriate care and services according to professional standards for one (#74) of two residents reviewed for catheters of 34 sample residents. Specifically, the facility failed to:-Obtain physician orders for catheter use for Resident #74; -Ensure Resident #74 had a clinical indication (diagnosis) for catheter use prior to administration;-Ensu.. Based on record review and interviews, the facility failed to ensure that a resident who was a trauma survivor received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#56) of one resident out of 34 sample residents.Specifically, the facility fai..