Englewood Post Acute and Rehabilitation

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Egress Deficiencies

Provide large enough exits.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Resident Assessment and Care Planning Deficiencies

Ensure each resident receives an accurate assessment.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Resident Assessment and Care Planning Deficiencies

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

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

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

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Smoke Deficiencies

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

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

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

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Smoke Deficiencies

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

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Services Deficiencies

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

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

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.

Nutrition and Dietary Deficiencies

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

Smoke Deficiencies

Install an approved automatic sprinkler system.

Egress Deficiencies

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

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Egress Deficiencies

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

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Based on observation and record review during the survey, it was determined that the facility failed to maintain emergency power systems in accordance with Section 9.1.3 ofthe Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 8.The facility did not have a full test compliant during the inspection.NFPA 110, Section 8.3.8. A fuel quality test shall be performed at least annually using applicable ASTM standards or the manufacturer ' s recommendations.This deficiency could affect occupants, including residents, staff, and visitors throughout the facility. The maintenance director discussed deficient items at the exit conference. Based on observation and staff interviews during record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code NFPA 1011. Exit Lights: no annual or monthly 30/90-minute inspection report available for reviewNFPA 101 7.9.2.1* Emergency illumination shall be provided for a minimum of one and 1/2 hours in the event of failure of normal lighting. Emergency lighting facilities shall be arranged to provide initial illumination that is not less than an average of 1 ft-candle (10.8 lux) and, at any point, not less than 0.1 ft-candle (1.1 lux), measured along the path of egress at floor level. Illumination levels shall be permitted to decline to not less than an average of 0.6 ft-candle (6.5 lux) and, at any point, not less than 0.06 ft-candle (0.65 lux) at the .. Based on observation, it was found that the facility did not meet the protection requirements in accordance with NFPA 101, 25, and 13.1. Painted sprinkler head mds coordinate room 2. Painted head Corridor outside rm 2123. Wires on sprinkler pipe riser4 Accounts payable painted sprinkler heads5. Painted head in employee break roomNFPA 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 fluid in the glass bulb heat responsive element, (5)* Loading (6) Painting unless painted by the sprinkler manufacturer. NFPA 25 5.2.2.2 Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe.This deficiency can potentially affect occupants, including residents.. Based on the record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6Fire drills closer than an hour apart, not at varied timesNFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions.This deficiency could affect occupants, including residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference. 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, Type I (332) construction with a partial basement. The basement is used for support services only. There is a partial crawl space adjacent to the basement. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression system and is classified as Fully Sprinklered. The facility was constructed in 1985 and is licensed for 82 beds. This re-certification survey conducted on December 3, 2024, was for compliance with the National Fire Protection Association, (NFPA 101) Life S..

A recertification survey with complaint #CO36744 was completed from 11/4/24 to 11/7/24. Six deficiencies were cited. An Emergency Preparedness survey was conducted from 11/4/24 to 11/7/24. No deficiencies were cited. Based on interviews and record review, the facility failed to thoroughly investigate resident-to-resident allegations of physical abuse and staff-to-resident allegations of neglect of care to prevent further instances of abuse and residents from feeling neglected for two (#60 and #18) of four residents out of 40 sample residents.Specifically, the facility failed to: -Develop a care plan focus for Resident #18, who had a known history of aggressive behaviors towards othe.. Based on observation and interviews, the facility failed to ensure that services provided met professional standards of quality for one (#21) of one resident out of 40 sample residents. Specifically, the facility failed to: -Ensure medications were not left unattended on top of the medication cart; and, -Ensure medications were not left unattended in Resident #21' s room.Findings include:I. Professional referenceAccording to the National Library of Med.. Based on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of four hallways.Specifically, the facility failed to:-Ensure appropriate infection control practices were followed during wound care; and,-Ensure housekeeping staff .. Based on observations and interviews, the facility failed to provide a comfortable and homelike environment in one of four units. Specifically, the facility failed to ensure: -Resident room #202, #204, #206, #209, and #212 were in good repair; and, -Baseboards in the common areas on the second floor unit were clean. Findings include: I. Facility policy and procedureThe Safe Homelike Environment policy, revised October 2024, was provided by the nursing home admi.. Based on record review and interviews, the facility failed to ensure the minimum data set (MDS) assessment accurately reflected residents' status based on the criteria outlined in the resident assessment instrument (RAI) for three (#15, #36 and #63) residents out of 40 sample residents. Specifically, the facility failed to:-Ensure the MDS assessments for Resident #15 and Resident #36 accurately documented that the residents had a preadmission assessm.. Based on record review and interviews, the facility failed to refer one (#20) of one resident reviewed out of 40 sample residents to the appropriate state-designated authority for Level II preadmission screening and resident review (PASRR) evaluation and determination for services.Specifically, the facility failed to:-Ensure Resident #20 was properly assessed on the PASRR Level I screen to gain and maintain their highest practicable medical, emotional and psychoso..