Heritage Park Care Center

Quality of Life and Care Deficiencies

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

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.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

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

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Smoke Deficiencies

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

Resident Rights Deficiencies

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

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

Quality of Life and Care Deficiencies

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

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

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.

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

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Nursing and Physician Services Deficiencies

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

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Nursing and Physician Services Deficiencies

Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

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

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

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

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

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 the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Quality of Life and Care Deficiencies

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

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

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 the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Infection Control Deficiencies

Perform COVID19 testing on residents and staff.

Egress Deficiencies

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

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Gas, Vacuum, and Electrical Systems Deficiencies

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

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Egress Deficiencies

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

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Resident Assessment and Care Planning Deficiencies

PASARR screening for Mental disorders or Intellectual Disabilities

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

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

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

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Services Deficiencies

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

The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register, Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag # K 000) are informational only and a representation of the facility' s general characteristics. The facility is a one-story wood-frame structure, Type V (111), constructed on 5/12/87 and does not have a basement. The facility was licensed for 90 beds and is licensed to operate a port.. Through document review during the survey, it was determined that the facility failed to maintain the electrical systems in accordance with NFPA 99. This was evidenced by:1) Receptacle Testing (99 6.3.4.1): Provided, but not meeting NFPA 99 standardsNFPA 996.3.4.1.1Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial in.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 72. This was evidenced by:1) Fire Alarm Annual: 7.18.24 Integrity Fire Safety Services, + shows failed battery test+ Horn not working in the spa area+ strobe not working in west wing hall+ Missing devices for flow switches on the annual report2) Fire Alarm Semi-Annual: Not provided3) Fire Alarm Sensitivit.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 99, and 110. This was evidenced by:1) Emergency Power (101 9.1.3.1 & 110) Load bank test (Monthly)(110 8.4.1): Not done per NFPA 110 standards2) Battery Testing(Monthly specific gravity,weekly voltage)(110 8.3.7): Not provided3) EPS missing the emergency stopNFPA 110 8.4.1* EPSSs, including a.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, and 10. This was evidenced by:1) Portable Fire Extinguishers (Monthly/Annually)(101 19.3.5.12 & 10 7.2): Annual report from 7.30.24 indicated that Type K FE due for HydroNFPA 101 9.7.4.1* Where required by the provisions of another sectionof this Code, portable fire extinguishers .. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) Fire Drills not done per NFPA 101 standardsNFPA 10119.7.1.6 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 condit.. Through observation during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101. This was evidenced by:1) The gardener hall egress pathway to the public way missing proper illuminated signageNFPA 101 39.2.10 Marking of Means of Egress. Means of egress shall have signs in accordance with Section 7.10.NFPA 1017.10.1.5.1 Access to exits shall be marked by approved, readily visible sign.. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 99 and NFPA 55. This was evidenced by:1) The oxygen trans-filling room needs mechanical ventilation 0-12" from the floor2) signage for full and empty containers NFPA 55 6.15.7.26.15.7.2 For gases that are heavier than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the floor.NFPA 99 11.5.2.3.1Transfil.. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 54. This was evidenced by:1) Gas valves on the dryer(s) not rated for more than 2000 feet elevation need high-elevation gas valvesNFPA 101 9.1.1 Gas. Equipment using gas and related gas piping shall be in accordance with NFPA 54, National Fuel Gas Code, or NFPA 58, Liquefied Petroleum Gas Code, unle..

A licensure survey was completed on 8/26/24 to 8/29/24. One deficiency was cited. Based on observation, record review and interviews, the facility failed to ensure one (#24) of three residents reviewed for weight loss out of 28 sample residents received the care and services necessary to meet their nutrition and hydration needs and to maintain their highest level of physical well-being. Resident #24 was admitted on 5/31/24 with a diagnosis of Alzheimer' s disease, dysphagia (difficulty swallowing), prediabetes and chronic kidney disease stage 3. On 7/16/24 the resident weighed 197 pounds (lbs) and on 8/29/24 the resident weighed 185 lbs. The resident lost 5.1% (10 lbs) of her body weight in 29 days. While nutritional interventions were initiated when a significant weight loss was identified on 7/12/24 (2 cal MedPass supplement), observations revealed the facility failed to promote the resident' s nutritional status by encouraging, and providing meals and snacks, documenting her intake of meals accurately and monitoring weekly weights. Findings include:I. Facility policy and procedureThe Weight policy, reviewed on 8/19/24 was provided by regional director of clinical services (RDCS) #2 on 8/29/24 at 2:35 p.m. It revealed in pertinent part, "Following a routine weighing schedule helps detect weight changes. Unless otherwise specified, a resident' s weight should be recorded at the time of admission, weekly for four weeks, and then monthly."A decrease in weight of 5% or more in a month or of more than 10% in 6 (six) months should be reported to the practitioner for further evaluation."II. Resident #24A. Resident statusResident #24, age greater than 65, was admitted on 5/3/21. According to the August 2024 computerized physician orders (CPO), diagnoses included Alzheimer' s disease, dysphagia, prediabetes and chronic kidney disease stage 3.According to the 8/5/24 facility assessment, the resident had severe cognitive impairments. Resident #24 was independent with eating. She required partial/moderate assistance with oral hygiene and was dependent on staff for all other activities of daily living (ADL). The facility assessment indicated the resident was pre..

A recertification survey with complaint #CO35421 and #CO37189 was completed on 8/26/24 to 8/29/24. Eighteen def.. An Emergency Preparedness survey was conducted from 8/26/24 to 8/29/24. No deficiencies were cited. Based on interviews and record review, the facility failed to ensure certified nurse aides (CNA) received at least 12 h.. Based on observation, record review and interviews, the facility failed to ensure one (#24) of three residents reviewe.. Based on observations, record review and interviews, the facility failed to consistently serve food that was palatable .. Based on observations, record review and interviews, the facility failed to ensure one (#24) of two residents reviewe.. Based on observations, record review and interviews, the facility failed to ensure proper treatment and assistive devi.. Based on observations, record review and interviews, the facility failed to ensure residents had the right to a dignifie.. Based on observations, record review and interviews, the facility failed to ensure staffing information was posted in .. Based on observations, record review and interviews, the facility failed to ensure that one (#241) of five residents ou.. Based on observations, record review and interviews, the facility failed to ensure that residents who entered the faci.. Based on observations, record review and interviews, the facility failed to ensure that three (#16, #14 and #17) of th.. Based on observations, record review and interviews, the facility failed to ensure two (#37 and #1) of two residents o.. Based on observations, record review and interviews, the facility failed to maintain an infection control program desi.. Based on observations, record review and interviews, the facility failed to store, prepare, distribute and serve food i.. Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at l.. Based on record review and interviews, the facility failed to conduct a preadmission screening resident review (PASR.. Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identif.. Based on record review and interviews, the facility failed to ensure four (#241, #242, #36, and #239) of five residents..