Katherine and Charles Hover Green Houses

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.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Nutrition and Dietary Deficiencies

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

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

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Resident Rights Deficiencies

Limit the charges against residents' personal funds for items or services for which payment is made under Medicare or Medicaid.

Nursing and Physician Services Deficiencies

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

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

Emergency Preparedness Deficiencies

Establish staff and initial training requirements.

Egress Deficiencies

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

Smoke Deficiencies

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

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

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

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.

Gas, Vacuum, and Electrical Systems Deficiencies

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

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

Smoke Deficiencies

Provide properly protected cooking facilities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Resident Assessment and Care Planning Deficiencies

Provide care by qualified persons according to each resident's written plan of care.

Nursing and Physician Services Deficiencies

Verify that a nurse aide has been trained; and if they haven't worked as a nurse aide for 2 years, receive retraining.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

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.

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.

Administration Deficiencies

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

Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidence by the following: 1. No records or documentation of generator battery monthly conductance testing.2. No records or documentation for generator load bank testing.3. No records or documentation for annual generator fu.. Based on observation and staff interview during record review, it was determined that the facility failed to maintain emergency lighting in accordance with NFPA 101, Life Safety Code Sections 21.2.9 and 7.9.3.1.1. This was evidenced by the following:1. No records or inadequate documentation for emergency lighting 30 second monthly and 90-minute annual testing.NFPA 101, 7.9.3.1.1 Periodic Testing of Emergency Lighting Equipment. (1) A functional test shall be c.. Based on observation it was determined that the facility failed to maintain all portable fire extinguishers as required by NFPA 10 Chapter 4 and LSC 101, 9.7.4. This was evidence by the following.1. No records or documentation of annual fire extinguisher inspection report. NFPA 101, 9.7.4. Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected and maintain.. Based on observation, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association (NFPA) 25,5.3.1.1.1 and NFPA 101, 19.7.6, and 4.6.12.This was evidence by the following.1. Missing quarterly fire sprinkler inspection reports.2. Missing annual fire sprinkler inspection report.3. Missing records for 5-year internal pipe inspection report.4. Storage is prohibited in all fire sprin.. Based on record review and staff interview during the survey, the facility failed to perform and document the exercising of all fire and smoke dampers at least every four years, in accordance with NFPA 90A, Standard for the Installation of Air-Conditioning and Ventilation Systems; section 3-4.7 Maintenance.This was evidenced by the following: 1. No records or documentation for smoke damper 4-year inspection and maintenance.NFPA 90A, Chapter .. Based on record review it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96, (Chapter 11, Section 11.6.2 and 11.7.1)This was evidence by the following:1. No current records or documentation for kitchen hood cleaning.2. No records or documentation for annual hood suppression system inspection.NFPA 96, 11.6.2* Hoods, grease removal devices, fans, ducts, and other appurtenances shall be cleaned to.. Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Sections 19.7.1.6 and 4.7.4. This was evidenced by the following: 1. Fire drills were not conducted during varying times and conditions. Time of drills were too close to previous drills on all shifts. 2. No records or documentation of fire drills for all shifts in all quarters.NFPA 101 Fire drills in health care occupancies shall include t.. Based record review it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the NFPA 101, Life Safety Code Section 19.3.4.1 and NFPA 72.This was evidenced by:1. No records or documentation for 2-year smoke detector sensitivity testing.2. All Fire alarm control panels have deficiency tags displayed.3. Bldg. 4 has deficiency tag stating inoperative smoke detector in riser room.NFPA 101, Section 9.6.1.. INITIAL COMENTS (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 February 20, 2024 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 18 "New Health Care Occupancies."This facility is located on a campus and has a tota..

A recertification survey with complaint #CO34741 was completed on 1/31/24 to 2/6/24. One deficiency was cited. An Emergency Preparedness survey was conducted from 1/31/24 to 2/6/24. Two deficiencies were cited. Based on record review and interview, the facility failed to develop and maintain an up-to-date emergency preparedness (EP) training program that aligns with the facility' s specific individualized EP plan, annual risk assessment, facility EP policies and procedures, the facility' s communication plan, that was delivered to all staff upon hire and annually thereafter. Additionally, the facility will extend training to volunteers and contracted providers who provide care and services in the facility environment. Specifically, the facility failed to:-Provide staff initial and annual training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role;-Maintain documentation of all eme.. Based on record review and interviews, the facility failed to develop, establish and maintain a comprehensive emergency preparedness (EP) program that met all of the required components taking into account a contingency plan in the event that essential resources were not available, and the EP program was reviewed annually and updated annually.Specifically, the facility to ensure the EP plan policies were updated annually. Findings include: I. Record reviewThe EP program binder was provided by the director of nursing (DON) on 2/5/24 at 10:45 a.m. -The EP program binder failed to contain an EP program plan that was updated annually. The most recent update was completed in December 2022. II. Staff interviewsThe maintenance director (MTD) and nursing home admi.. Based on record review and interviews, the facility failed to notify the provider when a resident had a significant change in condition requiring a need to alter treatment for two (#12 and #22) out of five residents out of 20 sample residents.Specifically, the facility failed to inform Resident #12 and Resident #22' s provider when medications were not administered according to the physician' s orders. Findings include: I. Facility policyThe Medication and Administration of Medications policy, revised 2/6/24, was provided by the director of nursing (DON) on 2/6/24 at 2:09 p.m. It read in pertinent part,"Medication technicians administering medications must use the medication list to identify and monitor for possible ineffective drug therapy and shall promptly report problems to the physician, inclu..