Life Care Center of Colorado Springs

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.

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.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Quality of Life and Care Deficiencies

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

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.

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

Resident Assessment and Care Planning Deficiencies

Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.

Infection Control Deficiencies

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

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 Section 9.6 and NFPA 72.1.Annual Fire Alarm Report shows that elevator detectors were missed on the Aug inspection | These were tested in Feb no inspection report is available to show that they were inspected in the last 12 months NFPA 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 requireme.. 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.Fuel report incomplete | need to re-sampled8.1.1 The routine Maintenance and operational testing program shall be based on all of the following: Manufacturers recommendationsInstruction manualsMinimum requirements of this chapterThe authority having jurisdiction 8.3.7.1 .. Based on observation and staff interview, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 19.2 and Chapter 7. 1.Delayed egress door in-op kitchen egress hallway | Mag-lock disengages with with fire alarm kitchen egressNFPA 101 7.2.1.6.1.1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordanc.. Based on observations and records review, it was determined that the facility did not maintain fire extinguishers In accordance with NFPA 10. 1.Elevator extinguisher downstairs needs to be moved to below 5ftNFPA 10 6.1.3.8 Installation Height.6.1.3.8.1 Fire extinguishers having a gross weight not exceeding 40 lb (18.14 kg) shall be installed so that the top of the fire extinguisher is not more than 5 ft (1.53 m) above the floor.5.5.5* Class K Cooking Media Fires.Fire extinguishers provided for the protection of cooking appliances that use combustible cooking media (veget.. 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.Leak on dry system needs to be repaired | facility working on repair | 2.Need to review 3 year full trip test | This will need to also be repeated after repair of system3.Loaded (dirty) sprinkler head dryer room NFPA 101 Life Safety Code Standards require automatic sprinkler systems to be continuously maintained in reliable operating condition and are inspected .. Based on record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.61. Fire Drills closer than an hour 2 and 3rd quarter 3rd shift NFPA 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 has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient.. 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).The facility is two story, Type V (111), construction with a partial lower level.. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1996 and is license for 121 beds. This re-certification survey conducted May 15..

A recertification survey was conducted from 4/10/24 to 4/16/24. Two deficiencies were cited. An Emergency Preparedness survey was conducted from 4/10/24 to 4/16/24. No deficiencies were cited. Based on observations, interviews, and record review, the facility failed to ensure one (#15) of two residents reviewed for communication out of 28 sample residents was provided appropriate treatment and services to maintain or improve their abilities.Specifically, the facility failed to provide Resident #15, who had difficulties with speech due to a stroke, with an appropriate communication tool to ensure the resident was able to effectively communicate her needs to staff.Findings include:I. Resident #15A. Resident status Resident #15, under age 65, was admitted on 8/30/22. According to the April 2024 computerized physician orders (CPO), the diagnoses included cerebral infarction (stroke). The 3/8/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a (BIMS) score of 14 out of 15. She needed substantial assistance from one staff member for transferring and needed supervision or hands on assistance of one staff member for eating and personal hygiene. The MDS assessment indicated Resident #15 was .. Based on observations, record review and interviews the facility failed to ensure one (#55) of one resident received treatment and care in accordance with professional standards of practice out of 28 sample residents. Specifically, the facility failed to ensure Resident #55 was assisted with applying her compression stockings to treat her bilateral lower leg edema.Findings include: I. Facility policy and procedureThe Anti Embolism (compression) Stocking Application policy, revised 9/8/23, was received by the director of nursing (DON) on 4/16/24 at 10:43 a.m. It read in pertinent part,"The facility will provide anti embolism stocking application in accordance with professional standards of practice."The services provided or arranged by the facility, as outlined by the comprehensive care plan, must meet the professional standards of quality."The facility will utilize Lippincott (nursing) procedures for anti embolism stocking application." The Anti Embolism stocking application checklist, undated, was provided by the DON on 4/16/..