Life Care Center of Evergreen

Nutrition and Dietary Deficiencies

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

Egress Deficiencies

Have properly located and lighted "Exit" signs.

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.

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.

Pharmacy Service Deficiencies

Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.

Administration Deficiencies

Provide timely, approved x-ray services, or have an agreement with an approved provider to obtain them.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

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

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Nutrition and Dietary Deficiencies

Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident.

Nutrition and Dietary Deficiencies

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

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.

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

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Infection Control Deficiencies

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

Egress Deficiencies

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

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

Have properly installed hallway dispensers for alcohol-based hand rub.

Services Deficiencies

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

Services Deficiencies

Have an externally vented heating system.

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.

1. Generator injection pump' s standby power is leaking. Please monitor the situation and keep an eye on it until September 13, 2024. Note from the report facility is to inspect the pump on a monthly basis.2. Rooms 133 and 134 do not have signs indicating oxygen use. The following rooms also do not have oxygen use signs: 201, 204, 205, 206, 207, 208, 209, 219, and 221. Fixed during inspection.3. Oxygen Room: Please provide "Full" and "Empty" signs. Fixed durin.. Based on a record review, observations, inspection, and interviews, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13. The deficient practice affected all smoke compartments. The deficient practice could affect all smoke zones,120 of 120 residents, and an indeterminable number of staff and visitors.1. During the inspection, observations and interviews with the maintenance director rev.. Based on observation and staff interviews during the survey, it was determined that the facility failed to maintain hazard areas in accordance with NFPA 10. The deficient practice affected all smoke compartments. The deficient practice could affect 4 of 7 smoke zones,80 of 120 residents, and an indeterminable number of staff and visitors.1. During the inspection, observations and interviews with the maintenance director revealed that wall penetrati.. Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain exit signage in accordance with Life Safety Code Section 7.10.1.2.1 and Chapter 19. The deficient practice affected all smoke compartments. The deficient practice could affect all smoke zones,120 of 120 residents, and an indeterminable number of staff and visitors.During the inspection, observations and interviews with the maintenance director reveal.. Based on observation and staff interviews, it was determined that the facility failed to maintain wiring in accordance with NFPA 99 and NFPA 70. The deficient practice affected all smoke compartments. The deficient practice could affect 1 of 7 smoke zones,20 of 120 residents, and an indeterminable number of staff and visitors.During the inspection, observations and interviews with the maintenance director revealed burn marks around the outlet and cr.. Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96, (Chapter 12, Section 12.1.2.3.1) and cooking appliance restraint as required by NFPA 54, 9.6.1.2. The deficient practice affected all smoke compartments. The deficient practice could affect 1 of 7 smoke zones,20 of 120 residents, and an indeterminable number of staff and visitors.1. During the inspection, observations and i.. Based on observations and a review of records, it was determined that the facility did not maintain fire extinguishers in accordance with NFPA 10. The deficient practice affected all smoke compartments. The deficient practice could affect 1 of 7 smoke zones,20 of 120 residents, and an indeterminable number of staff and visitors.During the inspection, observations and interviews with the maintenance director revealed that the kitchen extinguisher is mou.. 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 June 3, 2025, for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This structure is a two (2) story, Type II (111) cons..

A recertification survey with complaint #CO36535, #CO39696, #CO39983 and #CO40077 was completed on 5/12/25 to 5/15/25. Four deficiencies were cited. An Emergency Preparedness survey was conducted from 5/12/25 to 5/15/25. No deficiencies were cited. Based on interviews and record review, the facility failed to ensure one (#45) of one residents reviewed for radiology and diagnostic services, received timely care out of 32 sample residents. Specifically, the facility failed to schedule and obtain magnetic resonance imaging (MRI - diagnostic imaging) in a timely manner for Resident #45.Findings include: I. Facility policy and procedureThe Diagnostic Services policy, revised on 9/24/24, was provided by the nursing home administrator (NHA) on 5/15/25 at 6:15 p.m. It revealed in pertinent part,"The facility will ensure that diagnostics services meet the needs of residents. The facility is responsible for the quality and timeliness of serv.. Based on observations, record review and interviews, the facility failed to act upon the pharmacist' s recommendations in a timely manner for two (#27 and #20) of five residents out of 32 sample residents.Specifically the facility failed to:-Ensure two medications which potentially contributed to falls for Resident #27 were discontinued, per the pharmacist and physician' s recommendations; and,-Ensure Resident #20' s serum sodium levels were obtained timely after the pharmacist recommended the laboratory work to be completed. Findings include:I. Facility policy and procedureThe Pharmacy Recommendations policy and procedure, revised 11/19/24, was provided by the nursing hom.. Based on observations, 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 (#57) of two residents reviewed for catheter care out of 32 sample residents.Specifically, the facility failed to:-Obtain physician' s orders for the use and care of Resident #57' s catheter; and, -Maintain documentation for Resident #57' s catheter care and maintenance.Findings include:I. Facility policy and procedureThe Indwelling Urinary Catheter (Foley) Management policy, revised 6/27/23, was provided by the nursing home administrator (NHA) on 5/15/25 at 6:18 p.m. It read in pe.. Based on observations, record review and interviews, the facility failed to store, prepare and distribute food in a sanitary manner in the main kitchen.Specifically, the facility failed to:-Ensure employees performed hand hygiene appropriately during meal service; and,-Ensure food was labeled, dated and disposed of timely.Findings include:I. Ensure employees performed hand hygiene appropriately during meal serviceA. Professional referenceThe Colorado Retail Food Regulations, (3/16/24) and retrieved on 5/20/25 read in pertinent part, "Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation, including working with e..

Based on observation and staff interview, it was determined that the facility failed to arrange and maintain exit signage in accordance with Life Safety Code NFPA 1011.Activity office needs UL listed exit sign | If photoluminescence sign is used must have light shining on itNFPA 101 7.9.2.5 Unit equipment and battery systems for emergency luminaires shall be listed to ANSI/UL 924, Standard for Emergency Lighting and Power Equipment.These deficiencies have the potential to affect occupants, who might include residents, staff, and visitors within this area of the smoke compartment. Deficient items were discussed with the Administrator and Maintenance director at the exit conference. 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 signage needed for stairwell delayed egress doorNFPA 101, 7.2.1.6.1.1 A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1/8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS or PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 30 SECONDS (if approved by the local fire department) (3)*An irreversible process shall release the lock in the direction of egress within 15 secondsThese d.. Based on observation it was determined the facility failed to maintain corridor doors in accordance with NFPA 101.1.Rated door to elevator room missing middle hinge creating a gap space within the rated doorNFPA 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 smoke and shall be constructed of materials such as the following:(1) 13/4 in. (44 mm) thick, solid-bonded core wood(2) Material that resists fire for a minimum of 20 minutesThese deficiencies have the potentia.. 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 not conducted under varied conditions | Closer than hour over 12 month of drillsNFPA 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 items were discussed with the administrator and maintenance director at the exit conference. 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 November 16, 2023 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."This structure is a two (2) story, Type II (111) construction. This original facility was constructed in 1986. There is a partial basement that is used for support services and there is no resident access. The facility is licensed for 120 beds and the census on the date of the survey was 56.The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet-p..

A recertification survey with complaint #CO29879 was completed on 10/23/23 to 10/2623. Four deficiencies were cited. An Emergency Preparedness survey was conducted from 10/23/23 to 10/26/23. No deficiencies were cited. Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable and at a safe and appetizing temperature. Specifically, the facility failed to ensure resident food was palatable in taste and texture. Findings include:I. Facility policy and procedureThe Resident Satisfaction with Food and Dining policy and procedure, revised 4/25/23, was provided by the nursing home administrator (NHA) on 10/26/23 at 12:00 p.m. It revealed in pertinent part, "The facility will have a process in place to monitor the quality of food and beverages delivered to the residents. Each resident received and the facility provides food prepared by methods that.. 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 disease and infection.Specifically the facility failed to:-Ensure resident rooms were cleaned and disinfected properly; and,-Ensure staff administered medications in a hygienic manner.Findings include:I. Failure to clean residents room appropriatelyA. Facility policy and procedureThe Daily Room Cleaning policy, revised 7/19/23, received from the nursing home administrator (NHA) on 10/26/23 at 1:22 p.m. It revealed in pertinent part, "the cleanliness of each res.. Based on observations and interviews, the facility failed to ensure all drugs and biologicals used in the facility were properly stored in one out of three medication carts.Specifically, the facility failed to ensure medication carts were locked when left unattended and medications were not left unattended.Findings include:I. Facility policy and procedureThe Storage and Expiration Dating of Medications, Biologics policy, revised 7/21/22, was received from the nursing home administrator (NHA) on 10/16/23 at 1:22 p.m. It revealed in pertinent part, "the policy sets forth the procedures relating to the storage and expiration of medications, biologics, syringes and needles. Facility should ens.. Based on observations, record review and interviews, the facility failed to ensure menus met the needs of residents and were followed for mechanically altered diets.Specifically, meal portion sizes were served incorrectly for resident with puree diet orders.Findings include:I. Facility policy and procedureThe Therapeutic Diets policy and procedure, revised 4/25/23, was provided by the nursing home administrator (NHA) on 10/26/23 at 12:00 p.m. It revealed in pertinent part, "Therapeutic diets will be provided as prescribed by the attending physician or per state guidelines. The intent of this is to ensure the residents receive and consume foods in the appropriate form and/or the appropria..