Life Care Center of Greeley

Based on observation and staff interviews during the survey, it was determined the facility failed to maintain fire barriers in accordance with NFPA 101, 8.3.1.2This was evidenced by the following:1. The ceiling repair in the boiler room has an improper patch for ceiling rating. Scab patching is not allowed on rated walls and ceilings.NFPA 101, Section 8.2.3.1 ASTM E 119, Standard Test Methods for Fire Tests of Building Construction and MaterialsNFPA 101, Section 8.3.1.2 Fire barriers shall comply with one of the following:(1) The fire barriers are continuous from outside wall to outside wall or from one fire barrier to another, or a combination thereof, including continuity through all concealed spaces, such as those found above a ceiling, including interstitial spaces.(2)The fire barriers are continuous from outside wall to an outside wall or from one fire barrier to another and from the floor to the bottom of the interstitial space, provided that the construction assembly forming the bottom of the interstitial space has a fire-resistance rating not less than that of the fire barrier.The fire barrier deficiency can potentially affect all residents, visitors, and staff within those smoke compartments.This deficiency was discussed during the exit conference. 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.This was evidenced by the following:1. The kitchen stove cooking equipment is missing wheel-docking blocks.NFPA 96, 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for maintenance and cleaning, provided the appliances are returned to the approved design location prior to cooking operations.NFPA 96, 12.1.2.3.1 An approved method shall be provided that will ensure the appliance is returned to an approved design location.NFPA 54, 9.6.1.2 Restraint. A restraining device installed in accordance with the connector and appliance manufacturer' s installation instructions shall limit the movement of appliances with casters.This deficient practice could affect all residents and staff should a fire occur and the suppression system fail to operate effectively due to the non-code-compliant positioning of cooking appliances.This deficiency was discussed during the exit conference. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and represent 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 August 1, 2024, for compliance with the National Fire Protection Association (NFPA 101) Life Safety Code (2012) Chapter 19, "Existing Health Care Occupancies."This structure is a one (1) story, Type V (111) wood frame construction with no basement. The facility was constructed in 1998. The facility is licensed for 124 beds, and the census on the survey date was 75.The facility is fully sprinkled and protected by National Fire Protection Association (NFPA) 13 automatic wet-pipe and dry-pipe fire sprinkler systems. The dry-pipe fire sprinkler system protects the attic spaces and front canopy.The survey results were discussed with the Maintenance Director and the Facility Administrator during the exit conference.

A licensure survey was completed on 7/10/24 to 7/16/24. One deficiency was cited. Based on observations, record review and interviews, the facility failed to ensure one (#67) of three residents reviewed for pressure-related skin conditions out of 32 sample residents received care consistent with professional standards of practice to prevent pressure ulcers from developing.Resident #67, who was at risk for developing pressure injuries due to paraplegia, weakness and the inability to move both legs, was admitted on 6/20/24. The facility provided a pressure reducing mattress and wheelchair pad upon admission. The resident was able to make small movements to reposition herself, however, the staff did not provide the resident with consistent repositioning per the resident' s needs..On 7/4/24, a wound was observed on the resident' s sacral area (bony area just above the tailbone). The nurse who observed the wound on 7/4/24 failed to notify the unit manager or the physician of the wound.On 7/11/24, the wound was again noted by a nurse and a specialty mattress was ordered for the resident (seven days after the initial identification of the wound). On 7/12/24 and 7/15/24, the facility' s nurse practitioner (NP) and the resident' s physician documented the resident had what appeared to be an early stage wound to her coccyx which would continue to be monitored, however, neither the NP nor the physician observed the resident' s wound.On 7/15/24 (11 days after the initial identification of the wound) Resident #67' s wound was observed by the wound team for the first time. The wound was classified as a Stage 3 pressure injury to the sacrum and wound care orders for treatment of the wound and nutritional supplement orders were obtained from the physician (11 days after the initial identification of the wound).Due to the facility' s failures to implement timely interventions and obtain wound care orders after the initial identification of the wound, Resident #67 developed a Stage 3 pressure wound to her sacrum.The findings include:I. Professional referenceAccording to the National Pressure Injury Advisory Panel, European Pressure Injury A..

A recertification survey with #CO34612 was conducted on 7/10/24 to 7/16/24. Four deficiencies were cited. An Emergency Preparedness survey was conducted from 7/10/24 to 7/16/24. No deficiencies were cited. Based on observations, record review and interviews, the facility failed to ensure one (#67) of three residents reviewed for pressure-related skin conditions out of 32 sample residents received care consistent with professional standards of practice to prevent pressure ulcers from developing.Resident #67, who was at risk for developing pressure injuries due to paraplegia, weakness and the inability to move both legs, was admitted on 6/20/24. The facility provided a pressure reducing mattress and wheelchair pad upon admission. The resident was able to make small movements to reposition herself, however, the staff did not provide the resident with consistent repositioning per th.. Based on record review and interviews, the facility failed to ensure one (#6) of nine residents reviewed for accidents out of 32 sample residents remained as free from accident hazards as possible.The facility failed to prevent Resident #6' s fall from a mechanical (hoyer) lift while transferring her. On 4/29/24 two certified nurse aides (CNA) #1 and #3 attempted to transfer Resident #6 from her bed to her wheelchair. During the transfer, Resident #6 fell from the sling attached to the mechanical lift' s sling bar (a bar with two safety latches on each end the sling attaches to), onto the floor and hit her head on the mechanical lift. As a result, Resident #6 sustained head trauma (laceration) to the back.. Based on record review and interviews, the facility failed to provide services in accordance with currently accepted professional principles for one resident (#44) of three residents reviewed for blood pressure management out of 32 sample residents.Specifically, the facility failed to assess and document Resident #44' s blood pressure consistently prior to administering blood pressure medications. Findings include:I. Facility policy and procedure The Oral Medication Administration policy, revised 9/22/21, was provided by the nursing home administrator (NHA) on 7/17/24. It read in pertinent part, "The facility will provide oral medication administration in accordance with professional sta.. III. Failure to follow proper infection control procedures during wound careA. ObservationsOn 7/15/24 at 10:50 a.m. registered nurse (RN) #1 and RN #3 were observed providing wound care to Resident #21 in his room. Resident #21 was seated in his chair while wound care was provided to his right lower leg. Resident #21' s wound care supply container was set on his bedside table next to his chair.At 10:53 a.m. RN #3 began to unwrap the top of Resident #21' s ace bandage from his right calf. RN #3 reached into her right pants pocket and removed a pair of medical grade bandage scissors with her hand. -Without cleaning or sanitizing the scissors, RN #3 cut the top of Resident #21' s wound bandag..