Life Care Center of Littleton

Quality of Life and Care Deficiencies

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

Egress Deficiencies

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

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

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

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Nutrition and Dietary Deficiencies

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

Smoke Deficiencies

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

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Nutrition and Dietary Deficiencies

Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Resident Assessment and Care Planning Deficiencies

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

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

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections.

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

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.

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.

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Services Deficiencies

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

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

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.

Quality of Life and Care Deficiencies

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

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Emergency Preparedness Deficiencies

List the names and contact information of those in the facility.

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

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.

Environmental Deficiencies

Make sure there is a pest control program to prevent/deal with mice, insects, or other pests.

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.

Egress Deficiencies

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

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Resident Rights Deficiencies

Ensure that residents are fully informed and understand their health status, care and treatments.

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.

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. This was evidenced by the following:1. A semi-annual fire alarm inspection report was not provided.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 requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.NFPA 72, 14.. Based on observation and record review, it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 17 and NFPA 96. This was evidenced by the following:1. A report from an inspection performed by Diamond Fire on 9/6/24 stated that a hydro service is due on the kitchen hood system located in the Rehab Kitchen. 2. Commercial cooking equipment located under the kitchen hood suppression system does not have wheel chalks installed.NFPA 17, 11.5.1* The following parts of dry chemical extinguishing systems shall be subje.. Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.3.5.1. This was evidenced by the following:1. Unprotected fire barrier penetrations were observed throughout the facility. These areas included the Electrical Room (Rehab), Vacuum Room, Oxygen Room, and other various locations throughout the facility.NFPA 101, 8.3.5.1* Firestop Systems and Devices Required.Penetrations for cables, cable trays, conduits, pipes, tubes, combustion vents and exhaust ven.. Based on observation and staff interviews during the record review, it was determined that the facility failed to maintain emergency lighting in accordance with Life Safety Code NFPA 101 7.9.3 and 19.2.9.1. This was evidenced by the following:1. No documentation was available during the record review of the facility required Exit lights testing of the battery-powered emergency lighting system at 30-day intervals for not less than 30 seconds, as well as annually for not less than 1 ½ hours.NFPA 101 7.9.2.1* Emergency illumination shall be provided for a minimum of one and 1/.. Based on observation during the course of the survey it was determined the facility failed to maintain a hazardous area in accordance with NFPA 55. This was evidenced by the following:1. The oxygen transfill room does not have exhaust ventilation within 12 inches of the floor.NFPA 556.15.7 Inlets to the Exhaust System.6.15.7.1 The exhaust ventilation system design shall take into account the density of the potential gases released.6.15.7.2 For gases that are heavier than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the floor.6.15.7.3 For gases tha.. Based on observation, it was determined that the facility failed to maintain Fire/smoke doors in accordance with Life Safety Code NFPA 101 8.3.3.1 and 19.2.2.2.10.2. This was evidenced by the following:1. The fire door located near the MDS Office does not properly latch.NFPA 101 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and their accompanying hardware, including all frames, closing devices, anchorage, and sills in accordance with the requireme.. 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 one story, Type II (000) construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression system and is classified as Fully Sprinklered. The facility was constructed in 1998 and is licensed for 120 beds. This re-certification survey conducted on November 19, 2024..

A recertification survey with complaint #CO37025 and #CO37951 was completed on 11/4/24 to 11/7/24. Fourteen deficiencies were cited. An Emergency Preparedness survey was conducted from 11/4/24 to 11/7/24. No deficiencies were cited. Based on interviews and record review, the facility failed to ensure three (#89, #59 and #67) of three residents out of 41 sample residents received adequate supervision to prevent accidents.Resident #89, who had a history of falls, was.. Based on observations and interviews, the facility failed to ensure that all drugs and biologicals were properly stored and labeled according to professional standards of practice in two of six medication carts.Specifically, the facility fai.. 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 diseases and infe.. Based on observations, record review and interviews the facility failed to ensure one (#66) of one resident with limited range of motion received the appropriate treatment and services out of 41 sample residents. Specifically, the .. Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen and three of three nourishment rooms.Specifically, the facility f.. Based on observations, record review and interviews, the facility failed to honor resident choices for one (#201) of one resident out of 41 sample residents.Specifically, the facility failed to ensure Resident #201' s rehabilitation therapy w.. Based on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and c.. Based on observations, record review and interviews, the facility failed to use a person-centered approach when determining the use of a grab bar/bed rail for one (#59) of one resident reviewed for grab bars/bed rails out of 41 sa.. Based on observations, record review, and interviews the facility failed to ensure residents with percutaneous endoscopic gastrostomy (PEG) tubes received treatment and services to prevent complications for one (#21) of one r.. Based on 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 (#205) of one resident reviewed for cathet.. Based on record review and interviews, the facility failed to ensure two (#66 and #56) of five out of 41 sample residents were as free from unnecessary medications as possible. Specifically, the facility failed to:-Ensure consent .. Based on record review and interviews, the facility failed to implement an antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one (#69) of one resident reviewed for an.. Based on record review and interviews, the facility failed to meet all the requirements for the provision of hospice care for one (#38) of one resident reviewed for hospice services out of 41 sample residents. Specifically, the facility f.. Based on record review and staff interviews, the facility failed to incorporate the recommendations from the PASRR (preadmission screening and resident review) Level II determination and evaluation report into the assessment, care ..

A survey prompted by complaint #CO38392 was completed on 11/4/24 to 11/7/24. One deficiency was cited. Based on interviews and record review, the facility failed to ensure three (#89, #59 and #67) of three residents out of 40 sample residents received adequate supervision to prevent accidents.Resident #89, who had a history of falls, was admitted to the facility on 11/15/23 after sustaining multiple pelvic fractures related to a fall sustained at home. The facility initiated a fall care plan on 11/15/23 which identified the resident was at risk for falls due to a gait imbalance (unsteady gait), poor cognition and a history of falls. The care plan documented generalized fall interventions which were not specific to the resident. The facility completed an initial fall risk assessment on 11/15/23 which was not consistent with the resident' s care plan and inaccurately documented the resident had no history of falls, was independent and ambulated without problems using an assistive device. On 11/16/23, one day after the resident' s admission to the facility, nursing documentation identified Resident #89 had poor safety awareness and did not use her call light for assistance. However, the facility failed to implement further person-centered fall interventions for the resident.Resident #89 sustained unwitnessed falls without injury on 12/16/23 and 2/4/24. The facility failed to implement new resident-specific fall interventions after either of the falls.On 7/17/24, Resident #89 sustained a third fall that resulted in the resident sustaining a sternal contusion (bruising of the flat bone in the center of the chest) and three left-sided rib fractures which required hospitalization in the intensive care unit. The facility implemented a fall intervention for a "call, don' t fall" sign to be hung in the resident' s room. However, per documentation, the resident had already been identified to not use her call light to call for assistance and the facility did not identify further interventions.On 8/5/24 Resident #89 sustained a fourth fall that resulted in a laceration to her forehead which required a transfer to the hospital for staples to the laceration. The hospital identified the resident had additi..

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention' s (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 04/01/2024 and 04/07/2024, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.