Life Care Center of Pueblo

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.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Resident Assessment and Care Planning Deficiencies

Plan the resident's discharge to meet the resident's goals and needs.

Quality of Life and Care Deficiencies

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

Services Deficiencies

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

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Emergency Preparedness Deficiencies

Conduct testing and exercise requirements.

Egress Deficiencies

Meet other general requirements.

Egress Deficiencies

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

Egress Deficiencies

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

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

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

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

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.

Nursing and Physician Services Deficiencies

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

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

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.

Quality of Life and Care Deficiencies

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

Administration Deficiencies

Have a plan that describes the process for conducting QAPI and QAA activities.

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

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

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

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

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

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

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.

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.

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.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Services Deficiencies

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

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

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.

Quality of Life and Care Deficiencies

Ensure that the facility has sufficient staff members who possess the competencies and skills to meet the behavioral health needs of residents.

Resident Rights Deficiencies

Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Resident Rights Deficiencies

Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights.

Resident Rights Deficiencies

Notify the resident or the resident’s representative in writing how long the nursing home will hold the resident’s bed in cases of transfer to a hospital or therapeutic leave.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

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.

Egress Deficiencies

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

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

A complaint survey, prompted by #CO37004, #CO37009 and #CO37010 was conducted on 8/5/24 to 8/7/24. Five deficiencies were cited. Based on record review and interviews the facility failed to ensure residents were treated with dignity and respect for three (#1, #12 and #9) of four residents out of 13 sample residents.Resident #1, who was non-weight bearing on his right leg due to a broken ankle required staff assistance to transfer from his wheelchair to and from the toilet. According to Resident #1, certified nurse aide (CNA) #1 was rude to him when he requested assistance with transferring to the toilet and told him he could use the bathroom himself. CNA #1 did assist the resident onto the toilet, however when Resident #1 requested assistance to transfer back to his wheelchair after using the bathroom, .. Based on record review and interviews, the facility failed to develop and implement an effective discharge plan for one (#3) of three residents reviewed for discharge planning out of 13 sample residents. Specifically the facility failed to assist Resident #3 in the development of a safe and appropriate discharge plan. Findings include:I. Facility policy and procedureThe Against Medical Advice (AMA) Discharges policy and procedure, August 2023, was provided by the nursing home administrator (NHA) on 8/7/24 at 2:30 p.m. It read in pertinent part, "If a resident wishes to be discharged prior to the completion of medical treatment or against the advice of the attending physician to a setting.. Based on record review and interviews, the facility failed to ensure residents had the right to be free from physical abuse for one (#3) of three residents reviewed for abuse out of 13 sample residents. Resident #3 was admitted to the facility on 1/24/24 with a diagnosis of constipation. On 6/5/24, in the early morning hours, Resident #3 called for assistance. The resident told the staff that she was constipated and needed assistance or she wanted to go to the hospital. Registered nurse (RN) #1 came to her room. Certified nurse aide (CNA) #5 assisted Resident #3 to roll over. RN #1 began to insert a suppository and felt a hard stool in the resident' s rectum. As RN #1 removed the .. Based on record review and interviews, the facility failed to have evidence that all alleged abuse were thoroughly investigated for one (#3) of three residents reviewed for abuse of 13 sample residents.Specifically, the facility failed to thoroughly investigate an allegation of abuse.Findings include:I. Facility policy and procedureThe Abuse and Neglect policy and procedure, dated August 2021, was provided by the nursing home administrator (NHA) on 8/6/24 at 9:11 a.m. It read in pertinent part, "The facility must develop and implement written policies and procedures to investigate any such allegations. Have evidence that all alleged allegations of abuse are thoroughly investigated."II. Resident #3A.. Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (#3) of three residents reviewed for quality of care out of 13 sample residents. Specifically the facility failed to:-Follow the physician' s standing orders for bowel management for Resident #3;-Document the bowel medications that were administered to Resident #3;-Document the nursing medication reassessment;-Document the nursing abdominal and peri-rectal assessment; and,-Document the digital fecal disimpaction (procedure of removing stool from the rectum with a finge..

A survey prompted by complaint #CO37226 was completed on 8/5/24 to 8/7/24. Two deficiencies were cited. Based on record review and interviews the facility failed to ensure residents were treated with dignity and respect for three (#1, #12 and #9) of four residents out of 13 sample residents.Resident #1, who was non-weight bearing on his right leg due to a broken ankle required staff assistance to transfer from his wheelchair to and from the toilet. According to Resident #1, certified nurse aide (CNA) #1 was rude to him when he requested assistance with transferring to the toilet and told him he could use the bathroom himself. CNA #1 did assist the resident onto the toilet, however when Resident #1 requested assistance to transfer back to his wheelchair after using the bathroom, CNA #1 entered the resident' s room and refused to assist him. CNA #1 informed the resident "we are not doing this again" and left the resident' s room without assisting him. Resident #1 said he had to remain on the toilet until another CNA responded to his call light and came to assist him from the toilet back to his wheelchair. Resident #1 said the experience made him feel humiliated.On another occasion, Resident #1 said CNA #1 approached him in the dining room and when he did not respond to her, she laughed at him and rudely said "What' s the matter with you, you don' t have a mouth now" and "That' s right, you' re mad at me." Resident #1 again said the experience with CNA #1 humiliate.. Based on record review and interviews, the facility failed to ensure residents had the right to be free from physical abuse for one (#3) of three residents reviewed for abuse out of 13 sample residents. Resident #3 was admitted to the facility on 1/24/24 with a diagnosis of constipation. On 6/5/24, in the early morning hours, Resident #3 called for assistance. The resident told the staff that she was constipated and needed assistance or she wanted to go to the hospital. Registered nurse (RN) #1 came to her room. Certified nurse aide (CNA) #5 assisted Resident #3 to roll over. RN #1 began to insert a suppository and felt a hard stool in the resident' s rectum. As RN #1 removed the stool from Resident #3' s rectum, the resident was crying and yelling in pain and asking RN #1 to stop. However, RN #1 continued to proceed with the removal of the stool, while the resident was crying in pain, which caused mental anguish, emotional distress and fear for Resident #3.Additionally, the facility failed to document any information related to Resident #3' s fecal impaction and the procedure that occurred in Resident #3' s electronic medical record (EMR). Findings include:I. Professional referencesAccording to Setya A, Mathew G, Cagir B. (2023). Fecal Impaction. National Institutes of Health, retrieved on 8/6/24 from https://www.ncbi.nlm.nih.gov/books/NBK448094..

STANDARD is not met as evidenced by: Based on observation and staff interview during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code Section 19.3.6.3. This deficient practice could affect all residents within the smoke compartments should the .. STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to arrange the exit access so that exits are readily accessible at all times in accordance with Life Safety Code 101 Section 19.2.2.2.4, 7.2.1.5.3. This deficient practice could affect all res.. STANDARD is not met as evidenced by: Based on record review during the survey, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.2 and 4.7. This deficient practice could affect residents when staff are not trained in the emergency actions required during unusual.. STANDARD is not met as evidenced by: During the review of the facility records, with the staff, documentation was not available to confirm that the facility had a kitchen-hood-exhaust-system inspection as required by NFPA 96, (Chapter 11, Section 11.2.1-11.6.1). This deficient practice could affect all residents, and staff should a fire occur d.. STANDARD is not met as evidenced by: Based on observation and staff interview during the survey, it was determined that the facility failed to maintain marking of means of egress in accordance with Life Safety Section 7.10. This deficient practice could affect all residents, staff and visitors in the area if code compliant exit signage is not provid.. STANDARD is not met as evidenced by: 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. This deficient practice could affect all residents, staff and visitors throughout the facility if an exit leading to .. STANDARD is not met as evidenced by: Based on record review and staff interview during the course of the survey it was determined that the facility failed to maintain emergency power systems in accordance with Section 9.1.3 of the Life Safety Code and the referenced NFPA 110, Standard for Emergency and Standby Power Systems Chapter 8 This d.. STANDARD is not met based on observation and staff interviews of the emergency lighting, the facility failed to maintain the battery-powered emergency lights accordance with 7.9.3 and 19.2.9.1. This deficient practice could affect all residents and staff throughout the facility in the event of the loss of primary power. This was evidenc.. STANDARD not met as evidenced by: Through record review and staff interview during the survey, the facility failed to inspect and test the fire alarm system per NFPA 72 and 2012 Life Safety Code 101. Failure to maintain and test the fire alarm system has the potential to harm all occupants, staff and visitor within the facility if the fire alar.. The Colorado Department of Public Safety conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments, (ID Prefix Tag # K 000), are informational only and a representation of the facility' s general characteristics. The facility is a one story wood frame structure, Type V (111) construction, without..