Littleton Care and Rehabilitation Center

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 Rights Deficiencies

Honor the resident's right to organize and participate in resident/family groups in the facility.

Nursing and Physician Services Deficiencies

Post nurse staffing information every day.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

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.

Nutrition and Dietary Deficiencies

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

A survey prompted by #CO37546 and #CO37552 was conducted 10/2/24 to 10/3/24. Three deficiencies were cited. Based on observations, record review and interviews, the facility failed to ensure prompt action was taken upon the filing of a grievance of a group. Specifically, the facility failed to follow-up with concerns that were brought up by the group of residents during the resident council meetings regarding resident care and life in the facility. Findings include: I. Facility policyThe Grievance Policy, dated 10/3/24, was provided by the social services consultant (SSC) on 10/3/24 at 11:47 a.m. It read in pertinent part, "To address resident concerns without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their facility stay. To make prompt efforts to resolve grievances the resident may have."The Grievance Official is responsible for overseeing the grievance process, receiving and tracking grievances; leading any necessary investigations by the facil.. Based on observations, record reviews, and interviews, the facility failed to ensure staffing information was posted in a prominent place, readily accessible to residents and visitors. Specifically, the facility failed to:-Ensure nurse staffing data was posted on a consistent daily basis;-Ensure when nurse staffing data was posted, that it was posted in a prominent location, readily accessible to residents and visitors; and,-Ensure records of nurse staffing data were retained for 18 months.Findings include:I. ObservationsObservations in the facility on 10/2/24 at 9:55 a.m. revealed that the nurse staffing hours were not posted for the day.Observations in the facility on 10/3/24 at 10:03 a.m. revealed the nurse staffing hours were posted for 10/3/24, however, they were posted behind the main nurse' s station and were not easily accessible to residents and visitors.II. Staff interviewsThe facility' s scheduler was interviewed on 10/3/24 at 11:35 a.m. The scheduler said she was responsible for scheduling the nursing staff. She said she was resp.. Based on record review and interviews, the facility failed to ensure two (#1 and #5) 11 residents out of 12 sample residents were kept free from abuse.Resident #1, who had limited mobility and required staff assistance with bed mobility and transfers due to a recent hip surgery, was admitted to the facility on 7/21/24. On the night of 7/21/24, Resident #1 used her call light to request staff assistance with being repositioned in bed. The resident later used her call light to request staff assistance with going to the bathroom. Both times, when staff had not responded to the resident' s call light in over one hour, the resident called her legal representative. Both times, the resident' s representative called the facility and staff eventually answered Resident #1' s call light.Early in the morning on 7/22/24, Resident #1 again called her representative. The resident was crying and scared and wanted to leave the facility. Resident #1 reported that registered nurse (RN) #1 had come into her room, got close to her face and yelled ..

A survey prompted by complaint #CO37988 was completed on 10/2/24 to 10/3/24. One deficiency was cited. Based on record review and interviews, the facility failed to ensure two (#1 and #5) 11 residents out of 12 sample residents were kept free from abuse.Resident #1, who had limited mobility and required staff assistance with bed mobility and transfers due to a recent hip surgery, was admitted to the facility on 7/21/24. On the night of 7/21/24, Resident #1 used her call light to request staff assistance with being repositioned in bed. The resident later used her call light to request staff assistance with going to the bathroom. Both times, when staff had not responded to the resident' s call light in over one hour, the resident called her legal representative. Both times, the resident' s representative called the facility and staff eventually answered Resident #1' s call light.Early in the morning on 7/22/24, Resident #1 again called her representative. The resident was crying and scared and wanted to leave the facility. Resident #1 reported that registered nurse (RN) #1 had come into her room, got close to her face and yelled at her to stop using her call light. According to Resident #1, RN #1 told her if she did not stop using her call light, staff would not come to assist her. Resident #1' s representative arrived at the facility after receiving the phone call and removed Resident #1 from the facility due to the resident crying hysterically, being scared and not wanting to remain in the facility. The resident' s representative reported the incident to the local police department on 7/22/24.Certified nurse aide (CNA) #1, who witnessed the incident between RN #1 and Resident #1, wrote a statement on 7/22/24 which documented RN #1 had spoken sternly to the resident and told her to stop using her call light and nobody was going to answer the call light. The facility completed a grievance related to the allegation but failed to investigate the incident until 9/12/24, over one month later, when the facility was alerted by the state board of nursing that RN #1' s nursing license was being investigated for an allegation of abuse. The facility failed to conduct a complete investigation of t..

Based on a record review it was determined that the fire alarm inspection was not completed in accordance with the Life Safety Code Section 9.6 and NFPA 72.Fire Alarm | Devices on Integrity Fire Safety Services report do not match devices in facility | Not provided an accurate inspection for the facility 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- 14.4.2.2* Systems and associated equipment shall be tested according to Table 14.4.2.2. (15). Alarm notification appliances (a) Audible: Test shall be performed in accordance with the manufacturer ' s published instructions. Appliance locations shall be verified to be per approved layout, and it shall be confirmed that no floor plan changes affect the approved layout. It shall be verified that the candela rating marking agrees with the approved drawing. It shall be confirmed that each appliance flashes..These deficiencies have 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 person at the exit conference. 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).The facility is one-story, Type V (III) wood framed structure with a basement with an interior exit to grade level used only for support services. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic wet and dry fire suppression systems and is classified as Fully Sprinklered. The facility was constructed in 1960 and is licensed for 35 beds. This re-certification survey conducted on February 6, 2024, was for compliance with the NFPA 101, Life Safety Code (2012 edition) Chapter 19, "Existing Health Care Occupancies;" NFPA 99, Health Care Facilities Code (2012 edition); and all referenced standards. The facility will meet these requirements when all deficiencies are corrected. The deficiencies cited were discussed with the Executive Director and Plant Director during the exit conference conducted at the end on-site survey.