Pikes Peak Post Acute

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.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

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.

Nursing and Physician Services Deficiencies

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

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

Resident Rights Deficiencies

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

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.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Assist a resident in gaining access to vision and hearing services.

Quality of Life and Care Deficiencies

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

Environmental Deficiencies

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.

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.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

Quality of Life and Care Deficiencies

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

Resident Assessment and Care Planning Deficiencies

Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.

Resident Rights Deficiencies

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

Resident Rights Deficiencies

Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made.

*** CITATION TEXT NOT FOUND *** A document revisit was completed with all deficiencies being corrected. No other deficiencies were cited and no response is needed.

All observations were corrected during survey: Extension cord in use Room 406, Heater (not plugged in) in the dining room, Multiple refrigerators plugged into power strips, Fresh air vent to boiler room blocked. Based on observation and staff interview during the survey, it was determined that the facility failed to maintain the kitchen cooking appliance locations in accordance with National Fire Protection Association (NFPA) Standard 96. This was evidenced by the following:1.The stove tether needs to be connected to the wall and the appliance.NFPA 96, 12... Based on observation and staff interviews during the course of the survey, it was determined that the facility failed to maintain corridor doors in accordance with the Life Safety Code NFPA 1011.Kitchen fire door not closing from all positions.NFPA 101, 19.3.6.3.1 19.3.6.3.1* Doors protecting corridor openings in other than required enclosures of ve.. Based on observation and staff interviews, 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. 1.100 Hallway 15-second delay egress door non-compliant. Door did not function under normal conditions. Door tested and dropped with fire alarm. NFPA 1.. Based on observations and records review, it was determined that the facility failed to maintain smoke barrier protecton in accordance with NFPA 101.1.Ceiling penetration in the main janitor closet.2.Penetrations in the basement storage room need to be sealed.NFPA 101, Section 8.5.1, in part, smoke barriers shall be provided to subdi.. Based on observations and records review, it was determined that the facility failed to maintain the automatic sprinkler system in accordance with National Fire Protection Association NFPA 25 and NFPA 1011.North dining sprinkler head painted. Crooked sprinkler head. Open penetration next to the sprinkler.2.Soiled utility room dirty head.3.300 .. Based on record review and staff interviews during 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 8.1.Generator Missing Reports from June 20248.4.1* EPS.. Based on the record review, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.6. 1.Fire drills closer than an hour apart, not at varied times.NFPA 101, 19.7.1.6 Drills shall be conducted quarterly on each shift to familiarize facility personnel (nurses, interns, maintenance engineers, .. This survey was conducted in accordance with the Federal Register at Section 42 CFR Part 483.70(a).The Initial Comments (ID Prefix Tag K0000) are informational only and are a representation of the facility' s general characteristics. The building is a one story wood framed structure, Type V (111) with a partial basement. The .. Through observation during the survey, it was determined that the facility failed to meet the exit signage requirements in accordance with NFPA 101, 19.2.10.1.1. Kitchen needs listed exit signage.2. Add listed exit signage in the kitchen freezer area.3. 90 min report needs clarification on tested only two listed as tested.Life Safety Co..

A licensure survey was completed on 1/27/25 to 1/30/25. Two deficiencies were cited. Based on observations, record review and interviews, the facility failed to meet the 90 percent (%) staff vaccination rate for the influenza season. Specifically, the facility failed to accurately maintain proof of employees' annual influenza immunizations or medical exemptions to ensure the 90% staff vaccination rate for the current influenza season was met. Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC) Interim Guidance for Influenza Outbreak Management in Long-Term Care and Post-Acute Care Facilities (9/17/24), retrieved on 2/4/25 from, https://www.cdc.gov/flu/hcp/infection-control/ltc-facility-guidance.html, "CDC and the Advisory Committee on Immunization Practices (ACIP) recommend that all United States (U.S.) healthcare personnel get vaccinated annually against influenza. Healthcare personnel who get vaccinated may help to reduce transmission of influenza, staff illness and absenteeism and influenza-related illness and death, especially among people at increased risk for severe influenza complications."II. Facility policy and procedureThe Influenza Vaccine policy, revised March 2022, was provided by the director of nursing (DON) on 1/27/25 at 4:50 p.m. It read in pertinent part, "If an employee refuses the vaccine for any reason their names will be maintained by the infection pr.. Based on record review and interviews, the facility failed to ensure two (#4 and #155) of two residents out of 53 sample residents met all the requirements for placement on the secure locked unit. Specially, the facility failed to ensure Resident #4 and Resident #155, residing on the secured locked unit, had all requirements met for placement to the secure unit, to include: an initial evaluation for placement demonstrating the appropriateness for placement or documentation of the least restrictive alternatives which had been unsuccessful. Findings include: I. Resident #4A. Resident statusResident #4, age greater than 65, was admitted on 8/22/23. According to the January 2025 computerized physician orders (CPO), diagnoses included unspecified dementia.The 11/25/24 facility assessment revealed the resident had severe cognitive impairments. The resident could not complete the cognitive assessment therefore a staff assessment was completed. The staff assessment revealed the resident had short and long term memory deficits, impaired decision making and was only oriented to herself. The assessment documented the resident did not have behaviors of wandering.B. Record reviewReview of Resident #4' s psychosocial care plan, initiated on 9/5/24, revealed the resident had cognitive loss related to dementia and had behaviors of poor safety awareness and..