Pine Ridge Rehabilitation and Healthcare Center

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.

Infection Control Deficiencies

Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

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.

Pharmacy Service Deficiencies

Ensure each resident’s drug regimen must be free from unnecessary drugs.

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.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

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.

Resident Assessment and Care Planning Deficiencies

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

Nutrition and Dietary Deficiencies

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

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.

Smoke Deficiencies

Have an enclosure around a vertical opening shaft.

Quality of Life and Care Deficiencies

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

Nutrition and Dietary Deficiencies

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

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Resident Rights Deficiencies

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

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.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Respond appropriately to all alleged violations.

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.

Based on observation, it was determined that the facility failed to arrange and maintain the means of egress in accordance with Life Safety Code Section 7.2.1.6.1.1(4) or 7.2.1.5.10.2.1. Delayed egress hardware, the door did not have proper signage posted2. One motion locks need to be installed on doors for CNA room, Physical Therapy, BOM office, beauty room.7.2.1.6.1.1(4)A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1/8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress:PUSH UNTIL ALARM SOUNDSDOOR CAN BE OPENED IN 15/30 SECONDS7.2.1.5.10.2 The releasing mechanism shall open the door leaf with not more than one releasing operation, unless otherwise specified in 7.2.1.5.10.3, 7.2.1.5.10.4, or 7.2.1.5.10.6.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient item(s) were discussed with the maintenance team at the exit conference. Based on observation, it was determined that the facility failed to arrange and maintain the vertical openings in accordance with Life Safety Code Section 19.3.11. vertical opening to crawl space from portable AC unit exhaust duct work in Med room and activities room.19.3.1 Protection of Vertical Openings.Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the smoke compartment. Deficient item(s) were discussed with the maintenance team at the exit conference. The Colorado Department of Public Health and Environment conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a).Life safety features, which met the requirements for new construction at the time of licensure or certification, shall be maintained and not diminished.The initial comments (ID Prefix Tag K-0000) are informational only, and are a representation of the facility' s general characteristics.The facility is a type V (000) single-story structure with a full crawl space building, constructed November 26, 1997, with a connected eight room addition type V(111) constructed, August 11, 2005. The facility incorporates a distinct, two-hour, fire-rated separation from the rehabilitation area. The facility contains an automatic fire suppression system classified as fully sprinklered. The facility is licensed for 60 beds with a census on the day of survey of 44.The facility was surveyed, on January 31st 2024, for compliance to fire safety requirements using the National Fire Protection Association (NFPA) 101-Life Safety Code, 2012 Edition; under Chapter 19, Existing Health Care Occupancies; the NFPA 99- Health Care Facilities code, and all referenced standards. The facility will meet these requirements when the following deficiencies are corrected.The deficiencies were discussed with the Maintenance Supervisor during the wal..

A recertification survey was conducted from 1/7/24 to 1/10/24. Four deficiencies were cited. An Emergency Preparedness survey was conducted from 1/7/24 to 1/10/24. No deficiencies were cited. Based on observation, record review and interviews the facility failed to ensure four (#11, #12, #21 and #46) out of 18 sample residents received treatment and care in accordance with professional standards of practice.Specifically, the facility failed to ensure blood pressure medication was ordered with administration parameters for Residents #11, #12, #21 and #46.Findings include:I. Professional reference According to Khashayar, F., Arif, J. (2022). Beta Blockers. Stat Pearls. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK532906 retrieved on 1/19/24. "Beta receptors are found all over the body and induce a broad range of physiologic effects. The blockade of these recepto.. Based on observations and interviews the facility failed to ensure one of one medication refrigerators stored narcotic medications in accordance with accepted professional standards and that only licensed staff had access to resident-prescribed medications.Specifically, the facility failed to ensure controlled medications were in a locked storage container that was permanently secured to the refrigerator.Findings include: I. Facility policy and procedure The Storage of Medications policy and procedure, revised February 2023, was provided by the director of nursing (DON) on 1/9/24 at 1:00 p.m. It read in pertinent part, "Controlled substances (listed as Schedule 11-V of the Compr.. Based on observations and staff interviews, the facility failed to ensure the dietary department followed safe practices to prevent the potential contamination of food and spread of food-borne illness. Specifically, the facility failed to: -Ensure reheated food reached the appropriate temperature; and, -Ensure beard nets were worn in the kitchen. Findings include: I. Reheated food A. Professional reference The Colorado Department of Public Health and Environment (2019) The Colorado Retail Food Establishment Rules and Regulations, retrieved from: https://www.colorado.gov/pacific/sites/default/files/DEHS_RetailFd_6CCR10102_RFFC_EffJan2019.pdf. "Reheated i.. Based on record review and interviews, the facility failed to ensure two (#44 and #16) of seven residents reviewed for unnecessary medications out of 18 sample residents were free from unnecessary medications. Specifically, the facility failed to:-Ensure Resident # 44 was assessed by the interdisciplinary team (IDT) prior to implementation of a psychotropic medication treatment and appropriate non-pharmacological interventions were initiated;-Ensure Resident #16' s psychoactive medication, an antidepressant, was not increased without evidence and documentation of change of behaviors or attempts of non-pharmacological interventions, and,-Resident # 16' s hours of sleep were docu..