Southeast Colorado Hospital Ltc

Quality of Life and Care Deficiencies

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

Emergency Preparedness Deficiencies

Include a process for Emergency Preparedness collaboration.

Emergency Preparedness Deficiencies

Create arrangements with other facilities to receive patients.

Emergency Preparedness Deficiencies

Establish roles under a Waiver declared by secretary.

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Smoke Deficiencies

Provide properly protected cooking facilities.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Reasonably accommodate the needs and preferences of each resident.

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.

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.

Nutrition and Dietary Deficiencies

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

Construction Deficiencies

Install a two-hour-resistant firewall separation.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Have power receptacles that are properly grounded.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure gas and vacuum systems are inspected and tested as part of a maintenance program.

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.

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.

Resident Assessment and Care Planning Deficiencies

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

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

Egress Deficiencies

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

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Quality of Life and Care Deficiencies

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

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

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Services Deficiencies

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

A survey prompted by Incident #39846 was conducted on 4/21/25 to 4/22/25. One deficiency was cited. Based on record review and interviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (#1) of three residents reviewed for accidents out of three sample residents.Specifically, the facility failed to:-Ensure Resident #1 had an individualized care plan with person-centered interventions to prevent elopement; and,-Ensure Resident #1 was provided with the supervision necessary to prevent an elopement. Findings include:I. Facility policy and procedureThe Elopement and Wandering policy and procedure, revised June 2019, was provided by the nursing home administrator (NHA) on 4/22/25 at 3:05 p.m. It read in pertinent part, "The facility will strive to prevent unsafe wandering while maintaining the least restrictive environment for residents who are at risk for elopement."Procedure:-Staff will identify residents who are risk for harm because of unsafe wandering;-Staff will assess at-risk residents for potentially correctable risk factors related to unsafe wandering;-The resident' s care plan will indicate the resident is at risk for elopement;-Interventions to maintain safety will be included in residents' care plans;-Staff will document circumstances related to unsafe actions, including wandering by a resident;-Staff will institute a monitoring plan, as indicated for residents who are assessed to have a high risk of elopement or other unsafe behavior;-A Potential Elopement Risk Assessment will be completed for the resident;-If a resident residing in the long-term care side of the building is at risk of leaving the facility the resident will be taken to the Alzheimer' s unit for safety; and,-Staff will notify the administrator and director of nursing (DON) immediately and will institute appropriate measures for any resident who is discovered to be missing from the unit or facility."II. Resident #1A. Resident statusResident #1, age greater than 65, was admitted on 10/3/24. According to the April 2025 computerized physician orders (CPO), diagnoses included traumatic brain injury, post-traumatic he..

STANDARD is not met as evidenced by the following: During the review of the facility records with the staff, documentation was unavailable to confirm that the facility had a kitchen-hood-exhaust system cleaned as required by NFPA 96 (Chapter 11, Section 11.6.1). This deficient practice could affect all residents and staff should a fire occur due to failure to exhaust system shall be cleaned by a properly trained, qualified, and certified person(s).The Hood system accumulated significant grease build-up just three months after its last cleaning. It is required that systems serving high-volume cooking operations be cleaned quarterly.NFPA 96, Chapter 11, Section 11.6.1 Upon inspection, if the exhaust system is found to be contaminated with deposits from grease-laden vapors, the contaminated portions of the exhaust system shall be cleaned by a properly trained, qualified, and certified person(s) acceptable to the authority having jurisdiction.The Director of Maintenance acknowledged the condition of the grease build-up during a facility tour. STANDARD was not met, as evidenced by observation and staff interviews during the survey. It was determined that the facility failed to maintain sprinkler-protected hazardous areas per 212 Life Safety Code 101 Section 19.3.2.1. This deficient practice could affect all residents and staff in the main smoke compartment, including the beauty shop, should there be smoke and heat transfer between the hazardous area and other portions of the building. This was evidenced by the following.The beauty shop is over 50 square feet and contains storage for flammable and combustible beauty supplies, making it a hazardous area. Additionally, the door lacks a required self-closing device.2012 Life Safety Code -8.7.1.3 Doors in barriers required to have a fire-resistance rating shall have a minimum 3?4 -hour fire protection rating and shall be self-closing or automatic-closing.The Director of Maintenance acknowledged the area enclosures and door condition during a facility tour. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a). This facility, licensed for 23 beds on the date of this survey, is housed in a structure containing the Hospital, a Long-Term Care facility, and a secured unit. This structure one-story, composed of Type II (111) construction, has a fully sprinklered partial basement containing rooms that are utilized for storage, conferences and training, and physical therapy. The Hospital is separated from the Long Term Care facility and its adjacent secured unit by a two-hour fire separation. The Hospital facility, as well as the abutting facilities, are protected throughout by an automatic, National Fire Protection Association (NFPA), Type 13, fire suppression system. This survey, conducted December 3, 2024, inspected for compliance to Chapter 19, for Existing Health Care Occupancies, in the 2012 edition of the NFPA 101, the Life Safety Code. An exit conference with the Maintenance Director, and maintenance staff at conclusion of the survey.

A recertification survey was conducted from 11/18/24 to 11/21/24. Five deficiencies were cited. An Emergency Preparedness survey was conducted from 11/18/24 to 11/21/24. Three deficiencies were cited. Based on interviews and record review, the facility failed to ensure one (#18) of one resident out of 22 sample residents was kept free from abuse.Specifically, the facility failed to identify a pattern of concerns regarding the care provided by certified nurse aide (CNA) #1 in order to prevent an incident of verbal abuse by CNA #1 toward Resident .. Based on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in one of two medication carts and two of two medication storage rooms.Specifically, the facility failed to: -Ensure expired medications were removed from the medication car.. Based on observations and interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infection.Specifically, the facility failed to:-Ensure residents were offere.. Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain proper nutrition and personal hygiene for three (#4 and #21) of three residents reviewed out of 22 sample residents. Specifically, the facility failed to:-Pro.. Based on observations, record review and interviews, the facility failed to ensure the resident' s right to receive services in the facility with reasonable accommodation of the resident' s needs and preferences for two (#20 and #13) of five residents reviewed for accommodation of needs out of 22 sample residents. Specifically, the facility failed to .. Based on record review and interviews, the facility failed to develop and implement emergency preparedness (EP) policies and procedures based on the emergency preparedness plan and communication plan to include pre-arranged transfer agreements, in compliance with Federal, State and local laws that were reviewed and those agreements wer.. Based on record review and interviews, the facility failed to have a complete emergency preparedness and emergency communication plan to include a policy and procedure that addressed the role of the facility if a Section 1135 waiver of the Social Security Act (SSA), temporarily modifying some program requirements, was declared by the Secretary. .. Based on record review and staff interviews, the facility failed to develop and maintain an emergency preparedness (EP) plan that included a process for cooperation and collaboration with local, tribal, regional, State and Federal emergency preparedness officials efforts to maintain an integrated response during a disaster or emergency. S..