Trinidad Rehabilitation and Healthcare Center

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

Resident Assessment and Care Planning Deficiencies

Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.

Nutrition and Dietary Deficiencies

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

Emergency Preparedness Deficiencies

Establish methods for sharing information.

Nursing and Physician Services Deficiencies

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

Resident Rights Deficiencies

Allow resident to participate in the development and implementation of his or her person-centered plan of care.

Resident Rights Deficiencies

Allow residents to self-administer drugs if determined clinically appropriate.

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

Quality of Life and Care Deficiencies

Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.

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.

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.

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.

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.

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

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Nursing and Physician Services Deficiencies

Designate a physician to serve as medical director responsible for implementation of resident care policies and coordination of medical care in the facility.

Administration Deficiencies

Have an agreement with at least one or more hospitals certified by Medicare or Medicaid to make sure residents can be moved quickly to the hospital when they need medical care.

Administration Deficiencies

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

Emergency Preparedness Deficiencies

Establish policies and procedures for volunteers.

Resident Rights Deficiencies

Honor the resident's right to manage his or her financial affairs.

Resident Rights Deficiencies

Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

Quality of Life and Care Deficiencies

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

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Resident Rights Deficiencies

Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive.

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.

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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

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.

Nursing and Physician Services Deficiencies

Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.

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

Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.

Nutrition and Dietary Deficiencies

Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.

Resident Rights Deficiencies

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

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

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

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

Based on a record review, it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code Section 9.6 and NFPA 72.1. Annual Fire Alarm report states "Semi-Annual Visual Inspection Only"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, Na.. Based on documentation review, it was determined that the facility did not maintain proper electrical practices in accordance with NFPA 99 Health Care Facilities Code (2012). This was evidenced by:No written record of the continuity of the grounding circuit, polarity of hot and neutral connections, and retention force of the grounding blade in patient care rooms was conducted annually. NFPA Standard: NFPA 99 Health Care Facilities Code (2012)6.3.3.2 Re.. Based on observation and record review during the survey, it was determined that the facility failed to maintain the back-up emergency generator in accordance with National Fire Protection Association (NFPA) Standard 110. This was evidenced by the following: 1. Missing April and May 2024 generator inspection reports8.1.1 The routine Maintenance and operational testing program shall be based on all of the following: Manufacturers recommen.. Based on observation and staff interview during the course of the survey it was determined the facility failed to maintain smoke barriers in accordance with NFPA 101, 8.5.1. This was evidenced by the following:1.Door 22 needs repair did not latch, Door 20 needs a knob, Deadbolt in the fire door by room 14 (needs to be removed) 2.Fire doors by Green Mile Nurses station drags on floor 3.Generator room 2-hour rating needs to seal penetrations NFPA 101, Sectio.. 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 7.2.1.4.5.11. Egress doors 2, 8 & 7 green mile racked (sticking when opening) and north wing 7.2.1.4.5.1 The forces required to fully open any door leaf manually in a means of egress shall not exceed 15 lbf (67 N) to release the latch, 30 lbf (133 N) to set the leaf in motion, and 15 lb.. Based on observation it was determined that the facility failed to maintain the kitchen hood suppression system as required by NFPA 96, (Chapter 12, Section 12.1.2.3.1) and cooking appliance restraint as required by NFPA 54, 9.6.1.2. 1.Main stove needs placement markers to return after movement for system coverage...ie chalksNFPA 96, 12.1.2.3 The fire-extinguishing system shall not require reevaluation where the cooking appliances are moved for the purposes of .. INITIAL COMENTS (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 consists of two structures separated by a common wall having a two-hour fire rating, and the facility is licensed for 119 beds at the time of this survey. Building A1, constructed in 1957, is a Type V (111) single-stor.. The Colorado Department of Public Health and Environment 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 consists of two structures separated by a common wall having a two-hour fire rating, and the facility is licensed for 119 beds at the time of this survey. Building ..

A recertification survey with complaint #CO32340 and #CO35500 was completed on 6/2/24 to 6/5/24. Nine deficiencies were cited. An Emergency Preparedness survey was conducted from 6/2/24 to 6/5/24. One deficiency was cited. Based on interviews and record review, the facility failed to ensure two (#18 and #19) of four residents investigated for abuse out of 37 sample residents were kept free from physical abuse.Specifically, the facility failed to:-Prevent a physical altercation between Resident #93 and Resident #19, and,-Prevent a physical altercation between Resident #.. Based on observations and interviews, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the facility' s kitchen and dining room. Specifically, the facility failed to:-Ensure nourishment beverages in the main dining room and unit refrigerators were dated and labeled;-Ensure cooking utensils were dried.. Based on observations, record review and interviews, the facility failed to ensure one (#80) of three residents with skin conditions of 37 sample residents received the highest practicable treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan.Specifically, the facility failed t.. Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#87) of three residents reviewed for accidents/hazards out of 37 sample residents.Specifically, the facility failed to ensure Resident #87 had an order for a medication (Aleve) found .. Based on observations, record review, and interviews the facility failed to use a person-centered approach when determining the use of bed rails for four (#27, #36, #40, and #70) of ten residents reviewed for bed rails out of 37 sample residents.Specifically, for Resident #27, #36, #40 and #70, the facility failed to:-Assess the resident for risk of.. Based on record review and interview, the facility failed to have a complete emergency preparedness communication plan that complies with Federal, State, and local laws.Specifically, the facility failed to ensure there was a written plan for sharing information and medical documentation for residents under the facility' s care, with other health pro.. Based on record review and interviews, the facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four of four staff reviewed. Specifically, the facility had not completed annual performance reviews and/or provided r.. Based on record review and interviews, the facility failed to ensure residents had a right to participate in the development and implementation of their person-centered plan of care for one (#2) of one resident out of 37 sample residents. Specifically, the facility failed to invite Resident #2' s representative to participate in the care conferences.. Based on record review and interviews, the facility failed to ensure that the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#89) of five residents receiving hospice services out of 37 sample residents. Specifically, the facility failed to orient hospic.. Based on record review and interviews, the facility failed to ensure three (#2, #21, #54) of five residents reviewed for unnecessary medications out of 37 sample residents were free from unnecessary medications. Specifically, the facility failed to: -Ensure Resident #2, Resident #21 and Resident #54 had appropriate non-pharmacological interventions for ..