Valley Rehabilitation and Healthcare Center, the

Quality of Life and Care Deficiencies

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

Resident Rights Deficiencies

Let each resident or the resident's legal representative access or purchase copies of all the resident's records.

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.

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

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.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Provide properly protected cooking facilities.

Egress Deficiencies

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

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

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

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 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.

Quality of Life and Care Deficiencies

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

Smoke Deficiencies

Have a fire alarm with audible and visual signals that transmits the alarm automatically to notify emergency forces in event of fire.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Nutrition and Dietary Deficiencies

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

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

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

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Resident Rights Deficiencies

Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide.

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, 33,951 square foot, Type II (111) construction. The facility is protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire suppression system and is classified as Fully Sprinkled. The facility was constructed in 1992 and is licensed for 110 beds. This re-certification survey conducted on July 24, 2024, .. Through document review during the survey, it was determined that the facility failed to maintain the electrical systems in accordance with NFPA 99. This was evidenced by:1) Receptacle Testing (99 6.3.4.1): Not ProvidedNFPA 996.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be performed at interv.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 25. This was evidenced by:1) Fire Suppression Semi-Annual: 12.21.24 Not done per NFPA 25 standards, need to exercise valves and flow switches2) Fire Suppression Annual: 6.28.24 Cooper Fire report needs to reflect the year of heads.NFPA 101, 9.7.5 Maintenance and Testing.All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested, and maintained in accordance with NFPA 25, Sta.. Through observation during the survey, it was determined that the facility failed to maintain doors in accordance with NFPA 101. This was evidenced by:1) The courtyard needs to remove obstructions on the egress pathway to a public wayNFPA 101 7.1.10.1* General.Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed .. Through observation during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101. This was evidenced by:1) The courtyard needs exit signage to the public way2) Need to assess exit signage to dining hall per original design; doors do not swing in the path of travel as it is currently markedNFPA 101 19.2.10.1 & 7.10: Marking of Means of EgressThis deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the smoke compartment. Deficient items were disc.. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 99 and NFPA 55. This was evidenced by:1) trans-filling exhaust not within 12" of the floor NFPA 99 9.3.7.4 Transfilling area shall be provided with ventilation in accordance with NFPA 55, Compressed Gases and Cryogenic Fluids Code.NFPA 55 6.15.7.26.15.7.2 For gases that are heavier than air, exhaust shall be taken from a point within 12 in. (304.8 mm) of the floor.This deficiency has the potential to affect occupants, who might include r.. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 80. This was evidenced by:1) medical record storage not latching2) The dining hall office door closure needs to be adjusted3) A wing janitor closet needs a new door closure 4) Need closure reinstalled on the director of the nursing room5) Need closure reinstalled in the activity roomNFPA 101, 8.3.3.1Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, lab..

A recertification survey with complaint #CO36239 was completed on 6/24/24 to 6/27/24. Three deficiencies were cited. An Emergency Preparedness survey was conducted from 6/24/24 to 6/27/24. No deficiencies were cited. Based on observations and interviews, the facility failed to ensure all drugs and biologicals used in the facility were properly stored and labeled on three of five units.Specifically, the facility failed to ensure residents' topical medications were stored and locked in appropriate medication carts or medication storage rooms that were accessed only by authorized licensed personnel.Findings include:I. Facility policy and procedureThe Medication Labeling and Storage policy and procedure, reviewed February 2023, was provided by the nursing home administrator (NHA) on 6/26/24 at 2:20 p.m. It read in pertinent part,"Compartments (including, but not limited to drawers, cabinets, rooms, refrigerators, carts and boxes) containing medications and biologicals are locked when not in use, and trays or carts .. Based on observations, interviews and record review, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease and infection on four of five units.Specifically, the facility failed to:-Ensure residents' rooms were cleaned in a sanitary manner; -Ensure residents' personal care items were labeled and stored in a sanitary manner; and,-Ensure a urinary catheter was maintained in a sanitary manner.Findings include:I. Housekeeping failuresA. Professional referenceThe Centers for Disease Control and Prevention (CDC), Environment Cleaning Procedures (5/4/23), was retrieved on 7/1/24 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.ht.. Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the kitchen.Specifically, the facility failed to:-Ensure kitchen staff handled ready-to-eat foods in an appropriate sanitary manner to prevent cross contamination; and,-Ensure safe holding temperatures for food items were maintained.Findings include:I. Inappropriate handling of ready-to-eat foodsA. Professional referenceThe Colorado Retail Food Establishment Regulations, effective 3/16/24, were retrieved on 7/1/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, "Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as d..

Based on record review, the facility failed to report complete information about COVID-19 to the Centers for Disease Control and Prevention' s (CDC) National Healthcare Safety Network (NHSN) during a seven-day period that reporting was required by regulation.The CDC submitted data from the NHSN to the Centers for Medicare and Medicaid Services (CMS). Based on review of that data, CMS determined that between 03/06/2023 and 03/12/2023, the facility did not report complete information to NHSN about COVID-19 in the standardized format and frequency as specified by CMS and the CDC. This failure to report has the potential to cause more than minimal harm to all residents residing in the facility.