Walsh Healthcare Center

Environmental Deficiencies

Have enough outside ventilation via a window or mechanical ventilation, or both.

Administration Deficiencies

Electronically submit to CMS complete and accurate direct care staffing information, based on payroll and other verifiable and auditable data.

Smoke Deficiencies

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

Resident Rights Deficiencies

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

Infection Control Deficiencies

Implement a program that monitors antibiotic use.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Nutrition and Dietary Deficiencies

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

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Miscellaneous Deficiencies

Have restrictions on the use of flammable curtains.

Nursing and Physician Services Deficiencies

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

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

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.

Emergency Preparedness Deficiencies

Develop and maintain an Emergency Preparedness Program (EP).

Emergency Preparedness Deficiencies

Address subsistence needs for staff and patients.

Emergency Preparedness Deficiencies

List the names and contact information of those in the facility.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Miscellaneous Deficiencies

Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

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.

Resident Rights Deficiencies

Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.

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.

Nutrition and Dietary Deficiencies

Dispose of garbage and refuse properly.

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

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.

INITAIL COMENTS (ID Prefix Tag 161) 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 a one-story Type I (332) structure with a partial basement used for support services only. The facility licensed for 30 beds is protected by a National Fire Protection Association (NFPA) 13 automatic fire suppression system. This re-certification survey was conducted on February 6, 2024 for compliance with the fire safety requirements of the 2012 NFPA 101, Life Safety Code, Chapter 19, "Existing Health Care Occupancies." The survey concluded with a discussion of the deficiencies with the Administrator and Director of Maintenance. STANDARD is not met as evidenced by: Based on record review during the survey, it was determined that the facility failed to conduct fire drills in accordance with the Life Safety Code, Section 19.7.1.2 and 4.7. This deficient practice could affect residents when staff are not trained in the emergency actions required during unusual condition that can occur in an actual emergency. This was evidenced by the following: Fire drills are required to be conducted on each shift quarterly, the facility failed to conduct a fire drill on the first shift in the forth quarter. Life Safety Code, Section 19.7.1.2 requires, in part, that fire drills be conducted quarterly on each shift to familiarize personnel (nurses, interns, maintenance engineers, and administrative staff) with the signals and emergency action required under varied conditions. When drills are conducted between 9:00 pm and 6:00 am, a coded announcement shall be permitted to be used instead of audible alarms. Section 4.7.5 requires that drills be held unexpected times and under varying conditions to simulate the unusual conditions that can occur in an actual emergency.The Director of Maintenance acknowledge the conditions of fire drills deficiency during record review of the facility. STANDARD is not met as evidenced by: It was determined through observation during the survey that the facility failed to provide curtains that comply with NFPA 701 in all areas, as required by the Life Safety Code. This deficiency has the potential to affect all building occupants, including all staff, visitors, and residents. This was evidenced by:The facility was unable to provide documentation at the time of the survey to reflect that the curtains in several patient' s rooms met the requirements of NFPA 701:The loose hanging fabric deficiency was discussed during the survey and again during the exit conference.The Life Safety Code Section 21.7.5.1 requires that draperies, curtains (including cubicle curtains) and other loosely hanging fabrics and films serving as furnishings or decorations in health care occupancies shall be in accordance with the provisions of 10.3.1. Section 10.3.1 requires that draperies, curtains, and other similar loosely hanging furnishings and decorations be flame resistant as demonstrated by testing in accordance with NFPA 701, Standard Methods of Fire Tests for Flame Propagation of Textiles and Films.

A recertification survey was conducted from 1/22/24 to 1/24/24. Four deficiencies were cited. An Emergency Preparedness survey was conducted from 1/22/24 to 1/24/24. No deficiencies were cited. Based on interviews and observations, the facility failed to ensure residents consistently receive food prepared by methods that conserved nutritive value, palatable in taste, texture, appearance and temperature.Specifically, the facility failed to ensure resident food was palatable in taste, temperature, texture and appearance.Findings include:I. Resident interviewsAll residents were identified by facility and assessment as interviewable. Resident #8 was interviewed on 1/22/24 at 9:15 a.m. He said the food at the facility was alright but it was not very good. Resident #14 was interviewed on 1/22/24 at 9:21 a.m. She said the texture of the food was too hard for her and the food was ofte.. Based on observations and interviews, the facility failed to ensure food was stored, prepared and served under sanitary conditions in the kitchen. Specifically, the facility failed to ensure:-Perishable foods were discarded after the date of expiration; and, -Perishable foods were labeled and dated. Findings include: I. Professional reference According to the State Board of Health Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) retrieved 1/29/24 from https://cdphe.colorado.gov/environment/food-regulations it read in part, "A date marking system that meets the criteria using a method approved by the Department for refriger.. 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 must provide regular in-service education based on the outcome of these reviews for four of four certified nurse aides (CNAs) reviewed. Specifically, the facility did not provide inservice education based on the outcome of the performance reviews for CNA #1, #2, #3 and #4.Findings include: I. Record review CNA #1 (hired 5/4/11) had a performance review on 5/31/23.CNA #2 (hired 2/4/16) had a performance review on 3/15/23CNA #3 (hired 6/1/2020) had a performance review on 1/16/24.CNA #4 (hired 9/20/21) had a perf.. Based on record review and interviews, the facility failed to ensure three (#12, #5 and #9) of six residents reviewed for unnecessary medications out of 11 sample residents were free from unnecessary drugs. Specifically, the facility failed to:-Have an effective method to track behaviors for efficacy of psychotropic medications for Residents #12, #5 and #9; and,-Obtain consent for psychotropic medications prior to administration for Residents #5 and #9. Findings include: I. Facility policyThe Use of Psychotropic Medication policy, reviewed 10/4/23, was provided by the nursing home administrator (NHA) on 1/24/24. It read in pertinent part, "Residents are not given psy..