LAKEWOOD, CO- CEDARS HEALTHCARE CENTER

Facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care.

Resident #33 was interviewed on 8/11/21 at 2:09 p.m. She said the facility did not have enough staff for the residents and they were always low. The majority of the CNAs were from agencies so they were different people from day to day. Resident #33 said she preferred to be up and out of bed and dressed in the morning, however, because the facility had less staff that day and they were busy, she did not get assistance to get out of bed and change out of her pajamas.

The DON said she was aware showers were not completed at times due to staffing, however, they were to be made up the next day. The DON said the facility was continuing to admit new residents (with staffing shortages).

Facility failed to provide the appropriate care and services for one (#22) of two residents reviewed for enteral nutrition out of 32 sample residents.

On 8/12/21 at 8:50 am, Resident #22 was lying in her bed holding on to a stuffed animal. Her tube feeding pump was not hooked to the [MEDICATION(S)] bag, and she was not receiving her tube feeding. The Jeveti bag hanging on the IV pole was dated 8/10/21 with a start time of 11:30 p.m. The Jeveti bag which held a 1500 ml and and was currently turned off with 200 ml left in the bag.

The DON was interviewed on 8/12/21 at 5:00 p.m. The DON reviewed Resident #22’s MARs and confirmed she should have 55 ml 1.5 of jeviti tube feeding from 4:00 p.m. to 10:00 a.m. daily. She said it looked like the resident has received her scheduled feedings based on the documentation in the MAR. She went down to Resident #22’s room and agreed the feeding tube pump was not running and the Jeviti bag hanging on the IV pole was dated 8/10/21 hung at 11:30 p.m. She confirmed the bag had not been changed for two days and she would ask her evening nurse who just arrived to start Resident #22’s tube feeding.

Facility failed to ensure five (#56, #50, #35, #31, #61) of seven out of 32 sample residents received the necessary respiratory care as ordered by the physician. 

Resident #35 was interviewed on 8/16/21 at 3:34 p.m. He said that he required nine liters of oxygen through his nasal cannula and at times, used his [CONDITION(S)] when he slept. On his nasal cannula a hole about the size of one centimeter was on the tubing with a large amount of oxygen leaking from it. He said that he had difficulty breathing like he was short of air.
The nasal cannula tubing used by the resident was dated 4/1/21, four and a half months prior to the observation.

The DON said the facility was continuing to admit new residents (with staffing
shortages).