COLORADO SPRINGS, CO- KIOWA HILLS REHABILITATION AND NURSING

The Department of Health & Human Services conducted an inspection of the facility. The following  highlighted decencies listed below were found in a public survey.

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

Based on observations, record review and interviews, the facility failed to ensure residents were treated with respect and dignity by providing care in a dignified, respectful and individualized manner for one (#5) of three residents reviewed out of 33 sample residents.

Specifically, the facility failed to:
-Ensure Resident #5 was provided beverages of his choice when requested; and,
-Ensure Resident #5 was provided clothing when he requested to get dressed and was not dressed in a
hospital gown.

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

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 three (#5, #14 and #38) of five residents out of 33 sample residents.

Specifically, the facility failed to invite and conduct regular care conferences to review the resident’s plan of care with Resident #5, Resident #14 and Resident #38.

Honor the resident’s right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Based on record review and interviews, the facility failed to honor resident choices for one (#46) of two residents out of 33 sample residents.

Specifically, the facility failed to honor Resident #46’s preference for assistance with bathing from female shower aides.

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.

Based on observations and interviews, the facility failed to provide a functional, sanitary and comfortable environment for residents on four of five neighborhoods.

Specifically, the facility failed to maintain a comfortable air temperature range on four out of five
neighborhoods.

Honor the resident’s right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.

Based on interviews and record review, the facility failed to ensure residents and their representatives were provided prompt efforts by the facility to resolve grievances for one (#14) of four residents out of 33 sample residents.

Specifically, the facility failed to document and follow-up on grievances reported by Resident #14 regarding a missing blanket and socks.

Ensure services provided by the nursing facility meet professional standards of quality.

Based on observations and interviews, the facility failed to ensure residents were provided services that meet professional standards for five (#1, #205, #255, #46 and #4) of nine residents out of 33 sample residents.

Specifically, the facility failed to:
-Ensure Resident #1 and Resident #205 received medications in a timely manner according to the
physician’s orders; and,
-Ensure lancets were used instead of a syringe with a needle to check blood sugar levels for Resident #205, Resident #255, Resident #46 and Resident #4.

Provide activities to meet all resident’s needs.

Based on observations, record review and interviews, the facility failed to ensure one (#16) of three residents reviewed for activities out of 33 sample residents received an ongoing program of activities designed to meet needs and interests and promote physical, medical and psychosocial well-being.

Specifically, Resident #16 was not provided with meaningful activities or one-to-one staff visits per his individualized plan of care.

Ensure the activities program is directed by a qualified professional.

Based on record review and interviews, the facility failed to ensure the activities program was directed by a qualified professional.

Specifically, the facility failed to employ a qualified activities director in order to provide a program of activities for residents requiring activity and recreational support.

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

Based on observations, record review and interviews, the facility failed to ensure the residents environment remained as free of accident hazards as possible and ensured residents received adequate supervision and assistance to prevent a fall with major injury for one (#38) of three residents reviewed for accidents/hazards out of 33 sample residents.

Resident #38, who was at high risk for falls and had a history of a fall with a fracture, was admitted to the facility on [DATE] and readmitted on [DATE] after a hospital stay for repair of a right femur fracture. Per the resident’s fall care plan, staff were instructed to anticipate and meet the resident’s needs, keep the call light within reach and keep personal items within reach.

Resident #38 experienced a witnessed fall on 12/20/24 while trying to walk to her sink to get a drink of water, resulting in a fracture of her right femur. The staff failed to implement new interventions after the resident’s fall with major injury.

Observations of Resident #38 during the survey revealed staff were not consistently ensuring Resident #38’s call light was within reach when she was in her room.

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.

Based on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in two of four medication carts and one of one medication storage room.

Specifically, the facility failed to:
-Ensure expired medications were removed from the medication carts and medication storage room; and,
-Ensure over the counter medications intended for use by a single resident were labeled with the resident’s name.

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

Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen, satellite kitchen, and one of two nourishment refrigerators.

Specifically, the facility failed to:
-Ensure ready to eat foods were handled in a sanitary manner to prevent cross contamination in the main kitchen;
-Ensure safe and appropriate storage of food items in the kitchen and nourishment room refrigerators;
-Ensure proper hair restraints were worn in the kitchen;
-Ensure the kitchen and food service areas were kept clean; and,
-Ensure frozen meats were thawed in a safe manner.

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.

Based on observations, record review and interviews, the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#17) of two residents reviewed for hospice services out of 33 sample residents.

Specifically, for Resident #17, the facility failed to:
-Obtain a physician’s order for hospice care;
-Ensure the hospice agency’s notes were easily accessible to the facility staff and had consistent
communication and documentation of hospice care visits and updates; and,
-Initiate a hospice care plan timely.

Provide and implement an infection prevention and control program.

Based on record review, observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious disease.

Specifically, the facility failed to:
-Wear the appropriate personal protective equipment (PPE) when entering transmission based precaution rooms;
-Offer updated COVID-19 vaccinations and document consent or declination for vaccination for Residents #16, #36, #205 and #255;
-Ensure staff followed proper hand hygiene practices during meal delivery;
-Ensure staff followed proper infection prevention practices during wound care for Resident #37; and,
-Ensure resident’s glucometers were disinfected after each use.