AURORA, CO- LIFE CARE CENTER OF AURORA

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

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

Based on record review and interviews, the facility failed to ensure the residents’ environment remained as free from accident hazards as possible and prevent falls with major injury for two (#46 and #76) of four residents reviewed for falls out of 53 sample residents.

Resident #46, who had a known history of falls, had a diagnosis of obesity which required the use of a bariatric (to support substantial weight) bed with extensions to enable the bed frame to be made larger. On 1/29/24, the resident sustained a witnessed fall from her bed when she was being rolled on her side with the assistance of staff during a bed bath.

Resident #46 was sent to the hospital for evaluation of left knee pain following the fall where she was discovered to have a fracture of her left femur (thigh bone), which was surgically repaired on 1/30/24. The resident returned to the facility on [DATE] and was placed in the same bed she fell from on 1/29/24. The facility did not inspect the bed to ensure the extensions were pulled out appropriately and the mattress fit correctly prior to placing the resident back in the bed.

On 2/5/24 (4 days after Resident #46’s readmission to the facility), a rental supply company came to the facility to install bed canes (a device which can be utilized to assist a person to reposition themselves in bed). The rental supply company’s personnel discovered the extensions on Resident #46’s bed had not been pulled out prior to the resident’s fall from the bed and the facility had failed to pull the extensions out prior to the resident’s readmission to the facility.

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

Based on observation, record review and interviews, the facility failed to ensure the self-administration of medications was clinically appropriate for one (#40) resident out of 53 sample residents. Specifically, the facility failed to:
-Ensure Resident #40 was assessed for the appropriateness and safety of self-administration of topical medications; and,
-Ensure there was a physician order for self-administration of topical medications.

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

Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for one (#33) of five residents reviewed out of 53 sample residents.
Specifically, the facility failed to ensure Resident #33 received her scheduled showers, who was dependent on staff for bathing.

Assist a resident in gaining access to vision and hearing services.

Based on observations, interviews and record review, the facility failed to assist residents with making appointments and arranging transportation for one (#89) of three residents reviewed for vision/ancillary services out of 53 sample residents. Specifically, the facility failed to offer and make an appointment for optometry services for resident #89.

Provide appropriate foot care.

Based on observations, record review and interviews the facility failed to ensure one (#89) of three residents reviewed for ancillary services, such as podiatry services, out of 53 sample residents received proper foot care and treatment according to standards of practice.

Specifically, the facility failed to ensure podiatry care was provided timely and as requested by Resident #89.

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Based on observations, record review, and interviews, the facility failed to ensure residents with a
gastrostomy tube received appropriate treatment and services to prevent complications for one (#18) of three residents reviewed for tube feeding management out of 53 sample residents.

Specifically, the facility failed to label Resident #18’s tube feeding bag with the date and time the tube feeding bag was hung, the initials of the nurse hanging the tube feeding bag, the type of tube feeding the resident was receiving and the flow rate for the tube feeding administration.

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

Based on observations, record review and interviews, the facility failed to ensure two (#62 and #68) of four residents who required respiratory care received care consistent with professional standards of practice out of 53 sample residents.
Specifically, the facility failed to:
-Follow manufacturer recommendations to maintain, clean, sanitize and store Resident #62 and Resident #68’s continuous positive airway pressure (CPAP) mask and machine;
-Accurately complete section O in the minimum data set (MDS) assessment under respiratory treatments for Resident #62 and Resident #68;
-Ensure a care plan was in place to include settings, cleaning, disinfecting and storage of the CPAP for Resident #62; and,
-Ensure Resident #68’s CPAP mask sealed properly because it was torn.

Ensure medication error rates are not 5 percent or greater.

Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent.

Specifically, the facility had a medication error rate of 14.29%, which was five errors out of 35 opportunities for error.

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 observation and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly on one of four medication carts.
Specifically, the facility failed to:
-Ensure medication was not left unattended on the medication cart; and,
-Ensure tuberculin (medication to test for tuberculosis, a lung bacteria) vials were dated with open dates.

Provide routine and 24-hour emergency dental care for each resident.

Based on observations, record review and interviews, the facility failed to ensure one (#89) of three residents reviewed for ancillary services, such as dental services, out of 53 sample residents received routine dental care obtaining routine and 24-hour emergency dental care.

Specifically, the facility failed to refer Resident #89 to the dentist to replace lost dentures and repair loose fitting dentures.