COLORADO SPRINGS, CO- THE HEALTHCARE RESORT OF COLORADO SPRINGS

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

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Based on record review and interview, the facility failed to create an environment that protected six (#8, #4, #15, #87, #253, and #254) of eight out of 42 sample residents from mental and verbal abuse, contributing to residents experiencing, among other emotions, night terrors, anxiety, fear, and humiliation.

In interviews with Residents #8, #15, and #253, the residents stated certified nurse aide (CNA) #1 slammed and dropped food trays on their tables and slammed their doors shut, mocked them, yelled at them, made them feel like an idiot, and feel anxious, frightened, and humiliated. Resident #4 had tears in her eyes when CNA #1’s name was mentioned; when asked if she could talk further about him, she shook her head no and appeared sad.

Although the residents and visitors either spoke with management or filed complaint/concern forms about their interactions with CNA #1 as early as February 2023 and later in August, September, and October, their reports, despite their repetition, were not recognized as potential staff-to-resident abuse, leading to failures in reporting, investigating, and implementing corrective actions to protect and prevent further abuse.

The facility’s systemic failure to ensure residents were protected from staff-to-resident abuse created a situation of immediate jeopardy with Residents #234, #8, #15, and #4 sustaining actual serious harm, and the potential for serious harm to other residents residing in the facility.

Cross-reference F609 (reporting of alleged violations), F610 (investigation of alleged violations), and F867 (QAPI).

The resident has the right to receive notices in a format and a language he or she understands.

Based on observations and interviews, the facility failed to ensure residents received notices in a written description of their legal rights.

Specifically, the facility failed to post a sign with how to file a complaint to the State Survey Agency.

Allow residents to easily view the nursing home’s survey results and communicate with advocate agencies.

Based on observations and interviews, the facility failed to ensure the residents had access to the results of the facility’s most recent survey conducted by Federal or State surveyors over the past three years of survey, to include survey findings and any plan of correction, in a place readily accessible to to residents, family members and legal representatives of residents.

Specifically, the facility failed to make survey results accessible.

Develop and implement policies and procedures to prevent abuse, neglect, and theft.

Based on interviews and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse and/or mistreatment of facility residents.

Specifically, the facility failed to post a conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency and who the abuse coordinator was for the facility.

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Based on interviews and record review, the facility failed to timely report incidents of potential abuse to the proper authorities, including the state survey agency. This involved four residents (#4, #15, #87, #253) out of eight residents reviewed from a total sample of 42 residents.

Specifically, the facility leadership failed to ensure four incidents of potential verbal and/or mental abuse by a staff member, certified nurse aide (CNA) #1, were timely reported to authorities, including the state survey agency.

Respond appropriately to all alleged violations.

Based on record review and interviews with residents and staff interviews, the facility failed to ensure incidents of potential abuse involving five residents (#8, #4, #15, #87, and #253) out of a total sample of 42 residents were thoroughly investigated.

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety.

Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to freedom from abuse, reporting and investigating that rose to the level of immediate jeopardy and caused a pattern of psychosocial harm.

Provide and implement an infection prevention and control program.

Based on 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 development and transmission of diseases and infection for two out of four units in the facility.
Specifically, the facility failed to:
-Ensure housekeeping staff cleaned high touch areas were cleaned appropriately;
-Ensure housekeeping staff used proper surface disinfectant times;
-Ensure housekeeping staff cleaned from cleaner to dirtier areas;
-Ensure housekeeping staff changed gloves and performed hand hygiene between bathroom and bedroom;
-Ensure housekeeping staff changed mop heads between bathroom and bedroom;
-Ensure housekeeping staff changed cleaning cloths between bathroom and bedroom;
-Provide accurate isolation precautions, including isolation signage, appropriate use of personal protective equipment (PPE) and assure the resident doors remained closed; and,
-Appropriately store resident portable oxygen equipment.

Keep all essential equipment working safely.

Based on observation and interviews, the facility failed to ensure essential equipment was in proper working order.

Specifically, the facility failed to ensure the pellet base heating elements were in safe condition.