PUEBLO, CO- LIFE CARE CENTER OF PUEBLO

Based on observations, 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 qualify of care, quality of life, and resident safety.

Specifically, the facility failed to demonstrate that their quality assurance performance improvement (QAPI) program committee effectively identified quality care issues to address concerns related to abuse prevention, accident hazards, resident rights, respiratory care and highest practicable quality of life.

Findings include:
I. Cross-referenced citation with harm
Cross-reference F689: The facility failed to ensure residents were free from accident hazards related to falls for residents identified at high risk for falls and that all possible interventions were put into place and reevaluated to prevent further falls. In addition, the facility failed to ensure mechanical lifts were in safe and proper working condition.
Resident #83 sustained an injury (laceration) to her head requiring hospitalization and treatment. Resident #119 sustained a displaced apophyseal fracture of her left femur identified on 12/24/19 and subsequently admitted to the hospital for surgical intervention.

II. Cross-referenced citations
Cross-reference F600: The facility failed to ensure residents were protected from abuse.
Cross-reference F550: The failed to ensure residents were treated in a dignified manner.
Cross-reference F583: The facility failed to ensure residents’ private medical information was protected.
Cross-reference F684: The facility failed to provide care and services necessary to maintain the highest practicable physical well-being.
Cross-reference F880: The facility failed to ensure proper infection control processes were followed to prevent cross-contamination related to housekeeping, handwashing and wound care.

III. Repeat deficiencies
Review of the facility’s regulatory record revealed it failed to operate a QA program in a manner to prevent repeat deficiencies.

F550 During the 1/10/19 standard survey, F550 was cited at a D level for failure to ensure residents who expressed concerns did not perceive they were treated differently; residents who had high care needs did not perceive they were treated differently; and, follow-up with resident emotional needs after addressing resident reported concerns.
During the 1/30/2020 standard survey, F550 was cited at an E level for potential for more than minimal harm at a pattern.

F689 During the 7/25/19 abbreviated survey, F689 was cited at a D level for failure to transfer a resident with two people in accordance with their plan of care. During the 10/17/19 abbreviated survey, F689 was cited at an E level for potential for minimal harm at a pattern for failure to implement and care plan effective interventions timely after two resident falls, ensure complete and accurate neurological assessments for one of the resident’s and ensure a treatment cart was kept lock. During the 1/30/2020 standard survey, F689 was cited at a G level for actual harm.

F600 During the10/17/19 abbreviated survey, F600 was cited at a G level for actual harm for neglect and failure of staff to follow resident’s plan of care for transfers and attempted unsafe transfer resulting in a major injury.
During the 1/30/2020 standard survey, F600 was cited at a D” level.

F695 During the 7/25/19 abbreviated survey, F695 was cited at a D level for failure to ensure oxygen was administered according to physician’s orders [MEDICAL RECORD OR PHYSICIAN ORDER] .

F 880 During the 1/10/19 standard survey, F880 was cited at an F level, no actual harm with potential for more than minimal harm; widespread. During the 7/25/19 abbreviated survey F880 was cited at a D level for failure to follow proper sanitary practices and proper hand hygiene/glove use during incontinence care. During the 1/30/2020 standard survey, F 880 was cited at an E level.