Heritage Park Care Center
HERITAGE PARK CARE CENTER in CARBONDALE, CO — inspection on August 29, 2024.
Found 30 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
12:30 p.m., the following was observed:
residents were in the dining room.
At approximately 12:00 p.m. an unidentified resident asked for creamer. for their coffee.
The RD was heard telling the resident You don' t like creamer, you like your coffee black. -The RD did not provide the resident with creamer as requested.
At 12:15 p.m. an unidentified certified nurse aide (CNA) was observed standing while assisting Resident #24 with eating their meal.
At approximately 12:30 p.m. the RD was heard talking loudly about other residents ' decline and needing to change their diet orders.
The RD was heard asking multiple residents about their dentures and why they did not want to wear them.
The RD was heard talking about different resident's preferences to other residents' family members.
The RD could be overheard throughout the dining room. -Throughout the continuous observation, the RD was walking from resident to resident and assisting them with their meals while standing up.
The RD conversed with other employees instead of the residents while she was assisting them to eat their meals.
B.
Staff interviews The RD was interviewed on 8/29/24 at approximately 10:00 a.m.
The RD said she knew her voice was loud.
She said she had been told she was loud before.
She said when she was in the kitchen she had to speak loudly because of the overhead fans.
She said she viewed the facility as a family and she wanted to help everyone and that was why she would talk to all of the residents.
The social services director (SSD) was interviewed on 8/29/24 at 3:51 p.m.
The SSD said the facility had provided staff with education on dignity and respect.
She said staff received the education when new employees were hired and then annually thereafter.
She said all residents were to be treated with respect and dignity.
The SSD said she would review the resident rights with all staff.
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Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623
and did not find any other PASRRs that were not completed correctly.
The SSD said she planned to
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Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623
According to the August 2024 CPO, diagnoses included pneumonia, sleep related hypoventilation, hypertension and hepatitis C.
B.
Record review -Review of Resident #239's EMR revealed that a baseline care plan was not completed for the resident.
The comprehensive care plan, initiated on 8/7/24, initiated activities of daily living and discharge plan within 48 hours of the resident's admission to the facility. -However, a fall and history of falls care plan was not initiated until 8/12/24, a dietary care plan was not initiated until 8/20/24 and a therapy services care plan was not initiated VI.
Staff interviews Registered nurse (RN) #2 was interviewed on 8/29/24 at 8:54 a.m. RN #2 said when a resident was admitted to the facility, the RN had to initiate the care plan and enter the pertinent information about continence care and other pertinent care plan areas. RN #2 said the MDS coordinator (MDSC) completed the rest of the care plan.
The MDSC was interviewed on 8/29/24 at approximately 1:00 p.m.
The MDSC said the baseline care plan needed to be completed within 48 hours.
She reviewed the EMRs for Resident #241, #242, #36, and #239.
She said the baseline care plans for each resident were incomplete or had not been completed at all.
She said the care plans were not completed within 48 hours of the residents's admissions to the facility.
The MDSC said she would begin an audit to ensure the baseline care plans for all residents were completed timely following admission to the facility.
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Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623
At 12:29 p.m. the resident asked CNA #1 to help lay her down. CNA #1 said she would have to wait a
At 1:10 p.m. CNA #1 assisted the resident to the shower. -Resident #24 was not repositioned from 8:55 a.m. until 1:10 p.m.
C.
Resident's representative interview Resident #24's representative was interviewed on 8/29/24 at 11:30 a.m.
The resident's representative said she had a special chair made which tilted back for Resident #24.
She said it tilted back so that way her positioning was changed.
D.
Record review The skin care plan, revised on 8/18/24, revealed the resident was at risk for break in skin integrity including pressure related injury related to impaired mobility and function, weakness, incontinence, cognitive deficits and risk for malnutrition.
Pertinent interventions included assisting Resident #24 with repositioning every two hours and as needed.
The [NAME] (staff directive for person centered care), dated 8/29/24, documented the resident required extensive assistance of one to two staff members for transfers with the mechanical hoyer lift.
E.
Staff interviews Registered nurse (RN) #1 was interviewed on 8/28/24 at 12:30 p.m. RN #1 said Resident #24 was unable to move on her own. He said she required assistance from two staff members to transfer and reposition. He said the resident was at risk for skin breakdown because she had lack of mobility and was also incontinent of urine. RN #1 said Resident #24 needed to be repositioned every two hours.
The director of rehabilitation (DOR) was interviewed on 8/29/24 at approximately 1:00 p.m.
The DOR said Resident #24 had a tilt back wheelchair which was specially ordered.
The DOR said titting the wheelchair back helped with the repositioning of the resident and relieved pressure.
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Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623
for any signs or symptoms of UTIs. CNA #1 said Resident #1 had no rejections of care.
for nursing staff to recognize signs and symptoms of infection and report them to the physician.
The DON said she expected physicians and nursing staff to communicate when nursing staff identified new symptoms of infection in residents.
The DON said the facility had experienced difficulties with physician communication and the facility was currently transitioning to work with a new group of physician partners in the future.
The DON said she was unsure why it took more than a month for a provider to further investigate Resident #1's UTI symptoms.
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Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623
Resident #26 on 8/8/24.
interview above)
A progress notes dated 8/29/24 (during the survey) documented a staff member spoke to the audiology clinic and Resident #26's hearing aid would be replaced. -However, the facility failed to attempt to replace the hearing aid for more than two months after it was reported missing.
E.
Staff Interviews The social service director (SSD) was interviewed on 8/27/24 at 1:25 p.m.
The SSD said she was not involved in Resident #26's investigation concerning her hearing aid.
The SSD said the NHA completed all investigations of missing property and would only involve the SSD upon request.
The SSD said she did not know the current status of replacing Resident #26's hearing aid that was lost.
The NHA was interviewed on 8/27/24 at 1:44 p.m.
The NHA said Resident #26 was missing one hearing aid and the facility offered to replace it.
The NHA said she completed the investigation into the hearing aid.
The NHA said the hearing aid had not been replaced yet because the facility was experiencing logistical problems with reaching the audiology clinic.
The NHA said she did not have documentation that the facility attempted to get Resident #26's hearing aid replaced.
The NHA was interviewed again on 8/29/24 at 3:41 p.m.
The NHA said the facility's transportation driver was able to get ahold of the audiology clinic today (8/29/24) to discuss replacing Resident #26's hearing aid.
The NHA said the facility would implement a call log so the facility could document when calls were made to other care partners on behalf of resident care.
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Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623
not have a restorative program anymore.
She said the facility would like to reinstate it at some time
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Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623
7/11/24.
Although the resident was in isolation until 7/11/24, the weekly weights, which were recommended in
-The RAR committee recommended the resident to be weighed weekly on 7/12/24.
However, the facility did not weigh the resident weekly consistently.
III.
Staff interviews The RD and the clinical reimbursement specialist (CRS) were interviewed together on 8/29/24 at 12:10 p.m.
The RD said the resident was reviewed in the RAR meeting weekly.
She said the RAR meeting was used to analyze how the resident's nutritional needs were being met.
She said the resident's representative was notified of the resident's weight loss.
She said it was discussed with the representative that the resident would not receive a dinner meal, as she preferred to sleep.
She said in regards to not offering the resident dinner , she could have done a better job documenting the conversation She said there was not a physician's order for the resident to receive a 3:00 p.m. snack and the MAR showed that she did not consume a bedtime snack.
The RD said the resident had a significant weight loss and the resident's intake had been poor since July 2024.
She said the 2 cal MedPass was added twice daily, which she consumed on a regular basis.
She said the 2 cal MedPass should not be given with meals because it would fill the resident up with supplement and not food.
The RD said the resident's weekly weights were discussed in RAR.
She said however, because the resident was in isolation until 7/11/24, the weekly weights could not be completed.
She said the weekly weights were not resumed after the isolation and not completed.
The RD said the resident received a Magic Cup at lunch and breakfast.
She said there was no documentation of the Magic Cup being provided to the resident.
The director of nursing (DON) was interviewed on 8/29/24 at p.m.
The DON said the resident had a physician's order for a peanut butter and jelly sandwich, however, this was related to the resident having a minced and moist texture.
The DON said there was no documentation on the resident receiving a peanut butter and jelly sandwich as snack.
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Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623
CNA #5 was interviewed on 8/27/24 at 5:45 p.m. CNA #5 said the residents' portable oxygen tanks
-However, observations of Resident #16's, #14's and #17's oxygen tanks following CNA #5's interview revealed all three residents' portable oxygen tanks were empty (see observations above).
The director of nursing (DON) was interviewed on 8/27/24 at 6:15 p.m.
The DON said portable oxygen tanks were to be checked every two hours.
She said the tanks should also be checked prior to meals or if the resident was on the portable tanks for an extended period of time.
The DON was interviewed a second time on 8/29/24 at approximately 4:00 p.m.
The DON said she provided education (during the survey) to the certified nurse aides during the CNA huddles.
She said the education included checking the portable oxygen tanks every couple of hours, before meals and when residents were brought out of their rooms for activities.
III.
Failure to wear appropriate PPE while filling residents' oxygen tanks A.
Observations The facility's oxygen room was located on the Brother Ben's hallway.
The oxygen room had three liquid oxygen tanks.
The PPE staff was supposed to use to fill the portable oxygen tanks was hanging on the wall just inside the room.
The PPE provided included a pair of goggles, heavy gloves that went to the elbows, ear protection and a heavy yellow apron.
On 8/27/24 at approximately 6:15 p.m. three different employees, CNA #5, IP, and the NHA were observed filling portable oxygen tanks.
The NHA was wearing the appropriate PPE provided for safety. -CNA #5 and the IP failed to use the appropriate PPE while filling portable oxygen tanks.
The DON) was interviewed on 8/29/24 at approximately 4:00 p.m.
The DON said proper PPE needed to be worn when filling the portable oxygen tanks for the safety of the staff.
She said the appropriate PPE included an apron, eye protection and heavy gloves.
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Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623
outcome of these reviews for one out of five staff reviewed.
Specifically, the facility did not complete an annual performance review and/or provide regular in-service education based on the outcome of the review for certified nurse aide (CNA) #2.
Findings include: I.
Record review CNA #2 (hired on 6/22/22) did not have an annual performance review completed. CNA #2 did not have an in-service education plan based on the outcome of the review.
II.
Staff interviews The nursing home administrator (NHA) was interviewed on 8/29/24 at 10:11 a.m.
The NHA said she completed performance evaluations for CNAs in the facility.
The NHA said CNA #2 had been out of the country between January 2024 and April 2024 and was currently a PRN (as needed) employee.
The NHA said CNA #2 had worked in the facility in April 2024 after returning to the United States on 4/19/24.
The NHA said CNA #2 had not had a performance evaluation or in-service education based on the outcome of that review.
The NHA said she would do monthly audits moving forward to ensure all CNAs in the facility received timely annual evaluations.
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Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623
minimal harm was posted in a prominent place, readily accessible to residents and visitors.
unlicensed staff directly responsible for resident care per shift.
Findings include: I.
Observations Observations in the facility on 8/26/24 at 8:38 a.m. revealed the staff posting was dated 7/18/24.
The posting was located near the main nurse's station outside of the dining room.
Observations in the facility on 8/26/24 at 11:07 a.m. revealed the staff posting was dated 7/18/24.
The posting was located near the main nurse's station outside of the dining room.
II.
Staff interview The director of nursing (DON) was interviewed on 8/26/24 at 11:10 a.m.
The DON said the current staffing posted was dated 7/18/24.
The DON said the central supply staff member was responsible for posting the updated nurse staff posting in the facility.
The DON said the central supply staff member who normally updated nurse staff posting was on vacation and that the staff posting had not been updated in the facility after 7/18/24.
The DON said it was important to have updated staffing posted so visitors, residents and other staff members knew how many staff members were working in the facility.
Review of Resident #241's electronic medical record (EMR) failed to reveal documentation for physician's rationale for the extended use of the PRN lorazepam beyond 14 days.
II.
Staff interview The director of nursing (DON) was interviewed on 8/29/24 at p.m.
The DON said she was aware PRN psychotropic drugs were to not be given past 14 days without a documented physician's rationale.
She said she was not aware there was no rationale documented by the physician for the extended use of Resident #241's PRN lorazepam.
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Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623
The 6/12/24 resident council notes revealed a resident requested to have her meals served warmer.
-There was no documentation indicating how the facility took steps to address the resident's request of wanting warmer food.
V.
Staff interviews The registered dietitian (RD), the nursing home administrator (NHA) and the regional vice president (RVP) were interviewed together on 8/29/24 at 10:37 a.m The RD said the residents had not informed her that the meals were not served at the correct temperature or that the food did not taste good.
The RD said cold foods were on ice during service and served at 41 degrees F.
The RD said hot foods were served between 120 degrees F and 145 degrees F after the initial cooking temperature was reached.
The NHA said she had not heard anything from the residents regarding the temperatures or taste.
The NHA said the residents wanted to have food committee meetings during resident council meetings and the facility planned to combine the meetings in September 2024.
The RVP said the facility was going to take a look at what was going on with the temperatures and taste of the food.
The RD said it was important to serve food at the correct temperature and hot so the meal was enjoyable and safe to eat.
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Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623
grabbed a butter packet and the strings to her bracelet dragged through other opened packets of butter.
At 4:53 p.m. DA #2 grabbed another packet of butter and the strings to her bracelet drug through the other opened butter.
She placed the butter packet on a plate and the strings of her bracelet dragged across the food she was plating for a resident.
At 5:13 p.m. DA #2 reached over to grab an individual container of ketchup on the service line and the strings of her bracelet drug through the opened butter containers.
C.
Staff interviews The RVP was interviewed on 8/29/24 at 1:00 p.m.
The RVP said staff were not allowed to wear jewelry in the kitchen and she was unaware it was occurring.
The RVP said education was going to be provided to the dietary staff.
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Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623
affect the care the facility provided the residents.
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Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623
The IP and the DON were interviewed together a second time on 8/29/24 at 3:19 p.m.
The IP said
resident's room and in between cares in the resident's room as appropriate.
The IP said staff should offer to wash a resident's hands after assisting the resident to the bathroom.
The IP said staff should wash their hands after interacting with a resident's environment in their room.
The DON said nursing staff should offer hand hygiene to residents after they were assisted to the bathroom for toileting.
The IP said it was important to promote hand hygiene to prevent the spread of infection in the facility.
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Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623
dementia care and abuse prevention.
received at least 12 hours of annual in-service training that also included dementia management
certified nurse aides (CNA) reviewed.
Specifically, the facility failed to ensure CNA #2 and CNA #3 received 12 hours of continuing education annually.
Findings include: I.
Training record review Five randomly selected CNA training records were reviewed on 8/27/24. Of the five CNAs reviewed, CNA #2 and CNA #3 did not receive 12 hours of annual training.
A. CNA #2 -CNA #2, hired on 6/22/22, had participated in 10 hours and 30 minutes of training during the annual training year.
B. CNA #3 -CNA #3, hired on 6/11/14, had participated in 10 hours and 30 minutes of training during the annual training year.
II.
Staff interviews The nursing home administrator (NHA) was interviewed on 8/28/24 at 11:27 a.m.
The NHA said she kept the records for the annual staff training and verified that all of the staff members received appropriate training in the facility.
The NHA said she had recorded 10.5 hours of CNA training for CNA #2 and CNA #3, which also included dementia and abuse training.
The NHA said it was important for CNAs to complete their annual training to stay updated on current bedside skills and education.
The NHA said she would conduct an audit in the facility to ensure all staff had completed training appropriately moving forward.
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Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623
F-F550 dignity:
The facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect.
Cross-reference
F-F645 Preadmission Screening and Resident Review (PASRR) Level I:
The facility failed to ensure a PASRR Level I screening was completed within thirty days of admission.
Cross-reference
F-F655 baseline care plans:
The facility failed to develop and implement acute/baseline care plans.
Cross-reference
F-F677 activities of daily living for dependent residents:
The facility failed to provide appropriate treatment and services to maintain or improve residents' ability to perform activities of daily living.
Cross-reference
F-F684 quality of care:
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice.
Cross-reference
F-F685 treatment or devices to maintain hearing and vision:
The facility failed to ensure proper treatment and services to maintain hearing.
Cross-reference
F-F688 range of motion:
The facility failed to ensure residents with limited mobility reviewed for range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.
065237
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 065237 B.
Wing 08/29/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623
F-F692 nutrition and hydration:
The facility failed to ensure effective interventions were in place to address weight loss timely.
potential for actual harm Cross-reference
F-F695 respiratory:
The facility failed to ensure residents received proper respiratory treatment and care.
Cross-reference
F-F758 unnecessary psychotropic medications:
The facility failed to ensure residents were as free from unnecessary psychotropic drugs as possible.
Cross-reference
F-F804 palatable food:
The facility failed to ensure residents were provided with food cooked and served in a manner that conserved nutritive value, flavor, appearance, texture and at an appetizing temperature.
Cross-reference
F-F812 kitchen sanitation:
The facility failed to prepare and serve food in a sanitary manner.
III.
Staff interviews
The nursing home administrator (NHA) and regional vice president (RVP) were interviewed together on 8/29/24 at 7:43 p.m.
The NHA said the facility did not invite floor staff, residents or family members to their QAPI meetings or for feedback but the facility wanted to.
She said the facility had not accomplished getting others involved in the QAPI meetings.
The NHA said dignity, baseline care plans, positioning residents, restorative services, weight loss, oxygen canisters, as-needed psychotropic medications, PASRR Level I screens, palatable food and kitchen sanitation were not identified by the QAPI team as areas for improvement.
The NHA said hand hygiene and infection control were always watched as an area for improvement but resident hand hygiene and appropriate cleaning of resident rooms were not identified as an area for improvement until the annual recertification survey.
065237
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 065237 B.
Wing 08/29/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623
F-F880 infection control:
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.
Cross-reference
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.