Highline Post Acute
HIGHLINE POST ACUTE in DENVER, CO — inspection on August 15, 2024.
Found 11 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
nurse at the station answered the calls and diverted the call to residents from there.
cordless phones at each nurse's station. LPN #4 said the residents came to the nurse's station to get
receptionist transferred the call to the unit, the facility receptionist went to the unit and stood there until the nurse answered the phone. LPN #4 said the facility receptionists took messages and gave them to the unit nurse to pass onto the respective resident.
Receptionist #1 was interviewed on 8/15/24 at 12:08 p.m.
Receptionist #1 said residents had a phone at each unit.
Receptionist #1 said the facility receptionists took messages and gave them to the nurse on the unit or the resident themselves.
The social services director (SSD) was interviewed on 8/15/24 at 12:14 p.m.
The SSD said resident phone calls came through the reception desk and were diverted to whichever unit the resident resided on.
The SSD said the unit nurse either took a message or gave the phone to the resident to take the call.
The SSD said the unit phones were put in place around six months prior, and before that, there were phone lines in each residents' room.
The SSD said she did not know why the phone lines were taken out of the residents' rooms.
The SSD said she had received some grievances regarding family members leaving messages that were not followed through or not being able to get their call through to the cordless phone. -However, residents continued to feel as though they did not have adequate access or privacy to make phone calls (see resident interviews above).
065256 08/15/2024
Highline Post Acute 6060 E Iliff Ave Denver, CO 80222
The incontinence care plan, revised 10/6/23, revealed Resident #46 had mixed bladder incontinence
establishing voiding patterns and monitoring/documenting intake and output per facility policy.
The communication care plan, revised 10/6/23, revealed Resident #46 had communication problems resulting from hearing deficits.
Pertinent interventions included anticipating and meeting Resident #46's needs, asking yes or no questions when appropriate and using simple, brief and consistent words and cues when communicating.
The cognitive impairment care plan, revised 7/12/24, care plan revealed Resident #46 had cognitive loss related to altered cognitive performance.
Pertinent interventions included anticipating needs and meeting them promptly.
The 4/29/24 bowel and bladder assessment revealed Resident #46 had a neurogenic bladder and was on the check and change program.
The assessment revealed Resident #46 required one-person assistance for mobility and she was usually bed-bound.
The 7/19/24 nursing summary revealed Resident #46 was on the check and change program.
The 7/30/24 nursing summary revealed Resident #46 was on the check and change program.
The summary revealed Resident #46 was incontinent and she sometimes called the nursing staff in to change her. Resident #46 was very hard of hearing and nursing staff had to raise their voice and get close so the resident could lip read when communicating.
E.
Staff interviews CNA #4 was interviewed on 8/13/24 at 1:17 p.m. CNA #4 said Resident #46 used her call light to be changed. CNA #4 said Resident #46 used her call light whenever she needed to be changed. CNA #4 said Resident #46 had been incontinent of both bowel and bladder during the care provided just before the interview.
CNA #4 was interviewed a second time on 8/15/24 at 10:19 a.m. CNA #4 said the check and change program meant the residents were checked and changed every two hours. CNA #4 said this frequency did not vary by resident and was consistent across the board, meaning every resident had to be checked at least every two hours. CNA #4 said she was not sure where these checks were recorded in the resident's electronic medical record (EMR). -However, a continuous observation revealed Resident #46 was not checked or changed for over three hours (see observations above).
Licensed practical nurse (LPN) #1 was interviewed on 8/15/24 at 11:47 a.m. LPN #1 said the check and change program was used for residents who were incontinent. LPN #1 said the CNAs did not have an established time-frame for the check and change program, but they knew they needed to check the residents and have their schedule established for the day.
065256 08/15/2024
Highline Post Acute 6060 E Iliff Ave Denver, CO 80222
Resident #24.
She said nurses and CNAs were responsible for monitoring the level of oxygen each
concentrator to 4 LPM and Resident #24's oxygen concentrator to 2 LPM to match their physician's
LPN #4 was interviewed on 8/14/24 at 1:36 p.m. LPN #4 said Resident #24 had a physician's order for 2 LPM of oxygen continuously. LPN #4 said she was unsure why Resident #24 was on the incorrect liter flow of oxygen.
She said she should have checked the liter flow at the beginning of her shift when she was administering the resident's morning medications.
The director of nursing (DON) was interviewed on 8/14/24 at 1:45 p.m.
The DON said a physician's order was required for any medication or treatment.
She said, in an emergent situation, oxygen could be administered but a physician's order should be obtained within 24 hours of the change.
The DON said it was the responsibility of all nursing staff to ensure residents were on the correct liter flow of oxygen at the beginning of their shift and intermittently throughout their shift.
The DON said not following a physician's order for oxygen therapy could result in medical complications such as shortness of breath and cell damage to the brain.
The DON said she initiated audits (during the survey) of all the residents receiving oxygen therapy to ensure they were on the correct liter flow of oxygen.
The DON said she would provide education to all nursing staff regarding oxygen liter flow to prevent future incidents of residents receiving the incorrect liter flow of oxygen.
065256 08/15/2024
Highline Post Acute 6060 E Iliff Ave Denver, CO 80222
outcome of these reviews for five of five certified nurse aides (CNA).
Specifically, the facility failed to complete annual performance reviews for CNA #1, CNA #2, CNA #5, CNA #6 and CNA #7 in order to determine potential training needs.
Findings include: I.
Facility policy and procedure The Performance Evaluations policy and procedure, revised September 2020, was provided by the regional director of clinical services (RDCS) on 8/19/24 at 1:18 p.m. It read in pertinent part, The job performance of each employee shall be reviewed and evaluated at least annually.
A performance evaluation will be conducted on each employee at the conclusion of his/her 90 day probationary period, and at least annually thereafter.
Performance evaluations may be used in determining employee's promotion, shift/position transfer, demotions, terminations, wage increases and to improve the quality of the employee's work performance.
The written performance evaluations will contain the director's and/or supervisor's remarks and suggestions, any action that should be taken (further training), and goals.
II.
Record review Annual performance reviews were requested on 8/14/24 at 1:20 p.m for CNA #1 (hired on 3/31/21), CNA #2 (hired on 8/23/22), CNA #5 (hired on 12/22/22), CNA #6 (hired on 5/20/2020) and CNA #7 (hired on 5/1/14 ). -The facility was unable to provide annual performance evaluations for 2023-2024 for all five CNAs. -The director of nursing (DON) said the five CNAs did not have annual performance reviews and had not completed annual in-service education based on the outcome of their reviews.
Cross-reference F-F947 for failure to ensure CNAs received annual training as required.
III.
Staff interviews The DON was interviewed on 8/15/24 at 11:50 a.m.
The DON said she had just recently become the DON at the facility.
She said annual performance reviews had not been completed.
The RDCS was interviewed on 8/15/24 at 11:26 a.m.
The RDCS said the annual performance evaluations had not been completed as required.
She said, during the survey, the facility had put a plan in place to ensure annual performance reviews were completed timely.
065256 08/15/2024
Highline Post Acute 6060 E Iliff Ave Denver, CO 80222
facility's house stock for emergencies, for example when there was a new physician's order and the
own vial or pen for insulin.
On 8/14/24 at 12:13 p.m. the Capitol Hill medication cart was observed with registered nurse (RN) #1.
The following was observed: -One vial of Lantus insulin was stored next to Latanoprost 0.005% eye drops in the medication cart.
RN #1 was interviewed on 8/14/24 at 12:25 she said medications should be stored according to the route they were to be administered to prevent infections.
On 8/14/24 at 12:18 p.m. the Capitol Hill medication storage room was observed with RN #1.
The following was observed: -The medication storage refrigerator was unlocked and there were four 237 milliliters (ml) cartons of Boost (supplement drink) on the shelf with Lorazepam (antianxiety controlled medication), liquid cephalexin (antibiotic) and two boxes of Trulicity injectable pens (used for glucose control). -The medication refrigerator was a dormitory style refrigerator where the freezer compartment was in the main compartment of the refrigerator.
The freezer compartment had built up ice around and in the freezer.
RN #1 was interviewed on 8/14/24 at 12:25 p.m. RN #1 said there should not be food or oral nutritional supplements in the refrigerator with medications. RN #1 said the ice build up in the freezer compartment could potentially cause temperature fluctuations and medications needed to be kept within a certain temperature range.
IV.
Additional staff interviews The director of nursing (DON) was interviewed on 8/14/24 at 11:18 a.m.
The DON said insulin vials or pens should have the resident's name on them to verify who the medication belonged to.
The DON said she would pull the vial of glargine insulin from the medication cart.
The DON was interviewed a second time on 8/15/24 at 12:14 p.m.
The DON said the facility had obtained a new vial of glargine insulin to replace the glargine insulin vial that had no name on it from the Cherry Creek long hall medication cart.
The DON said food and nutritional supplements should not be stored with medications in the medication refrigerator in order to prevent contamination.
The DON said medications should be stored according to the route they were to be administered in the medication carts to prevent contamination/infection.
The DON said dormitory style refrigerators should not be used for medication storage as their temperatures could fluctuate and compromise medications.
The DON said she was not aware the facility had any dormitory style refrigerators.
065256 08/15/2024
Highline Post Acute 6060 E Iliff Ave Denver, CO 80222
mistake.
065256 08/15/2024
Highline Post Acute 6060 E Iliff Ave Denver, CO 80222
always receive what they ordered.
The residents said the kitchen served all of the residents the same food items.
The group said the kitchen staff gave the residents what the kitchen wanted to serve and did not explain why the residents did not get what they ordered.
V.
Additional staff interviews The DON and the regional director of clinical services (RDCS) was interviewed on 8/15/24 at 1:30 p.m.
The DON said the CNAs needed to notify the nurse or unit manager if a resident refused their meal.
The RDCS said the facility had given education to CNAs about offering alternative menu items to residents and making sure the care plan reflected it.
The DON and the RDCS said they were not aware residents were not receiving the alternative menu items they had requested.
The DON and the RDCS said they were not aware that residents were not receiving the menu items they had requested.
Dietary aide (DA) #2 was interviewed on 8/15/24 at 1:56 p.m. DA #2 said the CNAs took the residents' orders and were responsible for helping the residents fill out their meal tickets. DA #2 said all of the residents received the same meals despite what was written on their meal tickets.
065256 08/15/2024
Highline Post Acute 6060 E Iliff Ave Denver, CO 80222
sheet.
The NSD was interviewed on 8/14/24 at 2:50 p.m.
The NSD said the procedure for time and temperature control for food was heating hot food again to make sure it was a safe temperature prior to serving.
She said cold food items should be stored in an ice bath for service to ensure the food maintained the correct temperature.
The NSD said the ideal holding temperatures for hot foods was above 135 degrees F and for cold foods was below 36 degrees F.
The NSD said she did not think the steam table was holding temperatures well and she would look into ordering new equipment.
065256 08/15/2024
Highline Post Acute 6060 E Iliff Ave Denver, CO 80222
Resident #55 should be on EBP.
should wear a gown, gloves and mask when providing care for residents with indwelling lines, feeding
065256 08/15/2024
Highline Post Acute 6060 E Iliff Ave Denver, CO 80222
reviewed before the CNAs began working with the residents.
During a continuous observation of the lunch meal service in the secure unit on 8/14/24, beginning at 11:15 a. m. and ending at 2:00 p.m., the following was observed:
At 12:04 p.m. the lunch meal cart arrived at the secure unit.
Between 12:04 p.m. and 12:22 p.m. the facility staff served nine residents seated in the dining room their meal trays and each of the nine residents had a glass of cranberry juice on their meal tray.
-A total of nine residents eating in the dining room had a glass of pre-poured cranberry juice sent on the meal tray cart on each resident's meal tray.
-No other drinks were on the resident meal tray carts or offered to the residents.
B.
Staff interviews
Certified nurse aide (CNA) #2 was interviewed on 8/15/24 at 10:46 a.m. CNA #2 said the staff asked the residents for their preferences.
She said the residents' dislikes and allergies were listed on their care plans and the meal tickets. CNA #2 said the staff asked residents what their drink preferences were.
She said if a resident was unable to choose, the facility sent the resident cranberry juice because it was good for the resident's bladders. CNA #2 said the dietary staff used to send pitchers of different juices and milk to the secure unit for meal time but no longer did so. CNA #2 said the drinks for residents living on the secure unit were poured in the kitchen and sent in the meal tray cart at meal time.
065256
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 065256 B.
Wing 08/15/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Highline Post Acute 6060 E Iliff Ave Denver, CO 80222
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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.