South Valley Post Acute Rehabilitation
Inspection Findings
F-Tag F0689
F 0689
implemented of two-person assistance for transfer with staff.
Level of Harm - Minimal harm or potential for actual harm
-However, according to the fall care plan, the intervention for Resident #2 to become a two-person assist for transfers with staff was initiated on [DATE REDACTED].
Residents Affected - Some
C. Staff interviews CNA #5 was interviewed on [DATE REDACTED] at 2:33 p.m. CNA #5 said she was involved in Resident #2's assisted fall. She said she prepared to transfer Resident #2 from the bed to the wheelchair. She said the resident looked wobbly and weak, so she attempted to sit Resident #2 on the bed. CNA #5 said the resident was seated on the edge and had to be assisted to the ground. CNA #5 said Resident #2 was wearing non-slip socks and a gait belt when she attempted to independently transfer the resident from the bed to her chair.
She said Resident #2 usually required one-person staff assistance to transfer.
The DON was interviewed on [DATE REDACTED] at 2:46 p.m. The DON said when a fall was sustained by a resident,
the staff should try to determine the root cause of the fall with an IDT approach. She said the initial response should include making sure the resident was safe and could access their call light. The DON said
the care plan should be updated when new interventions. She said after Resident #2's fall on [DATE REDACTED] the fall care plan was revised with new interventions, including the two-person assist with transfers. The DON said
she was unable to determine if a two-person transfer occurred at the time of the fall.
The DON was interviewed again on [DATE REDACTED] at 4:13 p.m. The DON said CNA #5 transferred Resident #2 independently on [DATE REDACTED]. She said CNA #5 did not know Resident #2 became a two-person assist with transfers. She said the new intervention that was implemented after Resident #2's fall on [DATE REDACTED] of the resident becoming a two person transfer was not transcribed onto the CNA tasks, which led to CNA #5's lack of knowledge of the resident's current transfer status.
FORM CMS-2567 (02/99) Previous Versions Obsolete
Event ID:
Facility ID:
If continuation sheet
SOUTH VALLEY POST ACUTE REHABILITATION in DENVER, CO inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in DENVER, CO, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from SOUTH VALLEY POST ACUTE REHABILITATION or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.