Eagle Ridge Post Acute
EAGLE RIDGE POST ACUTE in GRAND JUNCTION, CO — inspection on June 12, 2024.
Found 27 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
F-F565:
The facility failed to ensure effective interventions to resident council grievances of call light response time.
Cross-reference
F-F567:
The facility failed to ensure proper consent and notification of spending of personal funds.
065286
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 065286 B.
Wing 06/12/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501
F-F580:
The facility failed to ensure a resident's representative was notified after a change in condition.
potential for actual harm Cross-reference
F-F582:
The facility failed to give the proper two day notification before Medicare A benefits expired.
Cross-reference
F-F610:
The facility failed to investigate a potential allegation of abuse.
Cross-reference
F-F644:
The facility failed to submit a PASRR Level I based on diagnosis.
Cross-reference
F-F645:
The facility failed to complete a PASRR Level II after a PASRR Level I determination.
Cross-reference
F-F661:
The facility failed to ensure a discharge summary was completed after a resident was discharged .
Cross-reference
F-F685:
The facility failed to ensure a resident received eye glasses after an eye exam.
Cross-reference
F-F688:
The facility failed to provide restorative nursing services.
Cross-reference
F-F689:
The facility failed to assess a resident after injuries were identified after a potential fall.
Cross-reference
F-F692:
The facility failed to implement interventions to prevent further weight loss after a resident had significant weight loss.
Cross-reference
F-F730:
The facility failed to complete annual evaluations for certified nurse aides (CNA).
Cross-reference
F-F732:
The facility failed to have an accurate nursing staff posting.
Cross-reference
F-F744:
The facility failed to provide adequate dementia care training for the secure unit; failed to implement a dementia care plan for refusals of food, medications, fluids and vital signs.
Cross-reference
F-F758:
The facility failed to limit PRN (as needed) psychotropic medications to 14 days or have physician documentation of the rationale.
Cross-reference
F-F761:
The facility failed to ensure all medications were stored appropriately and maintain medication refrigerator temperature logs.
Cross-reference
F-F804:
The facility failed to serve palatable food in taste and temperature.
Cross-reference
F-F805:
The facility failed to serve food according to a physician's order.
Cross-reference
F-F812:
The facility failed to prepare, store and serve food in a sanitary manner.
065286
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 065286 B.
Wing 06/12/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501
F-F842:
The facility failed to accurately document fluid intake.
F-F849:
The facility failed to ensure the facility received hospice notes and physician orders. potential for actual harm Cross-reference
According to Medaval Certified Accuracy (a company that provides accreditation, validation and equivalence services for medical devices) Equate 4000 series (UA-4000WM, retrieved on 6/20/24 from https://www. medaval.ie/resources/EN/devices/Equate-4000-Series-UA-4000WM.html,
The Equate 4000 Series (UA-4000WM) is an automatic blood pressure monitor.
Medaval has not found evidence proving the accuracy of its blood pressure measurement technology.
Blood pressure measurements are taken from the upper arm. It is intended for self-measurement and home use.
II.
Observations
On 6/6/24 at 9:48 a.m., licensed practical nurse (LPN) #5 was observed using an Equate model VA-4000WM blood pressure cuff to take Resident #166's blood pressure.
-LPN #5 did not use a blood pressure cuff rated for medical use to obtain Resident #166's blood pressure (see professional references above and interview below).
065286
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 065286 B.
Wing 06/12/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501
F-F882:
The facility failed to have an infection preventionist at least part time to run an effective infection control program.
Cross-reference
F-F908:
The facility failed to ensure the use of appropriate medical grade blood pressure cuffs.
Cross-reference
F-F943:
The facility failed to ensure all staff completed abuse training annually.
Cross-reference
F-F947:
The facility failed to ensure CNAs received 12 hours of required training annually.
Cross-reference EP004:
The facility failed to ensure the emergency preparedness plan was reviewed annually.
Cross-reference EP039:
The facility failed to conduct emergency exercises annually.
II.
Interviews
The NHA, the regional operations manager (ROM) and the director of nursing (DON) were interviewed together on [DATE] at 4:32 p.m.
The NHA said the QAPI committee meeting was held monthly.
The NHA said the meeting included the interdisciplinary (IDT) team as well as the medical director and pharmacist.
The NHA said the QAPI committee identified areas of concerns, created performance improvement plans, set goals and reviewed the progress of the plans and determined if additional meetings and education were needed on the concerns and/or one-on-on interventions.
The NHA said to ensure systematic change, the facility continued the conversations of the identified concern and determined if revisions to the plan were necessary.
The NHA said several of the identified concerns were reviewed in the QAPI meetings but the facility had had changes to personnel and the support provided was not enough.
The NHA said the facility had to make significant changes over the last few months.
The NHA said the changes were underway but not as quickly as the facility would want.
065286
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 065286 B.
Wing 06/12/2024
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501