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PRINTED: 03/01/2018

DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED


CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

ADVANCED HEALTH CARE OF AURORA 1800 SOUTH POTOMAC STREET


AURORA 80012

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


(EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

F 000 INITIAL COMMENTS F 000

A survey with complaints #CO 21127was


completed on 1/31/18. Deficiencies were cited.

F 580 483.10(g)(14)(i)-(iv)(15) Notify of Changes F 580 02/13/2018


SS=E (Injury/Decline/Room, etc.)

§483.10(g)(14) Notification of Changes.


(i) A facility must immediately inform the
resident; consult with the resident's physician;
and notify, consistent with his or her authority,
the resident representative(s) when there is-
(A) An accident involving the resident which
results in injury and has the potential for
requiring physician intervention;
(B) A significant change in the resident's
physical, mental, or psychosocial status (that is,
a deterioration in health, mental, or psychosocial
status in either life-threatening conditions or
clinical complications);
(C) A need to alter treatment significantly (that
is, a need to discontinue an existing form of
treatment due to adverse consequences, or to
commence a new form of treatment); or
(D) A decision to transfer or discharge the
resident from the facility as specified in
§483.15(c)(1)(ii).
(ii) When making notification under paragraph
(g)(14)(i) of this section, the facility must ensure
that all pertinent information specified in
§483.15(c)(2) is available and provided upon
request to the physician.
(iii) The facility must also promptly notify the
resident and the resident representative, if any,
when there is-
(A) A change in room or roommate assignment
as specified in §483.10(e)(6); or
(B) A change in resident rights under Federal or
State law or regulations as specified in
paragraph (e)(10) of this section.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards
provide sufficient protection to the patients . (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or
not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available
to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 1 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

ADVANCED HEALTH CARE OF AURORA 1800 SOUTH POTOMAC STREET


AURORA 80012

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


(EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

F 580 Continued From page 1 F 580

(iv) The facility must record and periodically


update the address (mailing and email) and
phone number of the resident
representative(s).

§483.10(g)(15)
Admission to a composite distinct part. A facility
that is a composite distinct part (as defined in
§483.5) must disclose in its admission
agreement its physical configuration, including
the various locations that comprise the
composite distinct part, and must specify the
policies that apply to room changes between its
different locations under §483.15(c)(9).

This REQUIREMENT is not met as evidenced


by:
On 2/1/18 at 11:00 a.m. the nursing home Plan of Correction
administrator (NHA) provided a copy of the Complaint Survey 01/05/2018 -
facilities policy and procedure, titled "Change in 02/01/2018
Patient Condition", last revised 12/8/16, included • F580: Notify of Changes
in pertinent part: "the nurse supervisor/charge (Injury/Decline/Room/Transfer, etc)
nurse will notify the patient ' s family or
representative when it is necessary to transfer o Patient Specific: Patient Number #7
the patient to a hospital/treatment center. A and #1 has been discharged.
representative of the business office will verify
the address and telephone number of the o Other Patients: On 2/13/2018, the
patient ' s family or representative." DON conducted an audit of all patients
that had been discharged since 2/07/2018
Resident Status to the hospital due to one of the following
reasons; Injury/Decline/Room/Transfer,
Resident #7 etc. and verified that the following was
completed; 1. Physician Order, 2.
Resident #7, age 71, was admitted to the facility Family/Responsible Party Notified, 3.
on 12/27/17 and discharged to the hospital on Nurses’ Progress note entered.
12/28/18. He was readmitted to the facility on
12/31/17. According to the face sheet, o All nurses on duty 2/13/2018 were
diagnoses included: atrial fibrillation (irregular in-serviced regarding “Notify of Changes”
heart rate), heart failure, and chronic obstructive to family and/or responsible party related
pulmonary disease. to Injury/Decline/Room/Transfer, etc. All

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 2 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

ADVANCED HEALTH CARE OF AURORA 1800 SOUTH POTOMAC STREET


AURORA 80012

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


(EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

F 580 Continued From page 2 F 580

nurses on duty were in-serviced regarding


The resident did not have an minimum data set the following must be completed; 1.
(MDS) assessment completed related to the Physician Order, 2. Family/Responsible
resident being in the facility less than 24 hours. Party Notified, 3. Nurses’ Progress note
entered.
The interim person centered care plan, initiated
12/27/17, indicated the resident had an o Systemic Changes: On 2/13/2018, all
alteration in cardiac or respiratory status. licensed nursing staff were in-serviced
Interventions included: and educated regarding “Notify of
-Medications as ordered; Changes” to family and/or responsible
-Labs as ordered; party related to
-Treatments as ordered; Injury/Decline/Room/Transfer, etc. All
-Oxygen as ordered; licensed nursing staff were in-serviced
-Vital signs daily; regarding the following must be
-Weight weekly; completed; 1. Physician Order, 2.
-Monitor for signs and symptoms of cardiac or Family/Responsible Party Notified, 3.
respiratory exacerbation and report changes to Nurses’ Progress note entered.
the physician.
o Monitors:
Record Review The Director of Nursing, or her designee,
will audit and document on current
According to the resident ' s face sheet, the patients weekly for 4 weeks, then monthly
resident ' s sister was listed as an emergency for 3 months, to ensure that the patients
contact, health and financial power of attorney that were discharged since 2/07/2018 to
with one phone number listed. There was also the hospital due to one of the following
another family member listed as an emergency reasons; Injury/Decline/Room/Transfer,
contact with two numbers listed. etc. and verify that the following was
completed; 1. Physician Order, 2.
According to the emergency contact form Family/Responsible Party Notified, 3.
located in the residents chart, the resident ' s Nurses’ Progress note entered. She will
sister was listed as the first emergency contact report the details of her findings at the
and another family member was listed as the quality assurance meeting. She will make
second emergency contact number. the necessary changes to the above plan
of corrections as needed.
According to a nurse ' s progress note on
12/28/17 at 3:56 p.m. the patient ' s heart rate o Date of Compliance: 2/13/2018
continued to read between 110-160 beats per
minute, electrocardiogram (EKG) results were
still pending. At 5:55 p.m. the patient's EKG
results came back, the physician was notified

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 3 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

ADVANCED HEALTH CARE OF AURORA 1800 SOUTH POTOMAC STREET


AURORA 80012

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


(EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

F 580 Continued From page 3 F 580

and the facility received orders to send the


patient to the emergency room. Paramedics
came and the patient left the facility via
stretcher.

There was no documentation in the resident ' s


record to indicate the resident ' s
representative/emergency contact had been
notified of the resident ' s transfer to the
emergency room.

Resident #1

Resident #1, age 77, was admitted on 11/7/17


and discharged to the emergency room on
11/9/17. According to the face sheet, diagnosis
included chronic obstructive pulmonary disease.

According to the 11/9/17 MDS assessment, the


resident had no cognitive impairment with a brief
interview for mental status (BIMS) score of 15
out of 15.

The interim person centered care plan, initiated


11/7/17, indicated the resident had an alteration
in cardiac or respiratory status. Interventions
included:
-Medications as ordered;
-Labs as ordered;
-Treatments as ordered;
-Oxygen as ordered;
-Vital signs daily;
-Weight weekly;
-Monitor for signs and symptoms of cardiac or
respiratory exacerbation and report changes to
the physician.

Family Interview

The resident ' s sister was interviewed on

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 4 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

ADVANCED HEALTH CARE OF AURORA 1800 SOUTH POTOMAC STREET


AURORA 80012

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


(EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

F 580 Continued From page 4 F 580

1/31/18 at 12:47 p.m. She said she was never


notified by the facility that her mother had been
transferred to the emergency room. She said
the emergency room physician was the only
contact she had in regards to her mother ' s
status on 11/9/17. She said she did not have
any messages to call the facility and did not
receive a call from her mother ' s private nurse.
She said she contacted the private nurse after
she had spoken with the emergency room
physician. She said her mother was a widow
and she was her mother ' s emergency contact
and power of attorney (POA).
Record Review

According to the resident ' s face sheet, the


emergency contact was listed as the resident ' s
spouse. It did not list the resident ' s daughter as
an emergency contact.

According to the emergency contact form, the


resident ' s daughter was listed first as an
emergency contact, however the number listed
was not correct. There were two other names
on the form listed as "friends" but no numbers
were listed.

According to a nursing progress note on 11/9/17


at 8:12 a.m. when the nurse went to the room to
check on the patient after shift change, the
patient was breathing but unresponsive. Vital
signs were obtained while another nurse called
911. The patient was picked up by paramedics
via stretcher at around 6:55 a.m. The patient's
daughter, who was the primary contact listed
was called with no response. A message was
left to call the facility back. Friends listed and the
second and third contact had no phone
numbers listed. The patient ' s caregiver/nurse
at home was called and notified. (This number

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 5 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

ADVANCED HEALTH CARE OF AURORA 1800 SOUTH POTOMAC STREET


AURORA 80012

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


(EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

F 580 Continued From page 5 F 580

could not be located in the resident ' s record).


The caregiver said she would get a hold of the
patient ' s daughter.

Staff Interviews

Registered nurse (RN) #1 was interviewed on


1/11/18 at 11:15 a.m. She said whenever they
transferred a resident to the hospital, they would
call the physician and get an order. They would
call 911, get the paperwork ready, write a
telephone order, notify the emergency medical
technicians (EMT) of the status of the resident
then the family would be called. She said they
always got vital signs and filled out a hospital
transfer sheet that was sent to the hospital with
the resident along with a copy of the telephone
order for the resident to be evaluated at the
emergency room. She said there was no
transfer discharge paperwork that stayed in the
resident ' s chart unless the resident returned
from the hospital, then the transfer sheet would
be put into the record, otherwise only a progress
note was done.

Licensed practical nurse (LPN) #1 was


interviewed on 1/11/18 at 12:15 p.m. She said
she was the nurse that sent resident #1 out to
the emergency room for respiratory distress.
She said she had attempted to call the contact
person on the chart but did not get an answer.
She said she left a message to call the facility
back. She said two other names were on the list
but did not have numbers. She said there was a
piece of paper in the chart that had her previous
caregivers name and number on it. She said
this person had been in the facility visiting with
the resident the previous day. She said she
called that number and was able to get a
message to this person that the resident had

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 6 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

ADVANCED HEALTH CARE OF AURORA 1800 SOUTH POTOMAC STREET


AURORA 80012

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


(EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

F 580 Continued From page 6 F 580

been sent out to the hospital. She said the


daughter ' s number was from out-of-state and
she never did receive a call back from the
daughter.

The director of nursing (DON) was interviewed


on 1/11/18 at 5:32 p.m. She said the nurse that
sent out resident #7 did not notify the power of
attorney but the nurse manager did but he did
not document it. She said this should have been
documented in a progress note in the residents
record.

RN #1 was interviewed again on 2/1/18 at 9:22


a.m. She said she was the admissions nurse
when resident #1 was admitted. She said the
emergency contact form was completed by her.
She said she got the information from the
patient. She said the facility liaison completed
the information on the face sheet.

The DON and the NHA were interviewed on


2/1/18 at 10:15 a.m. They said the admission
nurse obtained the information for the face
sheet and should cross reference it with the
information from the hospital. The NHA said,
"We are only as good as the information we
get." He said the business office manager would
then verify all the information such as Medicare
or insurance information and contact
information. He said it would then be verified
within 24 hours with the patient or the POA. The
DON said the staff usually referred to the
contact form and that information was gathered
from the resident. She did not feel it needed to
be verified.

F 610 483.12(c)(2)-(4) Investigate/Prevent/Correct F 610 02/13/2018


SS=D Alleged Violation

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 7 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

ADVANCED HEALTH CARE OF AURORA 1800 SOUTH POTOMAC STREET


AURORA 80012

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


(EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

F 610 Continued From page 7 F 610

§483.12(c) In response to allegations of abuse,


neglect, exploitation, or mistreatment, the facility
must:

§483.12(c)(2) Have evidence that all alleged


violations are thoroughly investigated.

§483.12(c)(3) Prevent further potential abuse,


neglect, exploitation, or mistreatment while the
investigation is in progress.

§483.12(c)(4) Report the results of all


investigations to the administrator or his or her
designated representative and to other officials
in accordance with State law, including to the
State Survey Agency, within 5 working days of
the incident, and if the alleged violation is
verified appropriate corrective action must be
taken.

This REQUIREMENT is not met as evidenced


by:
Based on record review and staff interviews, the Plan of Correction
facility failed to thoroughly investigate Complaint Survey 01/05/2018 -
allegations of possible resident abuse for one 02/01/2018
(#1) of three sample residents. • F610:
Specifically, the facility failed to conduct and Investigation/Prevention/Correct Alleged
document interviews with individuals pertinent to Violation
the investigation and to follow up on findings.
o Patient Specific:Patient Number #1
The findings included: has been discharged.

Facility Policy and Procedure o Other Patients: On 2/13/2018, the


NHA conducted an audit of all complaints
On 1/31/18 at 4:43 p.m. the nursing home as of 02/07/2018 related to “Response to
administrator (NHA) provided a copy of the allegations of abuse, neglect, exploitation,
facilities policy and procedure, titled "Reporting and/or mistreatment” and verified that the
and Investigating", last revised 12/20/17, which following complaints included; 1. Have
included in pertinent part: "The administrator evidence that all alleged violations are
and/or director of nursing will complete an thoroughly investigated, 2. Prevention of

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 8 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

ADVANCED HEALTH CARE OF AURORA 1800 SOUTH POTOMAC STREET


AURORA 80012

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


(EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

F 610 Continued From page 8 F 610

investigation of the incident including a written further potential abuse, neglect,


summary of the findings no later than five exploitation, and/or mistreatment while the
working days of the reported occurrence. The investigation is in progress 3. Report the
summary will include interview notes, incident results of all investigations in accordance
report, and written, signed and dated statements with State Law and Survey Agencies.
from the accused, any witnesses and the person
reporting the incident. All pertinent staff, o Systemic Changes: All complaints
resident(s), and other witnesses must be related to “Response to allegations of
interviewed and the results of the interview abuse, neglect, exploitation, and/or
documented in some form. Whenever possible, mistreatment” moving forward are to
have witnesses sign a written statement. In include the following; 1. Have evidence
cases of injury of unknown source, all staff that all alleged violations are thoroughly
having possible contact with the resident over investigated and include the conducted
the 24 hours prior to injury discovery must be and documented any/all interviews with
interviewed. In cases of unwitnessed incidents, individuals (i.e. direct staff, patient, and
the facility needs to determine when the resident visitor) pertinent to the investigation and
was last observed by staff and what the resident follow up on findings, 2. Prevention of
was doing at the time." further potential abuse, neglect,
exploitation, and/or mistreatment while the
Resident status investigation is in progress by suspending
any/all individuals identified as a person of
Resident #1, age 77, was admitted on 11/7/17. interest, 3. Report the results of all
According to the face sheet, diagnoses investigations in accordance with State
included: Chronic Obstructive Pulmonary Law and Survey Agencies (if necessary).
Disease, Pneumonia, atrial fibrillation,
depression and hypertension. o Monitors: The NHA, or designee, will
According to the 11/9/17 minimum data set audit and document on current patients
(MDS) assessment, the resident had no with complaints related to “Response to
cognitive impairment with a brief interview for allegations of abuse, neglect, exploitation,
mental status (BIMS) score of 15 out of 15. She and/or mistreatment” weekly for 4 weeks,
required extensive assistance of one staff then monthly for 3 months, to ensure that
member for bed mobility, transfers, toilet use the patients who report complaints include
and personal hygiene. the following; 1.Have evidence that all
alleged violations are thoroughly
The interim care plan, initiated on 11/7/17, investigated and include the conducted
indicated the resident had a self-care deficit and and documented any/all interviews with
required assistance with her activities of daily individuals (i.e. direct staff, patients, and
living (ADL). It also indicated the resident was visitors) pertinent to the investigation and
alert and oriented to person, place and time. follow up on findings, 2. Prevention of
further potential abuse, neglect,

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 9 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

ADVANCED HEALTH CARE OF AURORA 1800 SOUTH POTOMAC STREET


AURORA 80012

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


(EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

F 610 Continued From page 9 F 610

Staff Interviews exploitation, and/or mistreatment while the


investigation is in progress by suspending
The NHA was interviewed on 1/10/18 at 11:30 any/all individuals identified as a person of
a.m. He shared information about an ongoing interest, 3. Report the results of all
investigation being done by the police investigations in accordance with State
department. He said the facility first heard about Law and Survey Agencies (if necessary).
the allegation of possible sexual abuse when The NHA will report the details of her
the police department showed up at the facility findings at the quality assurance meeting.
the morning of 11/9/17 after resident #1 was The NHA will make the necessary
discharged to the emergency room in changes to the above plan of corrections
respiratory distress. as needed.

Review of the facility investigation into the o Date of Compliance: 2/13/2018


allegation revealed the following:

-The facility interviewed nine residents. Four of


the resident ' s resided on the same hall (Hall 3)
as the resident in question. They were all asked
three general questions about their stay:
1.) How has your stay at our facility been so far?
2.) How has the staff treated you?
3.) Do you have any concerns with the care that
you are receiving?
No issues or concerns were identified. There
were 17 resident ' s available to interview on
Hall 3 at the time in question.

-The facility interviewed multiple staff members.


They were all asked the same four general
questions: -
1.) In the last 72 hours have you witnessed
anything inappropriate as far as care or anything
abnormal for patient in room -?
2.) In the last 72 hours has the patient indicated
to you any concerns or anything abnormal or out
of the ordinary to you?
3.) In the last 72 hours did you notice anyone
that didn ' t have a reason to be in room-?
4.) In the last 72 hours have you seen any
visitors or non-staff members go into room -?

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 10 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

ADVANCED HEALTH CARE OF AURORA 1800 SOUTH POTOMAC STREET


AURORA 80012

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


(EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

F 610 Continued From page 10 F 610

There was no indication that any follow up had


been conducted with the results of these
questions. Several staff members ' mentioned
seeing a "woman/caregiver/nurse/lady in a
hat/family/friends" in the resident ' s room but no
follow up was made to indicate if this
person/persons were identified, if they were the
same person and if they were allowed to be in
the facility. There was no indication as to what
times this "visitor" was seen in the resident ' s
room.

-The facility checked the registered offender list


for all the residents that were currently in the
building. They did not follow up on any names
that came up to rule out if it was actually the
same person.

-They reviewed the camera footage and made


notes of who went up and down Hall 3 and the
time but they did not track/document what staff
went into the room in question and what was
being done while the staff was in the room.

The facility did not have any direct interviews


with the staff that took care of the resident to
determine what the resident ' s status/condition
was during the period of time in question.

Staff Interviews

The director of nursing (DON) was interviewed


on 1/11/18 at 4:36 p.m. She said she was
notified of the allegation when the police walked
in and said they were investigating a sexual
assault accusation and requested to see
resident #1 ' s room. She said they sat in on the
questioning of the staff by the police and did not
document what was said. She said the only
interviews the facility did with the staff was the

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 11 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

ADVANCED HEALTH CARE OF AURORA 1800 SOUTH POTOMAC STREET


AURORA 80012

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


(EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

F 610 Continued From page 11 F 610

general four questions. She said they did not


interview the direct care staff individually. She
said there were two cameras on Hall 3. She said
the police took copies of the footage. She said
they reviewed the footage and documented who
went down the hallway and when. She said they
did not have any concerns.

The facility was requested to document from the


camera footage, who went into resident #1 ' s
room in the 12 hours prior to her transfer, how
long they were in the room and what they were
doing in the room.

Upon return to the facility on 1/31/18 to


complete the investigation, the DON provided a
copy of the requested camera documentation at
8:32 a.m. She said the direct care staff of
resident #1 were not individually interviewed.

Record Review

The documentation of the video footage from


11/8/17 at 6:00 p.m. until 11/9/17 at 6:00 a.m.
revealed the following:
-The resident ' s room was entered 14 times.
Three of those times the action was
documented as "unknown"; and
-No staff member entered the room from 9:48
p.m. on 11/8/17 until 4:54 a.m. on 11/9/17.

Staff Interviews

The NHA was interviewed on 1/31/18 at 10:05


a.m. He said he did not feel like the facility
needed to interview any of the direct care staff
since they had answered the general four
questions and those answers did not raise any
concerns. He said the DON had sat in on the
interviews with police and none of the answers

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 12 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

ADVANCED HEALTH CARE OF AURORA 1800 SOUTH POTOMAC STREET


AURORA 80012

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


(EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

F 610 Continued From page 12 F 610

given raised any concerns. He said they did not


document these interviews. He said the person
that performed the registered offender lookup
did not print off the right form that showed there
were no concerns with any of their residents. He
said he would correct this. He also said he was
going to follow-up on "the visitor" mentioned in
the staff interview questions.

The NHA was interviewed again on 1/31/18 at


12:47 p.m. He said they were interviewing the
staff that had direct contact with resident #1. He
indicated that he understood how the
investigation was incomplete and was trying to
wrap up the loose ends.

Facility Follow-Up

On 1/31/18 at 4:15 p.m. the NHA presented a


summary of the investigation that included
interviews from the staff that took care of the
resident and a complete timeline of events.
Clarification was obtained on the registered
offender list. They also interviewed and
documented the staff that had answered they
had seen a visitor in the room of question.

F 658 483.21(b)(3)(i) Services Provided Meet F 658 02/13/2018


SS=D Professional Standards

§483.21(b)(3) Comprehensive Care Plans


The services provided or arranged by the
facility, as outlined by the comprehensive care
plan, must-
(i) Meet professional standards of quality.

This REQUIREMENT is not met as evidenced


by:
Based on record review and staff interview, the Plan of Correction
facility failed to ensure professional standards of Complaint Survey 01/05/2018 -

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 13 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

ADVANCED HEALTH CARE OF AURORA 1800 SOUTH POTOMAC STREET


AURORA 80012

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


(EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

F 658 Continued From page 13 F 658

practice were followed for four (#7, #1, #6 and 02/01/2018


#2) residents of six sample residents. • F658: Services Provided Meet
Professional Standards/Comprehensive
Specifically, the facility failed to obtain Care Plans
written/signed physician orders to transfer these
resident ' s out of the facility. o Patient Specific: Patient Number #7,
#1, #6, and #2 has been discharged Other
The findings included: Patients:

Resident Status o Other Patients: On 2/13/2018, the


DON conducted an audit of all patients
Resident #7 that had been discharged to the hospital
since 2/07/2018 and verified that the
Resident #7, age 71, was admitted to the facility facility obtained written/signed physicians
on 12/27/17 and discharged to the hospital on orders to transfer, which included the
12/28/18. He was readmitted to the facility on following was completed; 1. Physician
12/31/17. According to the face sheet, Written Order signed and dated by
diagnoses included: atrial fibrillation (irregular physician, 2. Physician Written Order
heart rate), heart failure, and chronic obstructive displays discharge location, 3. Physician
pulmonary disease. Written Order has Nurses’ signature.

The resident did not have an minimum data set o All nurses on duty 2/13/2018 were
(MDS) assessment completed related to the in-serviced regarding “Services Provided
resident being in the facility less than 24 hours. Meet Professional
Standards/Comprehensive Care Plans”
The interim person centered care plan, initiated related to obtaining a written/signed
12/27/17, indicated the resident had an physicians orders to transfer patient to
alteration in cardiac or respiratory status. emergency room. Nursing staff were
Interventions included: educated on the following; 1. Physician
-Medications as ordered; Written Order signed and dated by
-Labs as ordered; physician, 2. Physician Written Order
-Treatments as ordered; displays discharge location, 3. Physician
-Oxygen as ordered; Written Order has Nurses’ signature.
-Vital signs daily;
-Weight weekly; o Systemic Changes:On 2/13/2018, all
-Monitor for signs and symptoms of cardiac or licensed nursing staff were in-serviced
respiratory exacerbation and report changes to and educated regarding “Services
the physician. Provided Meet Professional
Standards/Comprehensive Care Plans”
Record Review related to obtaining a written/signed

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 14 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

ADVANCED HEALTH CARE OF AURORA 1800 SOUTH POTOMAC STREET


AURORA 80012

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


(EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

F 658 Continued From page 14 F 658

physicians orders to transfer patient to


According to a nurse ' s progress note on emergency room. All licensed nursing
12/28/17 at 3:56 p.m. the patient ' s heart rate staff were in-serviced regarding the
continued to read between 110-160 beats per following must be completed; 1. Physician
minute, echocardiogram (EKG) results were still Written Order signed and dated by
pending. At 5:55 p.m. the patient's EKG results physician, 2. Physician Written Order
came back, the physician was notified and the displays discharge location, 3. Physician
facility received verbal orders to send the patient Written Order has Nurses’ signature.
to the emergency room. Paramedics came and
the patient left the facility via stretcher. o Monitors: The Director of Nursing, or
her designee, will audit and document on
No signed physician ' s order was found in the current patients weekly for 4 weeks, then
resident ' s record to transfer the resident to the monthly for 3 months, to ensure that the
emergency room. patients that were being discharged to the
hospital have the following written/signed
Resident #1 physicians orders to transfer and verify
that the following was completed; 1.
Resident #1, age 77, was admitted on 11/7/17 Physician Written Order signed and dated
and discharged to the emergency room on by physician, 2. Physician Written Order
11/9/17. According to the face sheet, diagnosis displays discharge location, 3. Physician
included chronic obstructive pulmonary disease. Written Order has Nurses’ signature. She
will report the details of her findings at the
According to the 11/9/17 MDS assessment, the quality assurance meeting. She will make
resident had no cognitive impairment with a brief the necessary changes to the above plan
interview for mental status (BIMS) score of 15 of corrections as needed.
out of 15. o Date of Compliance: 2/13/2018

The interim person centered care plan, initiated


11/7/17, indicated the resident had an alteration
in cardiac or respiratory status. Interventions
included:
-Medications as ordered;
-Labs as ordered;
-Treatments as ordered;
-Oxygen as ordered;
-Vital signs daily;
-Weight weekly;
-Monitor for signs and symptoms of cardiac or
respiratory exacerbation and report changes to
the physician.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 15 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

ADVANCED HEALTH CARE OF AURORA 1800 SOUTH POTOMAC STREET


AURORA 80012

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


(EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

F 658 Continued From page 15 F 658

Record Review

According to a nursing progress note on 11/9/17


at 8:12 a.m. when the nurse went to the room to
check on the patient after shift change, the
patient was breathing but unresponsive. Vital
signs were obtained while another nurse called
911. The patient was picked up by paramedics
via stretcher at around 6:55 a.m.

No signed physician ' s order was found in the


resident ' s record to transfer the resident to the
emergency room.

Resident #6

Resident #6, age 75, was admitted to the facility


on 12/16/17 and discharged to the emergency
room on 12/27/17 and readmitted to the facility
on 1/3/18. According to the face sheet,
diagnosis included a broken internal right knee
prosthesis.

The 1/10/18 MDS indicated the resident had no


cognitive impairment with a BIMS score of 15
out of 15.

The interim person centered care plan initiated


12/16/17 indicated the resident was alert and
oriented to person, place and time. There was
an alteration in mobility/safety. Interventions
included:
-Weight bearing as tolerated;
-Assist of one person for transfers; and
-Wheelchair/walker used for mobility with
assistance.

Record Review
According to a nursing progress note on

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 16 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

ADVANCED HEALTH CARE OF AURORA 1800 SOUTH POTOMAC STREET


AURORA 80012

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


(EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

F 658 Continued From page 16 F 658

12/27/17 at 6:28 p.m. vital signs were taken at


6:32 a.m. The resident ' s temperature was
102.8, her pulse was 111 pulse, respirations
were 21, blood pressure was 94/47, and oxygen
saturation was at 94% on 2 liters via nasal
cannula. Upon assessment, the patient was
noted to be diaphoretic (sweating profusely) and
lethargic. Incision to left knee was well
approximated, steri-strips were in place. The
distal portion of incision was covered with a
dressing noted to have scant amount of blood
tinged drainage. The patient was given
medication for the fever per standing orders at
6:40 a.m. The on-call physician was notified at
6:50 a.m., and the facility received a verbal
order to send the patient to emergency room for
evaluation. The patient left the facility at 7:25
a.m. via stretcher with emergency medical
services for the hospital.

No signed physician ' s order was found in the


resident ' s record to transfer the resident to the
emergency room.

Resident #2

Resident #2, age 72, was admitted to the facility


on 12/27/17 and discharged to the emergency
room on 12/29/17. He was readmitted to the
facility on 1/1/18. According to the face sheet
diagnosis included infection to the right knee
prosthesis.

According to the 1/8/18 MDS, the resident had


no cognitive impairment with a BIMS score of 15
out of 15.

The interim person centered care plan initiated


12/27/17 indicated the resident was alert and
oriented to person, place, time and situation.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 17 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

ADVANCED HEALTH CARE OF AURORA 1800 SOUTH POTOMAC STREET


AURORA 80012

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


(EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

F 658 Continued From page 17 F 658

There was an alteration in mobility/safety.


Interventions included:
-Weight bearing as tolerated;
-Assist of one person for transfers; and
-Wheelchair/walker used for mobility with
assistance.

Record Review

According to a nursing progress note on 12/29/1


7at 5:55 p.m. around 12:00 p.m. the therapist
called the nurse to check on the residents left
knee. Upon assessment, dehiscence (breaking
open) to left knee incision was noted. The
dressing was noted with mild bleeding. The
patient denied new onset of pain. The dressing
was reinforced and the patient was sent to the
emergency around 12:27 p.m. by ambulance.

No signed physician ' s order was found in the


resident ' s record to transfer the resident to the
emergency room.

Staff Interviews

Registered nurse (RN) #1 was interviewed on


1/11/18 at 11:15 a.m. She said whenever they
transferred a resident to the hospital, they would
call the physician and get a verbal order. They
would call 911, get the paperwork ready, write a
telephone order, notify the emergency medical
technicians (EMT) of the status of the resident
then the family would be called. She said they
always got vital signs and filled out a hospital
transfer sheet that was sent to the hospital with
the resident along with a copy of the telephone
order for the resident to be evaluated at the
emergency room.

The director of nursing was interviewed on

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 18 of 19
PRINTED: 03/01/2018
DEPARTMENT OF HEALTH AND HUMAN SERVICES FORM APPROVED
CENTERS FOR MEDICARE & MEDICAID SERVICES OMB NO. 0938-0391

STATEMENT OF DEFICIENCIES ( X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (x3) DATE SURVEY
AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED
A. BUILDING:
B. WING _____________________________
065393 02/01/2018
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

ADVANCED HEALTH CARE OF AURORA 1800 SOUTH POTOMAC STREET


AURORA 80012

(X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID PROVIDER'S PLAN OF CORRECTION (X5)


(EACH DEFICIENCY MUST BE PRECEEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETION
PREFIX PREFIX
DATE
TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THE APPROPRIATE
DEFICIENCY)

F 658 Continued From page 18 F 658

1/11/18 at 5:32 p.m. She said a telephone order


should be written any time a resident was
transferred to the emergency room. She said
she was unable to locate any signed telephone
orders for any of the residents listed above.

FORM CMS-2567(02-99) Previous Versions Obsolete Event ID: XUB511 Facility ID: 02D982 If continuation sheet 19 of 19

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