Bruce Mccandless Colorado State Veterans Nursing Home

Based on observation and staff interview during the course of the survey, it was determined the facility failed to maintain the means of egress in accordance with NFPA 101, 19.2.1 and Chapter 7. The following evidenced this: The door in the kitchen needs to be a one motion lock.Life Safety Code Section 19.2.1 shall be in accordance with Chapter 7, Section 7.2.1.5 provides requirements for Locks, Latches and Alarm Devices. Section 7.2.1.5.10.2, in part, releasing mechanisms shall open the door with not more than one releasing operation.The means of egress deficiency has the potential to affect occupants, who might include staff and visitors within the affected smoke compartment; items were discussed during the survey and again during the exit conference. INITIAL COMENTS (ID Prefix Tag #K000) are informational only and a representation of the facility' s general characteristics. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The facility is a one (1) story, Type V (000) construction with a partial basement that is used for support services only, there is no resident access. The facility is licensed for 105 beds. The facility was constructed in 1975 and a remodel was completed 2006. The facility is fully protected throughout by a National Fire Protection Association (NFPA) 13 automatic fire sprinkler system, and is classified as Fully Sprinklered. This survey was conducted on July 2nd 2024 for compliance with the National Fire Protection Association, (NFPA 101) Life Safety Code (2012) Chapter 19 "Existing Health Care Occupancies."Each of the deficiencies were discussed with the Assistant Administrator and the Maintenance Director during the exit conference. Through observation during documentation review, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 25, and 13. This was evidenced by:1. Suppression report deficiency- Antifreeze system is UL listed but viscosity is incompatible. & nbsp; & nbsp; 2. Door #016 sprinkler heads closer than 6 feet. & nbsp; 3. Loaded heads throughout the kitchen area. & nbsp; & nbsp; 4. Rusted sprinkler head in freezer. 5. Anti-freeze riser was blocked by bookshelves in the Admissions office. &n..

A recertification survey was conducted from 6/3/24 to 6/6/24. Six deficiencies were cited. An Emergency Preparedness survey was conducted from 6/3/24 to 6/6/24. One deficiency was cited. Based on observations, record review and interviews, the facility failed to use a person centered approach when determining the use of bed rails and transfer poles for three (#12, #10 and #20) of eight residents reviewed for accident hazards out of 34 sample residents.Specifically, for Residents #12, #10 and #20, the facility failed to:-Review the risks versus the benefits of using a bed rail with the resident or the resident' s representative prior to use; -Obtain.. Based on observations, record review and staff interviews, the facility failed to ensure four (#10, #26, #21, #44) of eight out of 34 sample residents were provided services that meet professional standards of quality. Specifically, the facility failed to:-Clarify the physician' s orders with dose information for Residents #10, #26, #21 and #44 for Voltaren gel (topical pain medication); and,-Ensure Resident # 21 received follow up care with the ur.. Based on record review and interviews, the facility failed to conduct two exercises annually to test the facility' s emergency plan and maintain documentation of the facility' s response to all drills, tabletop exercises, and emergency events, and then revise the facility' s emergency plan, as needed.Specifically, the facility failed to: -Participate in a community-based full scale exercise or facility-based full scale exercise and/or actual emergency in the previous 12-.. Based on record review and interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#10) of one resident out of 34 sample residents.Specifically, the facility failed to ensure Resident #10' s blood pressure medication was consistently held when her diastolic blood pressure (the bottom number of a blood pressure reading) was below the physician ordered parameters.Findings include:I. Professi.. Based on record review and interviews, the facility failed to take steps to protect two (#35 and #36) of two residents reviewed for abuse out of 34 sample residents. Specifically, the facility failed to prevent a physical altercation between Resident #36 and Resident #35. Findings include: I. Facility policy & nbsp; .. Based on record review and staff interviews, the facility failed to develop and implement an antibiotic stewardship program which included antibiotic use protocols and a system to monitor antibiotic use for one (#21) of one resident out of 34 sample residents. Specifically, the facility failed to effectively track and monitor the use of long-term and short-term antibiotics prescribed for Resident #21.Findings include: I. Professional reference Accord.. Based on record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#49) of eight residents reviewed for accident hazards out of 34 sample residents.Resident #49 was identified as a high fall risk through facility assessment. Resident #49 needed substantial to maximum assistance rolling from left to right/right to left in bed. Resident #49' s care plan was reviewed on 4/4/24 a..

A licensure survey was completed on 6/3/24 to 6/6/24. One deficiency was cited. Based on record review and staff interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one (#49) of eight residents reviewed for accident hazards out of 34 sample residents.Resident #49 was identified as a high fall risk through facility assessment. Resident #49 needed substantial to maximum assistance rolling from left to right/right to left in bed. Resident #49' s care plan was reviewed on 4/4/24 and included an intervention for the assistance of two people with bed mobility (scooting, rolling, or moving from lying to sitting or sitting to lying) and transfers in and out bed. Resident #49 sustained a fall out of bed on 4/11/24 while receiving incontinence care from certified nurse aide (CNA) #1. CNA #1 was providing care for the resident without another staff member in the room for assistance. When CNA #1 rolled the resident toward her, the resident rolled too far over and began to fall off the bed. CNA #1 was unable to catch the resident and Resident #49 fell to the floor. Resident #49' s injuries included two forehead lacerations, bruising to her nose and mouth and bleeding in her mouth with a small laceration of the interior upper lip and bruising to the right eye. She was transported to the hospital for further treatment where imaging tests revealed Resident #49 had sustained C1 and C2 vertebrae (top of the neck) fractures from the fall.Due to the facility' s failure to ensure two staff members were present to assist Resident #49 with bed mobility during incontinence care, Resident #49 sustained a fall which resulted in a major injury.Findings include: I. Resident statusResident #49, over the age of 65, was admitted on 12/27/11, readmitted on 4/12/24 and passed away at the facility on 4/13/24. According to the April 2024 computerized physician orders (CPO), diagnoses included Alzheimer' s disease, dementia, atrial fibrillation , type II diabetes mellitus, chronic kidney disease, spinal stenosis , osteoarthritis, osteoporosis and history of falling.The 4/1/24 facility assessment revealed the reside..