Colorado State Veterans Nursing Home - Rifle

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide appropriate pressure ulcer care and prevent new ulcers from developing.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Environmental Deficiencies

Keep all essential equipment working safely.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Nursing and Physician Services Deficiencies

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Resident Assessment and Care Planning Deficiencies

Ensure services provided by the nursing facility meet professional standards of quality.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Confirmed flame retardant spray and destructive testing on Christmas Decorations. K-000-INITIAL COMMENTS (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 483.90(a).The initial comments (ID Prefix Tag #K000) are informational only and represent the facility' s general characteristics. This two-story Type II (111) structure is licensed for eighty-nine (89) residents. The census for .. Through document review and observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 25. This was evidenced by:1) Grass Mesa Commons has a quick response and standard response heads in the same compartment 2) reports do not indicate a flow switch time to show they are being tested.NFPA 101, 9.7.5 Maintenance and Testing.All automatic sprinkler and standpipe systems r.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 99, and 110. This was evidenced by:1) Generator fuel quality (annually) (110 8.3.8): 7.1.24 Failed fuel quality reportNFPA 110 8.3.8 A fuel quality test shall be performed at least annuallyUsing tests approved by ASTM standards.The deficiencies have the potential to affect occupants, including r.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by:1) Emergency Planning (101 4.8.2): The provided evacuation routes need to be updated to reflect the closest exit and area of refuge.NFPA 101 19.7.1 Evacuation and Relocation Plan and Fire Drills.19.7.1.1 The administration of every health care occupancy shall have, in effect and a.. Through observation during the survey, it was determined that the facility failed to maintain hazardous areas in accordance with NFPA 101. This was evidenced by:1) A chase for beverage syrup lines was created by the beverage vendor. The vendor added non-treated, wood 2" by 4" to the wall, which was visible behind an opening in the drywall of the syrup room.NFPA 101 19.1.6.4 Interior nonbearing walls in buildings of Type I or Type II construction s.. Through observation during the survey, it was determined that the facility failed to maintain hazardous areas in accordance with NFPA 101. This was evidenced by:1) The grass mesa wing rooms were converted to storage and deemed hazardous, so a door closure needs to be added.2) The syrup room has a hole in the wall that needs to be patchedNFPA 101 19.3.2 Protection from Hazards.NFPA 101 19.3.2.1.3 The doors shall be self-closing or automatic-cl.. Through observation during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 101. This was evidenced by:1) no exit sign needs to be added to grass mesa exterior fence gate2) Add exit sign to grass mesa middle exit door3) add an exit sign for a security door to the grass mesaNFPA 101 19.2.10.1 & 7.10: Marking of Means of EgressNFPA 101 7.10.1.5.1 Access to exits shall be marked .. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101. This was evidenced by: 1) double doors between the office and library need to be adjusted latch2) blue hall door door not latchingNFPA 101, 8.3.3.1 Openings required to have a fire protection rating by Table 8.3.4.2 shall be protected by approved, listed, labeled fire door assemblies and fire window assemblies and ..

A recertification survey with Incident #38356 was completed on 11/18/24 to 11/22/24. Nine deficiencies were cited. An Emergency Preparedness survey was conducted from 11/18/24 to 11/22/24. No deficiencies were cited. Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life, and resident safety. Specificall.. Based on observations, record review and interviews, the facility failed to ensure resident choices for one (#213) of two residents reviewed for activities of daily living (ADL) out of 40 sample residents. Specifically, the facility failed to provide bathing assistance for Resident #213 per her preference.Findings include: I. Facility policy and procedureThe.. Based on observations, record review and interviews, the facility failed to ensure two (#43 and #14) of seven residents received food and fluids prepared in a form designed to meet their needs per speech therapy recommendation, physician' s orders and the resident' s care plan out of 41 sample residents.Specifically, the facility failed to ensure Re.. Based on observations, record review and interviews, the facility failed to maintain all mechanical, electrical and patient care equipment in safe operating condition.Specifically, the facility failed to ensure facility staff used blood pressure cuffs rated for medical use.Findings include:I. Professional referenceAccording to the Davis Advantage for B.. Based on observations, record review and interviews, the facility failed to provide care and treatment to prevent the development and worsening of pressure injuries for one (#54) of two residents reviewed for pressure injuries out of 41 sample residents.Resident #54 was admitted to the facility on 7/18/24 with diagnoses of type 2 diabetes, history of t.. Based on record review and interviews, the facility failed to ensure all drugs and biologicals were properly stored in accordance with professional standards in two of three medication storage refrigerators.Specifically, the facility failed to maintain a medication refrigerator temperature log for the facility vaccine refrigerator and the medication refrige.. Based on record review and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases.Specifically, the facility failed to implement an effective water management plan.Findings include:I. Profes.. This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.

A licensure survey was completed on 11/18/24 to 11/22/24. Two deficiencies were cited. Based on observations, record review and interviews, the facility failed to provide care and treatment to prevent the development and worsening of pressure injuries for one (#54) of two residents reviewed for pressure injuries out of 41 sample residents.Resident #54 was admitted to the facility on 7/18/24 with diagnoses of type 2 diabetes, history of toe amputation, osteomyelitis (bone infection) and neuropathy.On 9/26/24, after not wearing her podiatry ordered offloading boots due to a red area on her heel, potentially from the podiatry offloading boot and/or a screw located on her wheelchair foot pedal, Resident #54 developed a blister on her left heel which progressed into an unstageable pressure ulcer. Resident #54 had physician' s orders for the offloading pressure relieving boots and the boots were care planned, however, the resident did not consistently wear the boots as ordered. The resident' s refusals to wear the boots were not documented or refusals were not careplanned and there were no care plan interventions directing staff what to do if the resident refused the boots. Resident #54 was able to identify why she did not consistently wear the pressure relieving boots but the facility did not ask the resident her reasoning or implement interventions to address the resident' s concerns with the pressure relieving boots.Due to the facility' s failures to ensure effective intervention.. This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.