Colorado Veterans Community Living Ctr at Homelake

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Properly select, install, inspect, or maintain portable fire extinguishes.

Resident Assessment and Care Planning Deficiencies

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

Quality of Life and Care Deficiencies

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

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.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Develop and implement policies and procedures for flu and pneumonia vaccinations.

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 safe and appropriate respiratory care for a resident when needed.

Nutrition and Dietary Deficiencies

Provide special eating equipment and utensils for residents who need them and appropriate assistance.

Smoke Deficiencies

Provide properly protected cooking facilities.

Quality of Life and Care Deficiencies

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

Based on observation it was determined that the facility failed to maintain the fire alarm system components and devices in accordance with the Life Safety Code 101 and NFPA 72. This was evidenced by the following:1. The main fire alarm panel in this facility showed a Trouble status for a CO Detector.2012 Life Safety Code 101 section 9.6.1.5* To ensure operational integrity, the fire alarm system shall have an approved maintenance and testing program complying with the applicable requirements of NFPA 70, National Electrical Code, and NFPA 72, National Fire Alarm and Signaling Code.Failure to maintain the fire alarm system has the potential to harm all occupants, staff, and visitors within the building should a delay occur in locating a fire throughout the facility.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors throughout the entire facility. Deficient items were discussed with the Administrator and Operations Manager at the exit conference. Based on observations and records review, it was determined that the facility did not maintain fire extinguishers In accordance with NFPA 10. This was evidenced by the following:1. The annual fire extinguisher inspection report performed by Pre Action Fire on 9/24/2024 stated that 35 fire extinguishers failed the annual inspection (Record Review). Based on observation (visually checking fire extinguisher tags throughout the facility) and interview, these 35 fire extinguisher failures have not been corrected at the time of the survey. The proivder failed to correct the identified failures. The Operations Manager stated that Pre Action Fire will perform the necessary repairs and provide an updated report once the corrective service has occurred.Life Safety Code 101, 2012 Edition, section 9.7.4. Where required by the provision of another section of this code, portable fire extinguishers shall be installed, inspected and maintained in accordance with NFPA 10 Standards for Portable Fire Extinguishers.NFPA 10, 2010 Edition, section 7.3.1.1.1 Fire extinguishers shall be subjected to maintenance at intervals of not more than 1 year, at the time of hydrostatic test, or when specifically indicated by an inspection or electronic notification.7.3.1.1.2 Fire extinguishers shall be internally examined at intervals not exceeding those specified in Table 7.3.1.1.2.This deficiency has the pot.. 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 a representation of the facility' s general characteristics. The facility is a one-story wood frame structure, Type V(111) construction, without a basement. The breezeway and associated attic space between the long-term care facility and the administration building is separated by two-hour fire rated construction. The facility and the administration buildings are protected throughout by a dry-pipe automatic fire sprinkler systems and is classified as Fully Sprinklered. The survey was conducted on November 13, 2024 using National Fire Protection Association (NFPA) 101, Life Safety Code, 2012 edition, Chapter 19 for Existing Health Care Occupancies. The facility is licensed for 60 beds. The census was reported to be 40 residents at the time of the survey. The deficiencies found during the survey were discussed with the Administrator and the Operations Manager during the Exit Conference. The facility will be in compliance upon the completion of the deficiencies noted during the survey.

A recertification survey was conducted from 10/14/24 to 10/17/24. Two deficiencies were cited. An Emergency Preparedness survey was conducted from 10/14/24 to 10/17/24. No deficiencies were cited. Based on observations, record review and interviews, the facility failed to provide services for two (#15 and #7) of two residents reviewed out of 23 sample residents according to professional standards of practice.Specifically, the facility failed to ensure Resident #15' s and Resident #7' s vital signs, specifically the resident' s blood pressure and pulse, were monitored and assessed prior to the administration of a blood pressure medication.Findings include:I. Professional referenceAccording to Kizior, R. J. Hodgson, K. J. (2023). Metoprolol. Saunders Nursing Drug Handbook. Elsevier. p. 770."Assess B/P (blood pressure), heart rate immediately before drug administration. If pulse in 60 beats per minute or less or systolic B/P is less than 90 mmHg (millimeters of mercury) withhold medication and contact physician." According to Kizior, R. J. Hodgson, K. J. (2023). Amlodipine. Saunders Nursing Drug Handbook. Elsevier. P. 60."Assess B/P, if systolic B/P is less than 90 mmHg, withhold medication, contact physician."According to Kizior, R. J. Hodgson.. Based on record review and interviews, the facility failed to maintain complete and accurate resident resuscitation choices in the medical record for three (#141, #13 and #32) of fourteen residents out of 23 sample residents.Specifically, the facility failed to:-Ensure a physician' s order was in place for a do not resuscitate (DNR) for Resident #141, who wished to be a DNR per the resident' s Medical Orders for Scope of Treatment (MOST) form;-Ensure documentation of a MOST form was in place for Resident #13; and,-Ensure the MOST form was discussed with and signed by Resident #32, who was cognitively intact.Findings include:I. Facility policy and procedureThe Advanced Directives and Resident Rights to Refuse Treatment policy and procedure, revised 9/9/24, was provided by the nursing home administrator (NHA) on 10/16/24 at 8:00 a.m. It read in pertinent part,"On admission, the facility will determine if the resident has executed an advance directive, and if not, determine whether the resident would like to formulat..

A survey prompted by complaint #CO35119 was completed 2/13/24. One deficiency was cited. Based on record review and staff interviews, the facility failed to ensure one (#1) of four residents reviewed for abuse out of four sample residents was kept free from abuse.Resident #2 and Resident #1 were involved in an altercation on 11/7/23. Resident #2 attacked Resident #1 and Resident #1 had injuries that included a scratch to his left forehead that was cleaned, a scratch on his nose, an abrasion to his left face/cheek, left jawline, left ear and bruising to the top of his left shoulder. There was redness around his neck and Resident #1 complained of severe left shoulder pain. Interventions added after the altercation were to move Resident #2 to a different hall and the resident was to be in the staff' s line of sight. However, those interventions were not effective due to another altercation that occurred on 1/3/24.According to Resident #1, on 1/3/24 Resident #2 pulled him down and hit him. Resident #2 had redness/possible bruising to the right hand at the base of the third finger knuckle and an abrasion on the back of his left hand. Resident #1 sustained a bloody nose, a skin tear to his nose and left hand and two abrasions to the forehead. He also sustained a fracture to one of the fingers on his right hand. Resident #1 was sent to the hospital for evaluation and treatment.The facility failed to implement measures to protect Resident #1 from abuse perpetrated by Resident #2, who was known to be physically aggressive. Findings include: I. Facility policy The Abuse policy, revised 10/16/23, was provided by the nursing home administrator (NHA) on 2/13/2024 at 4:05 p.m. It documented in pertinent part, "It is the policy of the (corporation) to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent mistreatment, abuse, neglect and exploitation. The (facility) will take necessary precautions to prevent resident abuse by anyone including staff members, other residents, volunteer, contracted staff, family members, resident rep..