Gunnison Valley Health Senior Care Center

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Resident Rights Deficiencies

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

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Egress Deficiencies

Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Nursing and Physician Services Deficiencies

Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

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 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

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Infection Control Deficiencies

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

The Colorado Division of Fire Prevention and Control conducted this survey in accordance with the Federal Register at Section 42 CFR 483.70(a). The initial comments (ID Prefix Tag # K 000) are informational only and represent the facility' s general characteristics. The facility is a Type V (111) single-story building constructed in 2018. This survey incorporated the entire facility as a single structure consisting of 51,498 sq. ft. It is protected by a fully automatic fire sprinkler system. The facility was licensed for 50 beds, and the census on the day of the survey was 28. The su.. 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) Fire Sprinkler Annual: 9.19.2023 Western Slope Fire & Safety, Not done in accordance with NFPA 25 standards. Missing forward flow test, main drain on all systems, and dry system information for both systems(only data for one system). 2) Leaking fire sprinkler head in the clean linen room.Based on a record review, it was determined that the facility failed to maintai.. Through document review during the survey, it was determined that the facility failed to meet the means of egress requirements in accordance with NFPA 99. This was evidenced by:1) Receptacle Testing (99 6.3.4.1): Not ProvidedNFPA 99 6.3.4.1.1 Where hospital-grade receptacles are required at patient bed locations and in locations where deep sedation or general anesthesia is administered, testing shall be performed after initial installation, replacement, or servicing of the device.6.3.4.1.2 Additional testing of receptacles in patient care rooms shall be per.. 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): Not ProvidedNFPA 9915.5.1.3 Emergency Generators and Standby Power Systems. Emergency generators and standby power systems, where required for compliance with this code, shall be installed, tested, and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems.NFPA 110 8.3.8 A fuel quality test.. 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 the following:1) The boiler room fire-rated wall between the break room and boilers is only protected from one side; 1-hour rated assemblies protecting hazardous areas are not installed properly.NFPA 101 18.3.2.1* Hazardous Areas. Any hazardous areas shall be protected in accordance with Section 8.7, and the areas described in Table 18.3.2.1 shall be protected as indicated.Boiler and fue.. 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) remove the hold-open device on the laundry clean storage room door 2) remove the hold-open device on the soiled linen room door 3) remove the hold-open device on the boiler room door 4) remove the hold-open device on the loading dock door.NFPA 101 21.2.2.4 Any door required to be self-closing shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8... Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and NFPA 54. This was evidenced by:1) Gas valves on the dryer(s) not rated for more than 2000 feet elevation need high-elevation gas valvesNFPA 54 11.1.2 High Altitude.Gas input ratings of appliances shall be used for elevations up to 2000 ft (600 m). The input ratings of appliances operating at elevations above 2000 ft (600 m) shall be reduced in accordance with one of the following methods:(1) At the rate of 4 percent for each 10..

A recertification survey was conducted from 4/22/24 to 4/24/24. One deficiency was cited. An Emergency Preparedness survey was conducted from 4/22/24 to 4/24/24. No deficiencies were cited. Based on record review and interviews, the facility failed to have a registered nurse (RN) scheduled eight hours consecutively every day for seven days a week.Specifically, the facility failed to have an RN on duty for eight consecutive hours consistently from 10/1/23 to 4/24/24.Findings include:I. Record reviewReview of the nursing schedule from 10/1/23 to 4/24/24 revealed the following:-In October 2023, the facility did not have an RN on duty for eight consecutive hours on three days during the month;-In November 2023, the facility did not have an RN on duty for eight consecutive hours on thirteen days during the month;-In December 2023, the facility did not have an RN on duty for eight consecutive hours on three days during the month; and,-In March 2024, the facility did not have an RN on duty for eight consecutive hours for twelve days.II. Staff interviewsThe nursing home administrator (NHA) was interviewed on 4/24/24 at 8:25 a.m. The NHA said the facility relied heavily on licensed practical nurses (LPN) to provide nursing care/ She said the facility' s location in the rural mountains made recruiting and retaining RNs was difficult.The director of nursing (DON) was interviewed on 4/24/24 at 10:26 a.m. The DON said the facility had a state waiver for the RN staffing requirement in place. She said she was unaware the state waiver did not apply to the fede..

A complaint survey, prompted by #CO35412 was conducted on 4/1/24-4/2/24. One deficiency was cited. Based on interviews and record review, the facility failed to ensure one (#1) out of three sample residents were kept free from abuse.The facility failed to provide increased oversight and monitoring to ensure Resident #1, who had severe cognitive impairment and was unable to consent to sexual contact of any type, was protected from sexual abuse by Resident #2, who was cognitively intact.On 2/13/24, Resident #2 was observed watching television in Resident #1' s room by two different staff members. At 9:23 p.m., over an hour after the last known observation of the two residents, certified nurse aide (CNA) #1 entered Resident #1' s room while doing routine rounds. Resident #1' s door had been closed and when CNA #1 entered Resident #1' s room, he observed Resident #2, who was nude, lying on top of Resident #1, who was also nude, and having sexual intercourse with her. A nurse was alerted and Resident #2 was removed from Resident #1' s room and placed on one-to-one supervision.However, due to the facility' s failures to provide increased oversight and monitoring of the residents once Resident #2 was observed in Resident #1' s room, Resident #1 sustained sexual abuse by Resident #2.Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 4/1/24-4/2/24, resulting in the deficiency being cited as past noncompliance with a correction date of 2/15/24.I. Incident of sexual abuseA. Sexual abuse investigationThe 2/13/24 sexual abuse incident investigation documented the following:The nurse was alerted by CNA #1 while he was doing his rounds, he found Resident #1 (female), nude, supine (lying flat on her back) on her bed with Resident #2 (male), nude, lying on top of her having intercourse. The nurse removed Resident #2 from Resident #1' s room. This incident occurred at approximately 9:30 p.m.The nurse and CNA #1 assessed Resident #1 for marks and bruising and placed a clean brief onto the resident. They placed the resident in bed, under the covers and left the lig..