Yampa Valley Healthcare Center

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

Resident Rights Deficiencies

Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice.

Quality of Life and Care Deficiencies

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

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

Smoke Deficiencies

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

Smoke Deficiencies

Follow proper procedures when the fire alarm was out of service for more than 4 hours.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

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

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

Provide a written emergency evacuation plan.

Miscellaneous Deficiencies

Have restrictions on the use of highly flammable decorations.

Miscellaneous Deficiencies

To conduct inspection, testing and maintenance of fire doors by qualified individuals.

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.

Nutrition and Dietary Deficiencies

Employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, including a qualified dietician.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Smoke Deficiencies

Provide properly protected cooking facilities.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

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

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

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

Nursing and Physician Services Deficiencies

Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Nutrition and Dietary Deficiencies

Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

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.

Quality of Life and Care Deficiencies

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

Pharmacy Service Deficiencies

Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

Resident Rights Deficiencies

The resident has the right to receive notices in a format and a language he or she understands.

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

Resident Rights Deficiencies

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Resident Assessment and Care Planning Deficiencies

Provide care by qualified persons according to each resident's written plan of care.

Quality of Life and Care Deficiencies

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

A complaint survey, prompted by #CO1945193, #CO1945196, #CO1945199 and #CO1945201 was conducted 8/4/25 and 8/5/25. One deficiency was cited. Based on record review and interviews, the facility failed to honor resident choices for six (#4, #10, #11, #14, #15 and #18) of 10 residents reviewed out of 18 sample residents.Specifically, the facility failed to offer Resident #4, Resident #10 and Resident #11, Resident #14, Resident #15 and Resident #18' s preferred community activities outside of the facility. Findings include:I. Resident #4A. Resident statuResident #4, age less than 65, was admitted on 1/27/24. According to the August 2025 computerized physician orders (CPO), diagnoses included acquired absence of the left leg (above the knee), neuromuscular dysfunction of the bladder, Spina Bifida and Osteochondrodysplasia (a genetic disorder affecting the legs). The 3/31/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She was dependent on staff assistance with repositioning, transfers, toileting, dressing and showering.B. Resident interviewResident #4 was interviewed on 8/5/25 at 9:15 a.m. Resident #4 said the bus the facility used to transport residents broke down around August last year (2024). Resident #4 said the bus was not replaced and the facility did not provide a community activity outside of the facility until June 2025. Resident #4 said she attended resident council meetings to complain about the lack of activities and filed a grievance with the facility. Resident #4 said the facility used to offer multiple trips to the store each month and activities at a local lake. She said the facility offered a group “stroll and roll” activity to a park down the road, but it was not the same since staff can only push so many wheelchairs and it was too far for most residents to walk independently. Resident #4 said she would like to be able to go into town for events or to the store again. C. Record reviewResident #4’s care plan, initiated on 5/20/24 and last revised on 1/29/25, indicated Resident #4 was dependent on staff meeting the emotional, intellectual, and social needs of Resident #4 due to their physical limitati..

1) The east hallway egress door labeled delayed egress appears to be on a timer. I was unable to test it. During the survey, the deadbolt lock was removed and made operational before leaving the facility. 2) Unable to inspect water .. This survey was conducted by the Colorado Division of Fire Prevention and Control 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 represen.. Through document review during the survey, it was determined that the facility failed to maintain the electrical systems in accordance with NFPA 99. This was evidenced by:1) Receptacle Testing (99 6.3.4.1): Not ProvidedNFPA 99.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 10. This was evidenced by:1) Portable Fire Extinguishers (Monthly/An.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 72. This was evidenced by: 1) Fire Alarm (72 14.3.1) - Told that the F.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 72. This was evidenced by: 1) The fire alarm system is out of service,.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 72. This was evidenced by:1) Annual: 3.1.2022 Pye Barker, the report.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101 and 80. This was evidenced by: 1) Fire Doors (annually)(80 5.2): Not Provi.. Through document review during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 101, 80, 90A, and 105. This was evidenced by:1) Fire Dampers (4-6 years)(101.. 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) Load bank test (Monthly)(110 8.4... 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 Lighting (Monthly & Annual)(10.. 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) Fire Safety Plan (101 19.7.2.2): Not Provided2) .. Through observation during the survey, it was determined that the facility failed to maintain the electrical systems in accordance with CMS SOM Appendix A, NFPA 99, and NFPA 70. This was evidenced by:1) remove the extension cord a.. Through observation during the survey, it was determined that the facility failed to meet the healthcare facilities code requirements in accordance with NFPA 101 and 54. This was evidenced by:1) Kitchen Suppression: (Semi.. Through observation during the survey, it was determined that the facility failed to meet the protection requirements in accordance with NFPA 99 and NFPA 55. This was evidenced by:1) Oxygen trans filling room missing signage on the .. 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) combustible Christmas decorations all over the facility witho.. 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) delayed egress door on physical therapy missing signage2) re..

A licensure survey was completed on 11/4/24 to 11/25/24. One deficiency was cited. Based on observations, record review and interviews, the facility failed to ensure two (#26 and #5) of six residents out of 16 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being.Resident #26 was admitted to the facility for long term care on 1/4/23 with diagnoses of dementia, hypotension (low blood pressure), hypokalemia (low potassium), hypothyroidism (low thyroid function) and depression. Upon admission on 1/4/23, Resident #26 weighed 152 pounds (lbs) and she reported she liked to eat eggs, coffee and sweets. Resident #26 had gradual weight gain until 4/12/24 when she weighed 190 lbs. At this time, the resident started gradually losing weight. On 9/4/24 the resident weighed 182 lbs. The resident sustained 12 lbs (6.5%) weight loss in one month, from 9/4/24 to 10/3/24, which was considered severe. The facility failed to implement effective person-centered nutrition interventions to address the resident' s decreased oral intake and severe weight loss. On 9/27/24, Resident #26 weighed 174 lbs, which indicated the resident had lost eight lbs in 20 days. The registered dietitian (RD) recommended implementing a house nutrition supplement, however, the facility failed to obtain a physician' s order for the house supplement and track the resident' s acceptance of the intervention. Due to the facility' s failures, Resident #26 continued to lose weight and weighed 168 lbs on 11/4/24, which indicated the resident lost 22 lbs (11.6%) in six months. Additionally, Resident #5 was admitted to the facility on 8/5/24 with diagnoses of chronic obstructive pulmonary disease (COPD), chronic respiratory failure with hypoxia, type 2 diabetes mellitus with diabetic chronic kidney disease, anxiety, anemia (low red blood cell count) and dysphagia.Resident #5 sustained a weight loss of 12.8% (24 lbs) from admission on 8/5/24 through 11/4/24, which was considered severe. According to Resident #5' s nutrition care plan, pertinent interventions were initiated on 8/28/24 which included a house shake on..

A recertification survey was conducted from 11/4/24 to 11/25/24. Four deficiencies were cited. An Emergency Preparedness survey was conducted from 11/4/24 to 11/25/24. No deficiencies were cited. Based on observations and interviews, the facility failed to ensure medications and biologicals were stored in accordance with accepted professional standards for one of one medication refrigerator. Specifically, the facility failed to ensure controlled medications were in a locked storage container that was permanently secured to the refrigerator. Findings include: I. Facility policy and procedure The Medication Labeling and Storage policy and procedure, revised February 2023, was provided by the nursing home administrator (NHA) on 11/6/24 at 3:40 p.m. It read in pertinent part, "Controlled substances (listed as Schedule II-V of the Comprehensive Drug Abuse Prevention a.. Based on observations, record review and interviews, the facility failed to designate a person to serve as the director of food and nutrition services who was a qualified dietitian, certified dietary manager (DM), or a certified food service manager. Specifically, the facility failed to employ a qualified DM or have a full time registered dietitian (RD).Findings include:I. ObservationsThe 11/4/24 at 11:37 a.m. kitchen tour revealed there was no dietary manager (DM) currently employed at the facility.II. Record review-The facility was unable to provide documentation that indicated there was an individual that was employed by the facility that was a qualified dietary manager. II. Staff interviews The nursing .. Based on observations, record review and interviews, the facility failed to ensure two (#26 and #5) of six residents out of 16 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being.Resident #26 was admitted to the facility for long term care on 1/4/23 with diagnoses of dementia, hypotension (low blood pressure), hypokalemia (low potassium), hypothyroidism (low thyroid function) and depression. Upon admission on 1/4/23, Resident #26 weighed 152 pounds (lbs) and she reported she liked to eat eggs, coffee and sweets. Resident #26 had gradual weight gain until 4/12/24 when she weighed 190 lbs. At this time, the r.. Based on observations, 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 ensure housekeeping staff followed proper infection control procedures for cleaning resident rooms. Findings include:I. Professional referenceAccording to the Centers for Disease Control and Prevention (CDC) Hand Hygiene in Healthcare Settings (1/18/21), retrieved on 11/7/24 from https://www.cdc.gov/handhygiene/providers/index.html, "Cleaning your hands reduces the spread of potential..