Colorado State Veterans Nursing Home - Rifle

Inspectors wroteBased on observations, interviews, and record review, the facility failed to protect three (#1, #3, and #2) out of seven residents from physical abuse out of 12 sample residents. Specifically, the facility failed to:-Protect Resident #2 and Resident #1 from physical abuse from each other; -Protect Resident #3 from physical abuse by Resident #1; and,-Protect Resident #2 from physical abuse by Resident #1.

Inspectors wroteBased on interviews, observations and record review the facility failed to provide necessary respiratory care and services, for one (#11) one resident out of 12 residents reviewed for oxygen therapy. Specifically the facility failed to:-Provide Resident #11 oxygen therapy as ordered; and,-Ensure the physician's order for Resident #11's oxygen therapy included the prescribed liter flow, method of delivery and duration of use.

Inspectors wroteD. Failure to update fall care plans and interventions to prevent falls and complete neurological assessments after a fall for Resident #18, Resident #43, and Resident #52. The Neuro (Neurological) check assessment form, dated 2024, was provided by the director of nursing (DON) on [DATE] at 12:11 p.m. It documented that when a resident experienced a fall, neurological checks are performed for 72 hours after the fall occurred. -The assessment form documented that four neurological checks must be completed every 15 minutes in the first hour after the fall event. The assessment form documented that neurological checks must be completed every 30 minutes in the second hour after the fall event. The assessment form documented that hourly neurological assessments are completed for four hours after the 30-minute checks were completed. [...]

Inspectors wroteBased 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 [DATE] 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. [...]

Inspectors wroteBased 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. Specifically, the quality assurance performance improvement (QAPI) program committee failed to implement an effective system to identify and address multiple concerns related to quality of care, including accidents/hazards, in which the facility failed to conduct safety risk assessments for residents with transfer poles which rose to the level of immediate jeopardy and created a situation that a serious adverse outcome was likely.

Inspectors wroteBased 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.

Inspectors wroteBased 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 refrigerator.

Inspectors wroteBased on observation, record review and staff interviews, the facility failed to ensure three (#12, #26 and #52) of seven residents reviewed for abuse out of 41 sample residents was kept free from abuse. Specifically, the facility failed to: -Protect Resident #12 from physical abuse from a staff member; and, -Protect Resident #26 from verbal abuse from Resident #52.

Inspectors wroteBased 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.

Inspectors wroteBased 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 Resident #43 and Resident #13, who were prescribed a mechanically altered diet texture, were served food in the correct form.

Inspectors wroteBased 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.

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure one (#1) of five residents out of 13 sample residents was free from significant medication errors. On 5/16/24, when Resident #1 was no longer able to swallow oral medication prescribed for pain relief, registered nurse (RN) #1 consulted with the resident's hospice provider and primary care practitioner for alternative medication orders. Nurse practitioner (NP) #1 called in a prescription for liquid morphine sulfate 20 milligrams (mg)/5 milliliters (ml), give 3.75 ml (which equaled 15 mg) and entered the new order into the resident's electronic medical record (EMR). RN #1 obtained a bottle of liquid morphine sulfate solution from the facility's emergency stock medication supply and proceeded to administer the medication to RN #1. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure timely physician visits for four (#9, #10, #12 and #13) of five residents reviewed for new admission physician visits out of 13 sample residents. Specifically, the facility failed to ensure the physician evaluated Resident #9, Resident #10, Resident #12 and Resident #13 within 30 days following admission to the facility.

Inspectors wroteBased on observation, record review and interviews the facility failed to ensure three (#55, #35 and #32) out of 34 sample residents received treatment and care in accordance with professional standards of practice. Specifically, the facility failed to: -Assess a Resident #55's change of condition and notify the resident's physician in a timely manner when the resident had ongoing vomiting and when the resident's abdomen was distended and tender to touch on 3/12/23; and, -Assess Resident #35 and Resident #32 vital signs were monitored prior to the administration of a blood pressure medication.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections in one of two dining rooms. Specifically, the facility failed to ensure residents had hand hygiene before meals.

Inspectors wroteBased on interviews and record review, the facility failed to ensure one (#42) of four out of 34 sample residents were kept free from physical abuse. Specifically, the facility failed to ensure effective personalized care planned behavioral interventions were in place for Resident #43, who had a history of physically abusive behaviors towards Resident #42.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure effective interventions were in place to address weight loss for two (#3 and #37) of seven residents reviewed for nutrition out of 34 sample residents. Specifically, the facility failed to ensure Resident #3 and #37 were provided nutritional interventions identified for their weight losss.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were free from abuse, neglect and exploitation for one (#16) of four residents reviewed for abuse out of 21 sample residents. Specifically, the facility failed to ensure Resident #16 was free from verbal abuse from a staff member. Resident #16 was told by registered nurse (RN) #6 that Resident #16 risked having to leave the facility and find another place of residence because of discussions he had with his own power of attorney (POA). The interaction with the RN left the resident feeling threatened and intimidated by the RN. He was worried about losing his home. In addition, the facility failed to thoroughly assign and complete corrective action following a substantiated allegation of verbal abuse, resulting in the continuation of Resident #16 feeling bullied and intimidated. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure each resident was treated with dignity and respect and cared for in a manner and in an environment that promoted maintenance or enhancement of quality of life for one (#10) of one resident reviewed for dignity out of 21 sample residents. Specifically, the facility failed to ensure Resident #10 was positioned correctly at the dining room table and while she received care from staff during meals.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide the highest practicable quality of care for one (#40) out of two residents reviewed for skin conditions or injuries out of 21 sample residents. Specifically, the facility failed to for Resident #40 ensure the resident had proper protection of her right heel wound to promote healing.

Inspectors wroteBased on observations, interviews and record review, the facility failed to maintain an infection control program designed to prevent the spread of infection during wound care for one (#40) of one resident with wounds, of 21 sample residents, and during the medication administration observation for one of four nurses. Specifically, the facility: -Failed to implement appropriate hand hygiene practices, glove use and sanitary conditions while providing wound care for Residents #40; and, -Failed to implement appropriate hand hygiene practices and glove use during medication administration.