Veterans Community Living Center at Fitzsimons

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 communicatable diseases and infections. Specifically, the facility failed to: -Ensure the facility's water management program (WMP) described the building water systems, identified specific areas where legionella could grow and spread and decided where and how to monitor control measures to prevent Legionella and waterborne pathogen growth; and, -Ensure scissors were cleaned in a sanitary manner after wound care.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure four (#127, #60, #45 and #92) of five residents reviewed for abuse out of 45 sample residents were kept free from abuse. Specifically, the facility failed to: -Prevent resident to resident physical abuse between Resident #127 and Resident #60, who had a known history of physically aggressive behaviors towards other residents and staff who he perceived to be in his personal space and had documented recent physically aggressive behaviors with staff; -Have timely effective interventions to protect Resident #127, who had a history of physical aggression and wandering into other residents' rooms and invading their personal space; and, -Prevent resident-to-resident sexual abuse of Resident #45 by Resident #92 on 5/29/24 and 9/16/24.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to revise and review comprehensive care plans for five (#122, #104, #81, #46 and #65) of 11 residents reviewed out of 45 total sample residents. Specifically, the facility failed to: -Ensure Resident #122, Resident #104 and Resident #81's care plans were reviewed and revised to reflect the use of an anticoagulant (blood thinner) medication; -Ensure Resident #46's care plan included prescribed medications for antianxiety, opioids, and anticoagulants; and, -Ensure Resident #65's skin treatment care plan was implemented.

Inspectors wroteBased on observations, record review and interview, the facility failed to assist a resident in obtaining routine or emergency dental services, as needed for three (#81, #45, and #93) out of 45 sample residents. Specifically, the facility failed to: -Ensure a referral to dental services was completed three days after Resident #81 broke two of his teeth and started to experience pain when he ate; -Ensure Resident #45 was seen by the dentist in a timely manner after the resident reported dental pain; and, -Assist Resident #93 in obtaining new dentures or fixing his broken dentures to address the mouth pain he was having.

Inspectors wroteBased on observations, record review and interviews, the facility failed to promote and maintain the resident's dignity for one (#65) of one resident reviewed for dignity and respect out of 45 sample residents. Specifically, the facility failed to ensure call light was in reach for Resident #65's use with limited range of motion.

Inspectors wroteBased on record review, observation and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for one (#65) of three residents reviewed out of 45 sample residents. Specifically, the facility failed to ensure a certified nurse aide (CNA) reported Resident #65's new skin alterations timely.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#45) of one resident, out of 45 sample residents, with limited range of motion (ROM) received appropriate treatment and services to prevent further decrease in ROM. Specifically, the facility failed to ensure the physician's order for Resident #45 to use the facility's exercise bike was followed.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide food that accommodated resident preferences for one (#10) of one resident out of 45 sample residents. Specifically, the facility failed to provide food choices according to Resident #10's preference.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure one (#106) out of 53 sample residents, was kept safe and free from elopement. Specifically, the facility failed to ensure Resident #106, who was diagnosed with dementia, was at a high risk of elopement and had multiple elopement attempts was kept safe. On 6/2/23, the security guard was posted at the front desk. Resident #106 approached the front door with a wanderguard in place (which did not alarm), informed the security guard he was going to go outside and then walked out the front door. A certified nurse aide (CNA) was outside, who was familiar with the resident's history and attempted to direct him back into the facility, but was unsuccessful. The resident only returned to the facility with police intervention. [...]

Inspectors wroteBased on record review and interviews, the facility failed to have a system for identifying deviations in performance and adverse events, and develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct identified quality deficiencies. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to elopement from the facility that led to an immediate jeopardy during the survey on 6/21/23 to 6/28/23. Cross-reference F689: The facility failed to ensure Resident #106, who was diagnosed with dementia, was at a high risk of elopement and had multiple elopement attempts was kept safe. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure that residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for eight (#80, #45, #101, #17, #63, #16, #87 and #66) of nine out of 53 sample residents. Specifically, the facility failed to ensure trauma assessments were conducted to determine the residents history of post-traumatic stress disorder (PTSD) and/or trauma, identify triggers and develop person centered interventions within the comprehensive care plan for Resident #80, #45, #101, #17, #63, #87, #16 and #66.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#28) of one out of 53 residents with limited range of motion received appropriate treatment and services. Specifically, the facility failed to ensure preventative measures were put into place for Resident #28's bilateral hand contractures.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to ensure one (#83) of five out of 53 sample residents were as free from unnecessary drugs as possible. Specifically, the facility failed to ensure Resident #83 was not given an excessive amount of acetaminophen that exceeded the recommended daily consumption.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#58) of five residents reviewed out of 53 sample residents were as free from unnecessary medications as possible. Specifically, the facility failed to ensure Resident #58 was assessed for depression prior to an antidepressant medication being ordered and administered at the request of the resident's family.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure beverages were provided to maintain resident hydration for one (#90) of two out of 53 sampled residents. Specifically, the facility failed to ensure Resident #90 was offered a sufficient amount of water throughout the day and that the water pitcher was kept within the resident's reach.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were free from restraint imposed for purposes of discipline or convenience for one out of two sample residents. Specifically, the facility failed to prevent the use of discipline by taking Resident #70's personal powered vehicle (mechanical wheelchair) away from him which caused the resident to feel humiliated and depressed.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure one (#88) of 10 residents reviewed for activities of 12 sample residents had an ongoing activity program based on comprehensive assessments, care plans and resident preferences. Specifically, the facility failed to provide person centered activities that met the interest and needs of Resident #88.

Inspectors wroteBased on record review and interviews, the facility failed to establish and maintain a communication process between the nursing home and the dialysis facility for one (#106) of one out of four sampled dialysis residents, consistent with professional standards of practice. Specifically, the facility failed to: -Ensure the agreement with the dialysis center was established prior to the resident received dialysis services; and -Reflect ongoing communication, coordination and collaboration between the facility staff and the dialysis staff.