Yampa Valley Healthcare Center

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were kept free from accidents or hazards for one (#3) of two residents out of six sample residents. Resident #3, was admitted on [DATE] with diagnoses of cerebral vascular disease (CVA), and diabetes. Resident #3 was dependent on staff assistance for transfers using a Hoyer lift (mechanical lift). On 10/28/25, the staff were transferring Resident #3 from her bed to the shower chair using the Hoyer lift. The Hoyer lift sling came unhooked from the Hoyer lift during the transfer, which resulted in Resident #3 falling to the floor. The resident hit her head when she fell and was transferred to the hospital for evaluation. At the hospital, the resident was diagnosed with an acute parafalcine subdural hematoma (blood accumulation on the brain). [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were free from accidents or hazards for three (#2, #5 and #3) of eight residents reviewed out of eight sample residents. Specifically, the facility failed to:-Implement interventions to prevent an elopement for Resident #2 and;-Implement fall interventions for Resident #5 and Resident #3.

Inspectors wroteReceived treatment and care in accordance with professional standards or practice out of eight sample residents. Specifically, the facility failed to:-Complete a wander risk assessment after Resident #1 had a change of condition and left the building;-Obtain physician's orders for the use of Resident #1's wanderguard; and, -Ensure Resident #1's care plan was updated with the use of a wander guard.

Inspectors wroteBased 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.

Inspectors wroteBased 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 [DATE], 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. [...]

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure residents were kept free from abuse for three (#1, #2 and #3) of six residents reviewed for abuse out of six sample residents. Resident #1, who had a diagnosis of Alzheimer's disease and a tendency to wander, had a plan of care which documented the resident had impaired safety awareness and wandered aimlessly. The interventions were to offer Resident #1 pleasant diversions, structured activities, food, conversation, television and card games. On 2/28/24 Resident #1 wandered into Resident #2's room. Resident #2 told Resident #1 he was in the wrong room and told him to leave. Resident #1 refused to leave the room which caused Resident #2 to push Resident #1 to the floor. A staff member, who was informed that Resident #1 went to the wrong room, rushed to the room but she was unable to open the door. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure one (#11) of two residents reviewed received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being level out of 25 sample residents. Resident #11 was at nutritional risk with diagnoses of gastroesophageal reflux disease, muscle weakness and dementia. The registered dietitian (RD) implemented measures for the resident's nutrition risk and weight. Observations during the survey revealed the resident was not provided finger foods or fortified foods at meals, a brightly colored plate and alternatives offered when Resident #11's intake was poor. The facility failed to implement nutritional recommendations at mealtimes. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure five (#3, #13, #20, #10 and #9) of six residents reviewed for activities of daily living (ADLs) out of 25 sample residents received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to ensure Residents #33, #13, #20, #10 and #9, who were dependent on staff for bathing care, were provided bathing consistently with their plan of care.

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure three (#25, #3 and #10) of three out of 25 sample residents who required respiratory care were provided such care consistent with professional standards of practice. Specifically, the facility failed to ensure oxygen concentrators had distilled water to humidify the oxygen concentrators for Resident #25, #3 and #10.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses of the facility's resident population in accordance with the facility assessment, resident census and daily care required by the residents. Cross-reference citations: -F677 activities of daily living for dependent residents; and, -F689 accident hazards.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents were free from significant medication errors for two (#10 and #14) of two residents reviewed for medication errors out of 25 sample residents. Specifically, the facility failed to ensure: -Resident #10 was administered her chronic obstructive pulmonary disease (COPD) medications ordered for nearly a week; and, -Resident #14 was administered his medication for Huntington's disease.

Inspectors wroteBased on interviews, observations and record review, the facility failed to consistently serve food that was palatable and attractive at the appropriate temperatures. Specifically, the facility failed to ensure resident food was palatable in taste, texture, temperature and appearance.

Inspectors wroteBased on interviews and record review, the facility failed to protect one (#23) resident from abuse out of 25 sample residents. Specifically, the facility failed to: -Ensure Resident #23 was protected from physical abuse by Resident #24 on 11/25/23; and, -Conduct a thorough investigation of a resident to resident altercation, including documentation of staff interviewed, which resulted in the appropriate authorities not being notified of physical abuse of Resident #23.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for two (#18 and #4) of four residents reviewed for pressure injuries out of 25 sample residents. Specifically, the facility failed to: -Consistently assess and document a pressure injury for Resident #18; -Obtain physician orders for the treatment of a pressure injury Resident #18; -Consistently assess and document a wound for Resident #4; -Obtain physician orders for the treatment of a wound for Resident #4; and, -Conduct weekly skin assessments for Resident #4.

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide an environment free from accident hazards for one (#3) out of 25 sample residents. Specifically, the facility failed to: -Investigate a fall Resident #3 on 1/17/24; -Properly secure Resident #3 in the facility van when going to an appointment on 1/24/24; -Ensure two staff assisted Resident #3 with a mechanical lift transfer.

Inspectors wroteBased on record review and interviews, the facility failed to provide appropriate pharmaceutical services to meet the needs of residents for one (#1) of three residents reviewed for pharmacy services out of 25 sample residents. Specifically, the facility failed to ensure medications were available to prevent missed doses of Prostat liquid (a protein supplement for wound healing) for Resident #1.

Inspectors wroteBased on observation and interviews, the facility failed to ensure residents received notice orally and in writing which included a written description of their legal rights. Specifically, the facility failed to: -Information of how to file a complaint with the State Agency; -Post local contact agency for information about returning to the community; -Post information on Medicaid fraud; and, -Post a list of names, addresses (mailing and email) and telephone numbers of all pertinent State Agencies in the facility.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure adequate supervision and provide assistance devices to prevent falls for one (#20) of six residents reviewed for falls out of 24 sample residents. The facility failed to ensure Resident #20, who had nine falls within six months, had effective interventions, supervision and assistance in place to prevent further falls. Resident #20 suffered multiple falls with injuries including lacerations to his face and his head, including an emergency room visit where he received six stitches and he continued to fall.

Inspectors wroteIV. Resident #4 A. Resident status Resident #4, age [AGE], was admitted on [DATE] with diagnoses of chronic obstructive pulmonary disease (COPD), emphysema and chronic respiratory failure with hypoxia (low oxygen level). The annual MDS assessment dated [DATE] showed the resident had a BIMS score of 14 out of 15, indicating intact cognitive status. The patient health questionnaire (PHQ) indicated depression. He had no hallucinations or delusions, but exhibited verbal behavioral symptoms directed toward others and rejected care one to three days. He needed supervision, cueing and set-up for meals. He weighed 160 pounds, his weight loss was no or unknown and he had experienced weight gain without a plan to do so. B. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure residents had safe, clean, comfortable and homelike environments in two of two resident hallways and one of two shower/tub rooms. Specifically, the facility failed to ensure: -Resident rooms were clean and in good repair; -Resident rooms were stocked with clean bath linens; -Room temperatures were maintained for resident comfort; -The shower room was safe, clean and in good repair; and, -The bath tub was in working order and available for resident use.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure that services provided or arranged are delivered by individuals who have the skills, experience and knowledge to do a particular task or activity which included proper licensure or certification. Specifically, the facility failed to ensure nurse aide (NA) #1 and NA #2 had the appropriate certifications to perform scheduled tasks for resident care.

Inspectors wroteBased 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 prevent the development and transmission of communicable diseases and infections for residents. Specifically, the facility failed to ensure: -Ensure staff offered residents hand hygiene appropriately; and, -Ensure proper hand hygiene standards were followed by staff during dining service.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to implement appropriate and timely interventions to ensure one (#17) of four residents reviewed for pressure ulcers out of 24 sample residents received the necessary care and treatment to prevent the development of a pressure injury to prevent reoccurring pressure ulcers. Specifically, the facility failed to implement precautions to prevent Resident #17's pressure ulcers from reoccurring on his heels and his bottom.

Inspectors wroteBased on observations, record review and interviews the facility failed to ensure one (#10) of two residents reviewed for appropriate mental health services out of 24 sample residents received proper treatment and services to attain their highest practicable mental and psychosocial well-being. Specifically, the facility failed to: -Ensure alternative services were offered, besides only therapy when the resident refused it; -Assist the resident with positive coping skills and ensure staff members knew what positive coping skills versus negative coping skills looked like; and, -Ensure the care plan reflected the services for the resident's needs and how staff could better assist with her mental well-being.

Inspectors wroteBased on observations, record review and interviews, the facility failed to protect seven of seven residents (#19, #25, #10 and four residents who asked to remain anonymous) out of 29 sample residents, from resident-to-resident abuse that contributed to the residents experiencing emotional and psychological harm. This deficiency was cited previously during a recertification survey on 3/25/21. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Specifically, the facility failed to protect the residents from repeated instances of verbal and mental abuse by Resident #19. Interviews revealed a pattern of abusive behavior including threats of retaliation by Resident #19 toward other residents which contributed to residents feeling fearful, helpless, isolated, anxious, and stressed. [...]

Inspectors wroteBased on record review, observations and interviews, the facility failed to ensure adequate nutrition and assistance to prevent weight loss for one (#20) of five residents reviewed out of 29 sample residents. Resident #20 lost seven pounds over an eight day period, and experienced significant weight loss. Resident #20 had a 5% weight loss from 2/7/22 to 2/21/22 and a 7.5% weight loss from 2/7/22 to 4/19/22. The facility failed to assess and implement timely interventions, including dining assistance, to prevent the resident's significant weight loss.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#19) of two out of 29 sample residents, received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. Specifically, the facility failed to implement effective interventions for Resident #19 to prevent and appropriately address Resident #19 abusive behaviors towards other residents. The facility failed to protect residents from continued verbal and mental abuse from Resident #19. Interviews revealed a pattern of abusive behavior including threats of retaliation by Resident #19 towards other residents, resulting in feelings of fear, helplessness, social isolation, humiliation, and extreme anxiety. The staff failed to document the all of Resident #19 behavior, creating a limited management awareness of the frequency of the behaviors towards residents. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide person-centered dementia care to five (#33, #14, #15, #29 and #91) of five residents reviewed out of 13 residents who resided on the dementia care secured unit (SCU). Resident #33 had dementia with lewy bodies and behavioral symptoms including repetitive verbalizations that affected her well-being and that of others around her. She had delusions and hallucinations, and talked loudly and often cursed to herself, causing other residents' anxiety to escalate. Resident #16, who was typically very quiet, walked by Resident #33 when she was cursing, yelled at her to shut the (obscenity)! and charged toward her. He would have possibly injured Resident #33 had a staff person not stepped between them and redirected him, apologizing and explaining that Resident #33 was not talking to him. [...]

Inspectors wroteBased on staff interview and record review, the facility failed to ensure nurses and certified nurse aides (CNAs) were evaluated for competency and skill sets necessary to care for residents' needs as identified through residents' assessments and care plans. Specifically, the facility failed to complete competency and skill sets with licensed nurses and CNAs within the previous 24 months.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to prepare, distribute and serve food in a sanitary manner in one of one kitchen. Specifically, the facility failed to: -Prevent potential cross contamination during meal preparation and meal delivery; -Demonstrate appropriate use of gloves when handling ready-to-eat foods; -Sanitize and wash hands between meal delivery.

Inspectors wroteBased on observations, interviews and record review, the facility was not administered in a manner that enabled it to use its resources efficiently and effectively to attain and maintain the highest practicable physical, mental and psychosocial well-being of each resident. Specifically, the resources of the facility were not effectively and efficiently utilized as evidenced by findings that revealed in part systemic problems in the areas of resident-to-resident verbal and mental abuse by Resident #19 directed toward multiple other residents who voiced they were traumatized and feared retaliation by Resident #19 and staff who failed to address their concerns. Administration likewise failed to meet Resident #19's needs by ensuring her behavioral and psychosocial needs were met. [...]

Inspectors wroteBased on observations, record review and interviews, the facility failed to develop and implement an effective quality assurance and process improvement system to effect change at the system level to prevent quality of care, quality of life and safety problems, and ensure improvements were sustained. The facility failed to identify quality deficiencies and develop effective action plans to ensure systemic and lasting change and improvements in the areas of abuse, behavioral care, dementia care, fall and accident prevention, unnecessary medications, nutrition, quality of care regarding skin and wound care, activities, nursing competencies, kitchen sanitation, and infection control. These failures contributed to physical, mental and psychosocial harm to residents and prevented residents from reaching their highest practicable physical, mental and psychosocial well-being.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure infection control practices were established and maintained to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of Coronavirus (COVID-19) and other communicable diseases, and infections. Specifically, the facility failed to: -Ensure staff offered residents hand hygiene appropriately; -Ensure staff appropriately donned personal protective equipment (PPE) correctly while providing resident cares; and, -Prevent infection control breaks on the dementia care secure unit to prevent potential cross-contamination.

Inspectors wroteBased on record review and interviews, the facility failed to prevent falls and accidents with injuries and potential for injuries resulting in hospitalizations, steri-strips and a fracture for five (#20, #29, #25, #1, and #24) of eight residents reviewed for falls out of 29 sample residents. Specifcally, the facility failed to: Resident #20 was identified as a high fall risk but experienced two falls with injury. Due to the facility's failure to provide assistance to the resident, the resident fell in his bedroom on 2/6/22 and suffered a two-inch by two-inch hematoma to the right parietal lobe (was not sent to the hospital) and fell on 3/29/22 and suffered a one centimeter laceration above the right eye and abrasions to both knees. Resident #25 was identified as a high fall risk, but failed to prevent a fall with injury. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure five (#33, #14, #15, #29, #9) of five residents reviewed out of 29 sample residents were free from unnecessary antipsychotic or psychoactive medications. Specifically: -Resident #33 was ordered Ativan (antianxiety medication) as-needed without instructions for frequency, a stop date within 14 days, non-pharmacological measures to implement before administration, or specific behavior monitoring; -Residents #14 and #15 were given antipsychotic medications with dementia diagnoses. Behavioral symptoms were not specifically assessed and documented, and non-pharmacological interventions were not assessed and implemented prior to administration. -Resident #15 was given an antipsychotic for a diagnosis of dementia. -Resident #29 was given antipsychotic medication with a dementia diagnosis. [...]

Inspectors wroteBased on record review, observations and interviews, the facility failed to provide meaningful activities for one (#20) of three residents reviewed out of 29 sample residents. Specifically, the facility failed to provide meaningful activities according to Resident #20's preferences, to ensure he reached his highest practicable psychosocial well-being.

Inspectors wroteBased on observations, record review, interviews, the facility failed to provide treatment and care in accordance with professional standards of practice for one (#11) of two residents out of 26 total sample residents. Specifically, the facility failed to: -Prevent the worsening of a developing diabetic ulcer which developed an infection, necrotic tissue, and exposed muscle and tendon of the right fourth toe; -Assess, monitor, and document the skin injuries to the resident's leg; and, -Create a person-centered care plan identifying Resident #11's current needs to promote the healing of the toe. The facility failed to consistently monitor, and documented changes weekly for the status of the wound.