Colorado State Veterans Nursing Home - Rifle

In the surveyor’s words

From the most serious findings on record at Colorado State Veterans Nursing Home - Rifle, in the surveyor’s own words.

• Immediate jeopardy, patternF689Nov 22, 2024

  Based on observations, record review and interviews, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and that each resident received adequate supervision and assistive devices to prevent accidents. This failure affected one discharged resident (#61) and 22 current residents (#34, #31, #22, #14, #46, #35, #2, #33, #45, #17, #21, #42, #47, #54, #4, #7, #58, #18, #43, #52, #40 and #29) out of 41 sample residents. Specifically: TRANSFER POLES On [DATE], Resident #61, severely cognitively impaired and with a history of falls, was discovered stuck between the bed and his transfer pole. […]

• Immediate jeopardy, isolatedF760Jun 6, 2024

  Based 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). […]

• Actual harm, isolatedF686Nov 22, 2024

  Based 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. […]

• Actual harm, isolatedF600Feb 14, 2022

  Based 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. […]

• No harm, potential for more than minimal, widespreadF867Nov 22, 2024

  Based 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. Findings include: I. […]