Colorado Veterans Community Living CTR at Homelake

In the surveyor’s words

From the most serious findings on record at Colorado Veterans Community Living CTR at Homelake, in the surveyor’s own words.

• Actual harm, isolatedF600Feb 13, 2024

  Based on record review and staff interviews, the facility failed to ensure one (#1) of four residents reviewed for abuse out of four sample residents was kept free from abuse. Resident #2 and Resident #1 were involved in an altercation on 11/7/23. Resident #2 attacked Resident #1 and Resident #1 had injuries that included a scratch to his left forehead that was cleaned, a scratch on his nose, an abrasion to his left face/cheek, left jawline, left ear and bruising to the top of his left shoulder. There was redness around his neck and Resident #1 complained of severe left shoulder pain. Interventions added after the altercation were to move Resident #2 to a different hall and the resident was to be in the staff's line of sight. […]

• No harm, potential for more than minimal, widespreadF812Mar 16, 2023

  Based on observations, record review, and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions in one kitchen. Specifically, the facility failed to ensure: -Appropriate hand hygiene by food service staff; and, -Foods of modified consistency were reheated to safe temperatures following the use of a multi-step preparation process. Findings include: I. Improper hand hygiene A. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg. […]

• No harm, potential for more than minimal, patternF883Mar 16, 2023

  Based on record review and staff interview, the facility failed to develop and implement policies and procedures related to pneumococcal immunizations for three (#91, #38 and #25) of five residents reviewed for vaccinations of 29 sample residents. Specifically, the facility failed to ensure Residents #91, #38 and #25 were offered and/or received pneumococcal immunization. Findings include: I. Professional reference According to the Center for Disease Control and Prevention (CDC), reviewed 11/21/22, retrieved on 3/27/23 from https://www.cdc.gov/flu/professionals/infectioncontrol/ltc-facility-guidance.htm. It read, in pertinent part, If possible, all residents should receive inactivated influenza vaccine (IIV) annually before influenza season. […]

• No harm, potential for more than minimal, isolatedF658Oct 17, 2024

  Based on observations, record review and interviews, the facility failed to provide services for two (#15 and #7) of two residents reviewed out of 23 sample residents according to professional standards of practice. Specifically, the facility failed to ensure Resident #15's and Resident #7's vital signs, specifically the resident's blood pressure and pulse, were monitored and assessed prior to the administration of a blood pressure medication. Findings include: I. Professional reference According to Kizior, R. J. [NAME], K. J. (2023). Metoprolol. [NAME] Nursing Drug Handbook. Elsevier. p. 770. Assess B/P (blood pressure), heart rate immediately before drug administration. […]

• No harm, potential for more than minimal, isolatedF678Oct 17, 2024

  Based on record review and interviews, the facility failed to maintain complete and accurate resident resuscitation choices in the medical record for three (#141, #13 and #32) of fourteen residents out of 23 sample residents. Specifically, the facility failed to: -Ensure a physician's order was in place for a do not resuscitate (DNR) for Resident #141, who wished to be a DNR per the resident's Medical Orders for Scope of Treatment (MOST) form; -Ensure documentation of a MOST form was in place for Resident #13; and, -Ensure the MOST form was discussed with and signed by Resident #32, who was cognitively intact. Findings include: I. […]