Garfield County Nursing Home

In the surveyor’s words

From the most serious findings on record at Garfield County Nursing Home, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Jun 25, 2025

  Based on observation and interview, the facility did not store, prepare, distribute, and serve food in accordance with professional standards for food service safety. Specifically, there was undated food in the refrigerator and freezer, kitchen staff were observed to not be wearing hairnets and beard coverings, and the sanitizer bucket was not testing at the required sanitation levels.Findings included:On 6/22/25 at 12:07 PM, an initial tour of the kitchen was conducted. The following observations were made:a. An open energy drink was out on the food prep table.b. Three bags of bread slices were unlabeled and undated in the refrigerator.c. Two slices of cheese and ham were in a bag that was undated and unlabeled in the refrigerator.d. […]

• No harm, potential for more than minimal, widespreadF812Sep 15, 2021

  Based on observation and interview, it was determined the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, items within the facility's walk-in fridge were observed stored uncovered and unlabelled, and the sanitizer level within the dish machine and sanitizer buckets was not maintained at manufacturer recommended levels. Findings included: 1. On 9/13/21 at 12:32 PM, the facility's walk-in and reach-in refrigerators were examined. a. A sheet pan containing a quinoa, corn, and rice mixture was observed in the walk-in fridge uncovered and unlabelled. b. A plastic bag containing a section of ham was observed in the walk-in refrigerator left open to air. c. […]

• No harm, potential for more than minimal, patternF605Jun 25, 2025

  3. Resident 5 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, depression and insomnia disorder. Resident 5's medical record was reviewed. A physician's order dated 1/29/19, documented sertraline (Zoloft) 25 mg. Administer 12.5 mg daily for a diagnosis of depression. A physician's order dated 1/29/19, documented zolpidem (Ambien) 5 mg daily at bedtime for a diagnosis of insomnia. A physician's order dated 2/14/20, documented diphenhydramine (Banophen) 25 mg daily at bedtime for a diagnosis of allergies and insomnia. A physician documented clinical contraindication was unable to be located and the medications had not received the appropriate GDR. 4. […]

• No harm, potential for more than minimal, patternF641Jun 25, 2025

  Based on interview and record review, the facility did not ensure an assessment accurately reflected the resident's status. Specifically, for 3 out of 12 sampled residents, residents were coded as taking antipsychotic medications when they were not taking them. Resident identifiers: 1, 8, and 12. Findings included: 1. Resident 1 was admitted to the facility on [DATE] with diagnoses which included, traumatic brain injury and depression. Resident 1's medical record was reviewed on 6/22/25 through 6/25/25. On 5/16/25, a quarterly Minimum Data Set (MDS) assessment documented that resident 1 was taking an antipsychotic medication. On 5/14/25 at 9:24 AM, a Long Term Care (LTC) Psychotropic Medication Review documented resident 1 was taking: a. […]

• No harm, potential for more than minimal, patternF880Jun 25, 2025

  Based on observation, interview, and record review, the facility did not 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. Specifically, for 3 out of 12 sampled residents, Enhanced Barrier Precautions (EBP) were not implemented for residents with wounds and indwelling urinary catheters. Resident identifiers: 2, 9, and 10.Findings included:1. Resident 2 was admitted to the facility on [DATE] with diagnoses which included, but were not limited to, urinary tract infection.On 6/22/25 at 1:29 PM, an interview was conducted with resident 2. Resident 2 was observed to have a down drain urinary catheter bag. […]