Glenwood Springs Healthcare

In the surveyor’s words

From the most serious findings on record at Glenwood Springs Healthcare, in the surveyor’s own words.

• Actual harm, isolatedF686Jul 31, 2024

  Based on observations, record review and interviews, the facility failed to provide the necessary treatment and services to treat and prevent pressure injuries for one (#1) of three residents reviewed for pressure ulcers out of 39 sample residents. Resident #1, who was known to be at risk for pressure injuries, was admitted on [DATE] and readmitted on [DATE]. The resident had diagnoses of multiple sclerosis (disabling disease of brain and spinal cord), neurogenic bladder and metabolic encephalopathy (brain disorder caused by chemical imbalance of the blood). Hospital documentation recommended treatment for the wounds which were present to the Resident #1's sacrum, right lower extremity and left lower extremity upon the resident's readmission to the facility on [DATE]. […]

• Actual harm, isolatedF686Jan 11, 2022

  Based on observation, record review and interviews, the facility failed to ensure one (#11) of two residents reviewed for pressure injuries, out of 26 sample residents, received care consistent with professional standards of practice to prevent and heal pressure injuries. Resident #11 had a facility acquired unstageable pressure injury which was not identified as unavoidable in the medical record. The review of the resident's progress notes and medical record between 11/11/21 and 1/10/22 did not identify the resident was seen by her primary physician or by a wound physician after it was identified the resident had an unstageable pressure injury/DTI (deep tissue injury). […]

• Actual harm, isolatedF600Aug 6, 2021

  Based on interviews and record review, the facility failed to provide a safe environment and protect residents from staff-to-resident abuse involving two (#1 and #2) of four sample residents were free from verbal and physical abuse. The facility failed to ensure Resident #1 was free from abuse by certified nurse aide (CNA) #1. The resident reported she was verbally and physically abused by CNA #1 on 6/11/21. Although CNA #1 was suspended and instructed not to provide care for Resident #1, the resident said she was angry at the time of the incident and fearful of retaliation afterward, and felt the nursing home administrator (NHA) minimized her concerns and failed to [MEDICATION(S)]. […]

• Actual harm, isolatedF610Aug 6, 2021

  Based on record review and staff interviews, the facility failed to thoroughly investigate allegations of verbal and physical abuse involving two (#1 and #2) of four sample residents. Specifically, the facility failed to: -Thoroughly investigate the alleged violation; -Prevent further abuse, neglect, exploitation and mistreatment from occurring while the investigation is in progress; and -Take appropriate corrective action, as a result of investigation findings. The failures resulted in incidents of abuse involving incontinence care with certified nurse aides (CNAs). The first incident resulted in an allegation of verbal and physical abuse by CNA #1 towards Resident #1 on 6/11/21. […]

• Actual harm, isolatedF689Mar 11, 2021

  Based on observations, record review and interviews, the facility failed to provide supervision and assistance to prevent falls with injury for one (#2) of three residents reviewed for falls/accidents out of seven sample residents. The facility failed to observe and supervise, anticipate needs and implement fall prevention measures for Resident #2, who was impulsive, had a history of [REDACTED]. The facility failed to complete accurate fall risk assessments on two occasions. The facility's interdisciplinary team (IDT) failed to determine the actual root cause of why Resident #2 continued to fall. The facility failed to implement new fall interventions following each of the resident's ten falls in the facility between 9/30/2020 and 3/11/21. The resident sustained [REDACTED]. […]