Gunnison Valley Health Senior Care Center

In the surveyor’s words

From the most serious findings on record at Gunnison Valley Health Senior Care Center, in the surveyor’s own words.

• Actual harm, isolatedF600Apr 2, 2024

  Based on interviews and record review, the facility failed to ensure one (#1) out of three sample residents were kept free from abuse. The facility failed to provide increased oversight and monitoring to ensure Resident #1, who had severe cognitive impairment and was unable to consent to sexual contact of any type, was protected from sexual abuse by Resident #2, who was cognitively intact. On 2/13/24, Resident #2 was observed watching television in Resident #1's room by two different staff members. At 9:23 p.m., over an hour after the last known observation of the two residents, certified nurse aide (CNA) #1 entered Resident #1's room while doing routine rounds. […]

• No harm, potential for more than minimal, patternF550Jan 29, 2026

  Based on observations, record review and interviews, the facility failed to ensure residents were treated with respect and dignity for five (#24, #17, #3, #14 and #28) of 10 residents reviewed for respect and dignity out of 22 sample residents. Specifically, the facility failed to ensure Resident #24, Resident #17, Resident #3, Resident #14 and Resident #28, who required meal assistance were treated with respect and dignity. Findings include:I. Facility policy and procedureThe Resident Dignity and Respect policy, undated, was provided by the nursing home administrator (NHA) on 1/28/26 at 2:53 p.m. […]

• No harm, potential for more than minimal, patternF727Apr 24, 2024

  Based on record review and interviews, the facility failed to have a registered nurse (RN) scheduled eight hours consecutively every day for seven days a week. Specifically, the facility failed to have an RN on duty for eight consecutive hours consistently from 10/1/23 to 4/24/24. Findings include: I. Record review Review of the nursing schedule from 10/1/23 to 4/24/24 revealed the following: -In October 2023, the facility did not have an RN on duty for eight consecutive hours on three days during the month; -In November 2023, the facility did not have an RN on duty for eight consecutive hours on thirteen days during the month; -In December 2023, the facility did not have an RN on duty for eight consecutive hours on three days during the month; and, -In March 2024, the facility did not… […]

• No harm, potential for more than minimal, isolatedF759Jan 29, 2026

  Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%). Specifically, the facility's medication error rate was 6.25%, with two errors out of 32 opportunities for error. Findings include:I. Facility policy and procedureThe Facility Administration of Medication policy, last revised 3/12/25, was provided by the nursing home administrator (NHA) on 1/30/26 at 8:49 a.m. It read in pertinent part, Qualified, authorized staff members do the following prior to administering medications: Obtain medication orders from a licensed practitioner as permitted by law and regulation. Review all medication orders in a timely manner. Clarify the order with the prescriber, if necessary. […]