Spanish Peaks Veterans Community Living Center

In the surveyor’s words

From the most serious findings on record at Spanish Peaks Veterans Community Living Center, in the surveyor’s own words.

• Actual harm, isolatedF684Jun 29, 2023

  Based on record review, observations and interviews, the facility failed to ensure one (#4) of four residents received prompt dental services out of 21 sample residents. Resident #4 started complaining about upper and lower gum pain preventing him from wearing his dentures on 5/31/23. Through an observation and the resident interview, he grimaced and closed his eyes when trying to chew the food offered and he said he had difficulty eating at times due to his dentures not fitting properly. Due to the facility's failures to provide emergent and timely dental care and services, the resident expressed sadness, had ongoing mouth pain and had difficulty eating the meals provided to him. Findings include: I. Resident status Resident #4, age 85, was admitted on [DATE]. […]

• No harm, potential for more than minimal, widespreadF812Jun 29, 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; -Cutting boards were free from deep scratches and stains; and, -Beard restraints were worn in kitchen areas while serving food. Findings include: I. Improper hand hygiene A. Professional references According to the Colorado Retail Food Establishment Rules and Regulations (effective 1/1/19) pg.46-47, Food employees shall clean their hands and exposed portions of their arms immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single-service items… […]

• No harm, potential for more than minimal, patternF600Dec 5, 2024

  Based on record review and interviews, the facility failed to ensure three (#65, #56 and #12) of three residents reviewed out of 28 sample residents were kept free from abuse. Specifically, the facility failed to: -Prevent a resident-to-resident altercation between Resident #65 and Resident #56; and, -Protect Resident #12 from physical abuse by Resident #65. Findings include: I. Facility policy and procedure The Abuse Prohibition policy and procedure, dated 8/1/18, was provided by the nursing home administrator (NHA) on 12/2/24 at 12:39 p.m. […]

• No harm, potential for more than minimal, patternF700Dec 5, 2024

  Based on record review, observations and interviews, the facility failed to ensure a through safety assessment was completed and documented before the installation of side/bed rails for four (#70, #57, #63 and #38) of 10 residents out of 28 sample residents. Specifically, for Residents #70, #57, #63 and #38, the facility failed to: -Ensure the residents were thoroughly assessed prior to the installation of bed rails, to include the residents' medical diagnoses, conditions, symptoms and/or behavioral symptoms, size and weight, sleep habits, medication(s), acute medical or surgical interventions, underlying medical conditions, existence of delirium, ability to toilet self safely, communication and mobility (in and out of bed); and, -Evaluate the use of alternative interventions prior to the… […]

• No harm, potential for more than minimal, patternF689Jun 29, 2023

  Based on observations, record review and interview, the facility failed to ensure that the resident environment remained as free of accident hazards as possible; and each resident received adequate supervision and assistance devices to prevent accidents for two (#70 and #4) of five residents reviewed for assistive devices out of 21 sample residents and residents at risk for unsafe water temperatures. Specifically, the facility failed to: -Ensure safe water temperatures; -Assess for effectiveness of bed alarm and to ensure alarm was not utilized for the convenience of staff for Resident #70; and, -Ensure Resident #4's room was free from accidents/hazards causing injuries to his lower extremities Findings include: I. […]