Veterans Community Living Center at Fitzsimons

In the surveyor’s words

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

• Immediate jeopardy, isolatedF689Jun 28, 2023

  Based on observation, record review and interviews, the facility failed to ensure one (#106) out of 53 sample residents, was kept safe and free from elopement. Specifically, the facility failed to ensure Resident #106, who was diagnosed with dementia, was at a high risk of elopement and had multiple elopement attempts was kept safe. On 6/2/23, the security guard was posted at the front desk. Resident #106 approached the front door with a wanderguard in place (which did not alarm), informed the security guard he was going to go outside and then walked out the front door. A certified nurse aide (CNA) was outside, who was familiar with the resident's history and attempted to direct him back into the facility, but was unsuccessful. […]

• Immediate jeopardy, isolatedF678Feb 27, 2023

  Based on record review and interviews, the facility failed to ensure personnel provided basic life support, including cardiopulmonary resuscitation (CPR), to residents requiring such emergency care prior to the arrival of emergency medical personnel, in accordance with physician's orders and the residents advance directives, for two (#3 and #4) of three residents reviewed for medical orders for scope of treatment (MOST) and CPR directives, out of 17 sample residents. On [DATE] at approximately 10:00 p.m., Resident #4 was discovered unresponsive, not breathing and without a pulse; and on [DATE] at approximately 10:45 p.m. Resident #3 was discovered unresponsive, not breathing and without a pulse. […]

• Actual harm, isolatedF600Feb 27, 2023

  Based on observation, record review and interviews, the facility failed to ensure that all residents were free from abuse, neglect, and exploitation, for two residents (#1 and #2) in one allegation of three residents reviewed for abuse out of 17 sample residents. On 1/26/23 at 12:54 a.m., Resident #1 was wandering the secured unit without staff supervision. Staff were unaware that Resident #1 had entered Resident #2's room in the night until Resident #1 was observed, by the unit nurse, exiting Resident #2's room with Resident #2 following behind. […]

• No harm, potential for more than minimal, widespreadF880Nov 21, 2024

  Based on observations, record review and staff interviews, the facility failed to 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 communicatable diseases and infections. Specifically, the facility failed to: -Ensure the facility's water management program (WMP) described the building water systems, identified specific areas where legionella could grow and spread and decided where and how to monitor control measures to prevent Legionella and waterborne pathogen growth; and, -Ensure scissors were cleaned in a sanitary manner after wound care. Findings include: I. Water management program A. […]

• No harm, potential for more than minimal, widespreadF867Jun 28, 2023

  Based on record review and interviews, the facility failed to have a system for identifying deviations in performance and adverse events, and develop and implement appropriate quality assurance and performance improvement (QA/QAPI) plans of action to correct identified quality deficiencies. Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to elopement from the facility that led to an immediate jeopardy during the survey on 6/21/23 to 6/28/23. Cross-reference F689: The facility failed to ensure Resident #106, who was diagnosed with dementia, was at a high risk of elopement and had multiple elopement attempts was kept safe. […]