Inspection Reports for
Colorado Veterans Community Living Ctr at Homelake
3749 SHERMAN AVE, MONTE VISTA, CO, 81144-9403
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
3 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
42% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Complaint Investigation
Deficiencies: 2
Date: Oct 17, 2024
Visit Reason
The inspection was conducted due to complaints regarding failure to provide professional standards of care in monitoring vital signs before administering blood pressure medications and failure to maintain accurate resident resuscitation choices in medical records.
Complaint Details
The complaint investigation found substantiated issues related to failure to monitor vital signs before medication administration and incomplete documentation of residents' resuscitation preferences.
Findings
The facility failed to ensure vital signs were monitored and assessed prior to administration of blood pressure medications for two residents. Additionally, the facility failed to maintain complete and accurate resident resuscitation orders for three residents, including missing physician orders and incomplete documentation of MOST forms.
Deficiencies (2)
F 0658: The facility failed to ensure Resident #15's and Resident #7's vital signs, specifically blood pressure and pulse, were monitored and assessed prior to administration of blood pressure medications.
F 0678: The facility failed to maintain complete and accurate resident resuscitation choices in the medical record for three residents, including missing physician orders for DNR and incomplete or unsigned MOST forms.
Report Facts
Residents reviewed: 23
Residents affected: 2
Residents affected: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Nurse #2 | Observed administering medications without checking vital signs | |
| Registered Nurse #1 | Interviewed about vital sign monitoring practices | |
| Director of Nursing (DON) | Interviewed regarding facility policies and follow-up actions | |
| Nursing Home Administrator (NHA) | Provided facility policies and documentation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Feb 13, 2024
Visit Reason
The inspection was conducted due to complaints and allegations of resident-to-resident abuse involving two residents at the facility.
Complaint Details
The complaint involved substantiated resident-to-resident physical abuse. Resident #2 attacked Resident #1 on 11/7/23 and again on 1/3/24, causing injuries that required hospital evaluation and treatment. The facility's investigation confirmed the abuse and noted ineffective interventions.
Findings
The facility failed to protect Resident #1 from physical abuse by Resident #2, who was known to be physically aggressive. Two altercations occurred on 11/7/23 and 1/3/24 resulting in injuries to Resident #1, including a fractured finger and multiple abrasions.
Deficiencies (1)
F 0600: The facility failed to protect Resident #1 from all types of abuse, including physical abuse by Resident #2. Resident #1 sustained multiple injuries from two altercations with Resident #2, and the facility's interventions were ineffective in preventing further abuse.
Report Facts
Residents Affected: 2
BIMS score Resident #1: 8
BIMS score Resident #2: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Witnessed first altercation and intervened |
| CNA #2 | Certified Nurse Aide | Provided information on resident behaviors and interventions |
| RN #1 | Registered Nurse | Interviewed regarding resident altercations and behaviors |
| Social Service Director | Abuse Coordinator | Interviewed about substantiation of abuse and investigation |
| Nursing Home Administrator | Administrator | Provided facility abuse policy and interviewed about incidents |
Inspection Report
Routine
Deficiencies: 5
Date: Mar 16, 2023
Visit Reason
Routine inspection of Colorado Veterans Community Living Center at Homelake to assess compliance with health and safety regulations including resident care, respiratory treatment, adaptive equipment use, food safety, and vaccination policies.
Findings
The facility was found deficient in providing adequate supervision during meals for a resident with choking risk, ensuring physician orders for continuous oxygen use, providing special eating equipment correctly, maintaining proper food handling and reheating procedures, and implementing pneumococcal vaccination policies and documentation.
Deficiencies (5)
F 0689: The facility failed to provide supervision during meals for Resident #27 who required supervision due to choking and coughing risks, resulting in potential accident hazards.
F 0695: The facility failed to ensure a physician's order was in place for Resident #15's continuous oxygen use, compromising proper respiratory care.
F 0810: The facility failed to provide special eating equipment and utensils as ordered for Resident #20, including weighted utensils, Dycem placemat, sippy cup, and correct scoop plate positioning during all meals.
F 0812: The facility failed to ensure proper hand hygiene by food service staff and failed to reheat modified consistency foods to safe temperatures before serving.
F 0883: The facility failed to develop and implement policies and procedures ensuring pneumococcal vaccinations were offered and documented for residents #91, #38, and #25.
Report Facts
Residents reviewed: 22
Residents affected: 1
Residents affected: 1
Residents affected: 1
Residents affected: 3
Food temperatures recorded: 124
Food temperatures recorded: 106
Food temperatures recorded: 129
Food temperatures recorded: 167
Food temperatures recorded: 169
Food temperatures recorded: 170
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Named in supervision deficiency for Resident #27 |
| CNA #2 | Certified Nurse Aide | Observed Resident #27 choking and assisted during incident |
| ADON | Assistant Director of Nursing | Observed Resident #27 and interviewed regarding supervision |
| DM | Dietary Manager | Interviewed regarding food service deficiencies and adaptive equipment |
| DCO | Director of Clinical Operations | Interviewed regarding vaccination deficiencies and resident care |
| RN #3 | Registered Nurse | Observed Resident #15 oxygen use and interviewed about oxygen order |
Inspection Report
Deficiencies: 1
Date: Dec 2, 2021
Visit Reason
The inspection was conducted to assess compliance with respiratory care standards, specifically to evaluate whether oxygen therapy was administered according to physician orders for residents requiring oxygen therapy.
Findings
The facility failed to ensure that oxygen was administered according to physician orders for two residents (#20 and #27) out of three reviewed for oxygen therapy. Resident #20 was receiving two liters of oxygen despite an order for one liter, and Resident #27 was not wearing oxygen despite having an order for two liters.
Deficiencies (1)
F 0695: The facility failed to provide safe and appropriate respiratory care by not administering oxygen according to physician orders for residents needing oxygen therapy. Resident #20 received two liters of oxygen when the order was for one liter, and Resident #27 did not wear oxygen despite an order for two liters.
Report Facts
Residents reviewed for oxygen therapy: 3
Residents affected: 2
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