Inspection Reports for
Columbine Manor Care Center
530 W 16TH ST, SALIDA, CO, 81201-2240
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
4% better than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
8
6
4
2
0
Inspection Report
Routine
Deficiencies: 6
Date: Oct 12, 2023
Visit Reason
The inspection was conducted to evaluate compliance with professional standards of quality in medication administration, resident care, respiratory care, food safety, infection prevention and control, and facility maintenance.
Findings
The facility failed to ensure proper medication orders and consents, timely nursing assessments after falls, appropriate oxygen therapy orders and administration, safe food storage and temperature monitoring, proper dish room sanitation, effective infection prevention and control including PPE use and respiratory equipment maintenance, and designation of a qualified infection preventionist during a COVID-19 outbreak.
Deficiencies (6)
F0658: The facility failed to clarify physician's orders and obtain dose information for topical skin medications for Residents #44, #103, and #203, hold Digoxin when Resident #47's heart rate was below 60, and ensure consents and black box warnings were in place for antidepressants before administration for Resident #47.
F0659: The facility failed to ensure Resident #105 was assessed by a registered nurse after multiple falls, with licensed practical nurses documenting falls but not performing injury assessments.
F0695: The facility failed to ensure Residents #17 and #47 received oxygen therapy as ordered and failed to have a physician's order in place for Resident #17's oxygen use.
F0812: The facility failed to monitor, hold, and cool potentially hazardous foods at appropriate temperatures and maintain dish room sanitation, including missing wall tiles and sticky buildup.
F0880: The facility failed to maintain an infection control program by using expired Legionella test kits, improper disposal of PPE during a COVID-19 outbreak, and failure to change oxygen cannulas weekly for two residents.
F0882: The facility failed to designate an interim infection preventionist with completed specialized training during a COVID-19 outbreak.
Report Facts
Residents tested positive for COVID-19: 20
Oxygen flow rate: 3
Oxygen flow rate: 2
Food temperature: 124
Food temperature: 127
Food temperature: 50.6
Food temperature: 54
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #1 | Registered Nurse | Interviewed regarding medication consents and Digoxin administration |
| Director of Nursing | Director of Nursing (DON) | Interviewed regarding medication consents, Digoxin administration, falls assessments, oxygen therapy, and infection prevention |
| Regional Director of Clinical Services | Regional Director of Clinical Services (RDCS) | Interviewed regarding consents for psychotropic medications |
| Certified Nurse Aide #1 | Certified Nurse Aide (CNA) | Interviewed regarding falls reporting and oxygen therapy |
| Certified Nurse Aide #2 | Certified Nurse Aide (CNA) | Interviewed regarding oxygen cannula change policy |
| Certified Nurse Aide #3 | Certified Nurse Aide (CNA) | Interviewed regarding improper PPE disposal |
| Nutrition Services Manager | Nutrition Services Manager (NSD) | Interviewed regarding food temperature monitoring and dish room cleaning |
| Environmental Services Director | Environmental Services Director (ES) | Interviewed regarding Legionella testing and dish room maintenance |
| Infection Preventionist | Infection Preventionist (IP) | Interviewed regarding infection prevention training and COVID-19 outbreak |
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Oct 20, 2022
Visit Reason
The inspection was conducted as an annual survey to assess compliance with regulatory requirements for nursing home care, including environment, resident care, medication management, dietary services, and vaccination programs.
Findings
The facility was found deficient in maintaining a sanitary and safe environment, providing appropriate resident care including activities and respiratory care, medication management, dietary safety, and vaccination programs. Multiple minimal harm deficiencies were cited related to environmental cleanliness, oxygen concentrator use, resident activities, medication labeling, food safety, and staff vaccination tracking.
Deficiencies (8)
F 0584: The facility failed to maintain a sanitary, orderly, and comfortable environment in 12 of 22 resident rooms and three hallways, including damaged walls, dirty floors, and improper use of power strips for oxygen concentrators.
F 0679: The facility failed to provide an ongoing activities program that met resident #34's interests and needs, resulting in lack of meaningful activity and social interaction.
F 0684: The facility failed to ensure resident #35 received prescribed ted hose daily as ordered, with staff unaware of the order and no documented refusals.
F 0695: The facility failed to ensure oxygen therapy was administered according to physician orders for resident #15, with oxygen concentrator set at five liters instead of the ordered three liters.
F 0761: The facility failed to ensure drugs and biologicals were properly labeled and stored, including expired nitroglycerin tablets and undated Novolog flexpen and Breo inhaler in medication carts.
F 0812: The facility failed to follow safe dietary practices including proper food labeling and dating, prohibiting jewelry during food service, ensuring appropriate hand hygiene by food service staff, and maintaining sufficient dishwasher sanitizing solution levels.
F 0883: The facility failed to ensure a proper pneumococcal immunization program, failing to offer and provide pneumococcal vaccine to residents #30 and #39, with incomplete documentation and consent.
F 0888: The facility failed to develop and implement a COVID-19 staff vaccination process that included all staff and agency personnel, with incomplete tracking and documentation of vaccination status.
Report Facts
Residents reviewed for activities: 17
Residents reviewed for quality of care: 17
Residents reviewed for oxygen use: 17
Staff vaccination matrix count: 50
Agency staff not included in vaccination matrix: 6
Facility certified nurse aides not included in vaccination matrix: 8
Facility registered nurse not included in vaccination matrix: 1
Facility licensed practical nurse not included in vaccination matrix: 1
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Aug 5, 2021
Visit Reason
The inspection was conducted due to concerns about medication security in the facility's medication storage room.
Complaint Details
The investigation was complaint-related, focusing on medication security. The deficiency was substantiated based on observations and staff interviews.
Findings
The facility failed to ensure the medication storage room was properly locked on multiple occasions, allowing potential access by residents and visitors. Interviews and observations confirmed the door was left unlocked and ajar several times during the evening shift.
Deficiencies (1)
F 0761: The facility failed to ensure the medication storage room was locked securely on two occasions, allowing potential access to medications including narcotics. This failure was observed and confirmed through staff interviews and direct observation.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding medication room security and observed leaving the door unlocked initially. |
| RN #1 | Registered Nurse | Interviewed and observed leaving the medication room door unlocked and later securing it. |
| CNA #1 | Certified Nurse Aide | Observed assisting Resident #24 away from the unlocked medication room door. |
| Director of Nursing | Director of Nursing | Interviewed about facility policy on medication room security. |
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