Inspection Reports for
Glenwood Springs Healthcare
2305 BLAKE AVE, GLENWOOD SPRINGS, CO, 81601-
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
10 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
92% worse than Colorado average
Colorado average: 5.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Inspection Report
Routine
Census: 40
Deficiencies: 2
Date: Oct 17, 2024
Visit Reason
The inspection was conducted as a routine survey to assess compliance with regulatory requirements related to resident care, including nutrition and staffing adequacy.
Findings
The facility failed to accurately obtain and document resident weights per physician orders, specifically for Resident #6, and failed to provide sufficient nursing staff to meet residents' needs in a timely manner, resulting in delayed call light responses. Both issues were associated with minimal harm or potential for actual harm.
Deficiencies (2)
F 0692: The facility failed to accurately obtain and document Resident #6's weights and did not weigh the resident per physician's orders, leading to inaccurate weight records.
F 0725: The facility failed to provide enough nursing staff daily to meet resident needs and did not have a licensed nurse in charge on each shift, resulting in untimely responses to resident call lights.
Report Facts
Residents in facility: 40
Call lights turned on: 200
Call lights turned on: 150
Call lights turned on: 126
Call lights turned on: 141
Call lights turned on: 162
Call lights turned on: 163
Call lights turned on: 144
Call lights turned on: 167
Call lights turned on: 162
Call lights turned on: 169
Call lights turned on: 122
Call lights turned on: 144
Call lights turned on: 147
Call lights turned on: 207
Call lights turned on: 130
Weight of wheelchair: 43.5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Registered Dietitian | Interviewed regarding nutritional recommendations and weight monitoring. | |
| Director of Nursing | Interviewed regarding weight documentation and staffing issues; provided follow-up documentation. | |
| Nursing Home Administrator | Interviewed regarding facility assessment and call light response times. |
Inspection Report
Routine
Deficiencies: 7
Date: Oct 17, 2024
Visit Reason
The inspection was conducted to evaluate compliance with regulatory standards related to resident care, safety, infection control, food service, and other operational aspects of the nursing home.
Findings
The facility was found deficient in multiple areas including failure to address resident complaints about call light response times, improper blood pressure measurement technique, lack of individualized activities in residents' preferred language, unsafe hot water temperatures, inadequate fall prevention and post-fall assessments, serving food at improper temperatures, unsanitary food storage and handling practices, and failure to offer COVID-19 vaccinations and education to eligible residents.
Deficiencies (7)
F 0565: The facility failed to promptly address resident group complaints about long call light response times, resulting in unresolved concerns and delays in staff assistance.
F 0658: The facility failed to ensure Resident #12's blood pressure was measured according to professional standards by placing the cuff over clothing.
F 0679: The facility failed to provide individualized activities in Spanish for Resident #15, whose preferred language was Spanish.
F 0689: The facility failed to maintain safe hot water temperatures, initiate timely fall prevention plans, and complete neurological assessments after a fall for Resident #6.
F 0804: The facility failed to serve food at palatable temperatures, with salads served too warm and hot foods served lukewarm during meal service.
F 0812: The facility failed to store dented canned foods properly and failed to perform appropriate hand hygiene during food preparation and service.
F 0880: The facility failed to offer COVID-19 vaccinations and provide vaccination education to eligible residents #28, #12, #5, and #17.
Report Facts
Call lights activated: 200
Call lights delayed over 15 minutes: 40
Hot water temperature: 131
Hot water heater temperature: 140
Fall risk evaluation date: Jul 2, 2024
Fall incident date: Aug 21, 2024
Food temperature: 41
Food temperature: 85.2
Food temperature: 107
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN #2 | Registered Nurse | Named in blood pressure measurement deficiency |
| DON | Director of Nursing | Interviewed regarding blood pressure measurement, fall prevention, and COVID-19 vaccination deficiencies |
| AD | Activity Director | Interviewed regarding lack of Spanish language activities |
| CNA #1 | Certified Nurse Aide | Interviewed regarding fall prevention and activities |
| MSD | Maintenance Services Director | Interviewed regarding hot water temperature deficiencies |
| CK #1 | Cook | Interviewed regarding food temperature and hand hygiene deficiencies |
| DM | Dietary Manager | Interviewed regarding food service deficiencies and dented can storage |
| IP | Infection Preventionist | Interviewed regarding COVID-19 vaccination program |
Inspection Report
Complaint Investigation
Deficiencies: 6
Date: Jul 31, 2024
Visit Reason
The inspection was conducted due to a complaint investigation regarding the facility's failure to provide appropriate pressure ulcer care and prevent new pressure ulcers from developing in Resident #1.
Complaint Details
The complaint investigation focused on Resident #1's pressure ulcer care. The resident developed two pressure ulcers at the facility that worsened to stage 4. The facility was found to have failed in timely care planning, wound assessment, physician notification, and intervention implementation. Resident #1 reported not always receiving weekly skin assessments and not receiving promised specialty shoes. The medical director and staff interviews confirmed these failures and the avoidability of the wounds.
Findings
The facility failed to timely implement care plans and interventions to prevent and treat pressure injuries for Resident #1, resulting in two stage 2 pressure injuries worsening to stage 4. The facility also failed to conduct consistent weekly wound assessments, notify physicians of wound deterioration, and implement new interventions as wounds worsened. Resident #1 was documented to refuse some care, but the facility did not adequately reoffer care or educate the resident on risks. A Performance Improvement Plan was initiated to address wound care deficiencies.
Deficiencies (6)
F 0686: The facility failed to provide appropriate pressure ulcer care and prevent new ulcers from developing, resulting in two stage 2 pressure injuries worsening to stage 4 in Resident #1.
The facility failed to conduct weekly wound assessments consistently between 5/6/24 and 7/30/24, missing several weekly assessments.
The facility failed to notify the resident's physician or medical director when pressure injuries worsened to stage 4.
The facility failed to implement new interventions after wound deterioration was documented on multiple occasions between 5/30/24 and 6/28/24.
The facility failed to provide promised specialty footwear (DARCO boot) to Resident #1.
The facility failed to reoffer care or educate Resident #1 adequately after documented refusals of care related to wound management.
Report Facts
Pressure ulcer measurements: 2.8
Pressure ulcer measurements: 2
Pressure ulcer measurements: 1
Pressure ulcer measurements: 1.2
Pressure ulcer measurements: 1
Pressure ulcer measurements: 1.5
Pressure ulcer measurements: 4
Pressure ulcer measurements: 0.3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Interviewed regarding Resident #1's care refusals and wound care |
| DON | Director of Nursing | Interviewed about wound care management, facility deficiencies, and Performance Improvement Plan |
| NHA | Nursing Home Administrator | Interviewed about facility notification failures and wound care oversight |
| MD | Medical Director | Interviewed regarding Resident #1's wounds, physician notifications, and wound care recommendations |
Inspection Report
Routine
Deficiencies: 9
Date: Mar 30, 2023
Visit Reason
Routine inspection of Glenwood Springs Healthcare to assess compliance with regulatory standards including resident care, medication administration, activities, vision and dental services, food and nutrition services, and infection control.
Findings
The facility failed to consistently honor resident bathing preferences, clarify medication orders for diclofenac gel, ensure certified nurse aide medication authority, provide adequate activities, maintain vision and dental care follow-up, provide trauma-informed care, and maintain proper food safety and infection control practices including hand hygiene and PPE use.
Deficiencies (9)
F 0561: The facility failed to honor resident bathing preferences for three residents, resulting in inconsistent shower provision contrary to their choices.
F 0658: The facility failed to clarify physician orders for diclofenac gel, resulting in administration without proper dose measurement.
F 0659: The facility failed to ensure a certified nurse aide with medication authority was properly licensed, resulting in unqualified medication administration.
F 0679: The facility failed to provide adequate activities and develop comprehensive care plans addressing socialization and activity needs for two residents.
F 0685: The facility failed to ensure proper follow-up for eye care for two residents, including scheduling cataract surgery and annual eye exams.
F 0699: The facility failed to provide trauma-informed care for a resident with PTSD, lacking assessment of triggers and individualized care planning.
F 0791: The facility failed to assist a resident in obtaining dental services and did not ensure dental services were offered or scheduled.
F 0802: The facility failed to provide sufficient support personnel to safely and effectively carry out food and nutrition service functions, including improper dishwasher use, inadequate hand hygiene, improper food cooling, and unsafe food storage.
F 0880: The facility failed to maintain an infection prevention and control program, including inadequate hand hygiene, improper PPE use, and insufficient housekeeping cleaning practices.
Report Facts
Dishwasher sanitizer concentration: 300
Dishwasher rinse temperature: 105
Dishwasher rinse temperature: 142
Chicken cooking temperature: 160
Resident #22 BIMS score: 2
Resident #40 BIMS score: 1
Resident #15 BIMS score: 15
Resident #12 BIMS score: 14
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA #1 | Certified Nurse Aide | Worked with medication authority without proper state licensure |
| RN #2 | Registered Nurse | Unaware diclofenac gel required measured dose; observed administering medication |
| LPN #1 | Licensed Practical Nurse | Administered diclofenac gel without measuring dose |
| DA #1 | Dietary Aide | Observed multiple hand hygiene and glove use violations in food preparation and serving |
| DM | Dining Manager | Interviewed about food safety, dishwasher use, and hand hygiene practices |
| RD | Registered Dietitian | Provided policies and interviewed about food safety and infection control |
| HSKP #1 | Housekeeper | Observed failing to change gloves or perform hand hygiene between cleaning tasks |
| NHA | Nursing Home Administrator | Interviewed multiple times about facility policies, deficiencies, and corrective actions |
| ADON | Assistant Director of Nursing | Interviewed about infection control and staff training |
| SSD | Social Services Director | Interviewed about ancillary services scheduling and resident care |
| RNC | Regional Nurse Consultant | Interviewed about clinical oversight and behavioral health services |
Inspection Report
Routine
Deficiencies: 6
Date: Jan 11, 2022
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident care, pressure ulcer prevention, restorative services, catheter care, food service, and kitchen sanitation.
Findings
The facility failed to honor resident bathing preferences, provide appropriate pressure ulcer care, ensure restorative services for a resident, maintain proper catheter care, serve palatable food at safe temperatures, and maintain sanitary kitchen conditions.
Deficiencies (6)
F 0561: The facility failed to honor bathing preferences for four residents, resulting in infrequent showers or baths not aligned with their wishes.
F 0686: The facility failed to provide appropriate care for a resident's unstageable pressure injury, including delayed provision of pressure reducing mattress and incomplete documentation.
F 0688: The facility failed to provide restorative nursing services for a resident discharged from therapy, resulting in functional decline.
F 0690: The facility failed to provide consistent suprapubic catheter care with soap and water and failed to document abnormal findings of redness and drainage at the catheter site.
F 0804: The facility failed to ensure food was served at safe and appetizing temperatures and failed to provide palatable food choices, leading to resident complaints.
F 0812: The facility failed to handle ready-to-eat foods properly, maintain sanitary food storage, and keep the kitchen clean and in good repair.
Report Facts
Days without documented catheter care: 5
Pressure injury measurement: 3
Food temperature: 89
Food temperature: 90
Food temperature: 110
Food temperature: 115
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN #1 | Licensed Practical Nurse | Named in catheter care deficiency and corrective action |
| Director of Nursing | Director of Nursing | Interviewed regarding bathing, pressure injury care, catheter care, and restorative services |
| Dietary Cook | Dietary Cook | Observed mishandling food and failure to document food temperatures |
| Dietary Supervisor | Dietary Supervisor | Interviewed about food service issues and kitchen sanitation |
| Director of Therapy | Director of Therapy | Interviewed regarding restorative services for Resident #5 |
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