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SPANISH PEAKS VETERANS COMMUNITY LIVING CENTER Inspection Report, Violations & Safety Grade (WALSENBURG, Colorado)

23500 US HIGHWAY 160, WALSENBURG, Colorado 81089

Phone: 7197384540

CMS Overall:3/5

Overview & Bed Count

Certified Beds
120
Avg Residents/Day
72
Ownership
Government - Hospital district
Provider Type
Medicaid
County
Huerfano
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
Yes

CMS Star Ratings

Overall3/5
Health2/5
Staffing5/5
Quality4/5

Nurse Staffing Check

MetricThis FacilityColorado AvgDifference
RN Hours per Resident per Day1.160.81+0.35
Total Nurse Hours per Resident per Day4.813.69+1.12
CMS Staffing Rating5/53.1/5-
Nursing Staff Turnover41.7%47%-

Health Citation History

24 health citations on record

DateCategoryDescriptionSeverity
2025-06-18Freedom from Abuse, Neglect, and Exploitation DeficienciesProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.D – Moderate Harm Potential
2024-12-05Freedom from Abuse, Neglect, and Exploitation DeficienciesProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.E – Moderate Harm Potential
2024-12-05Quality of Life and Care DeficienciesTry different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail.E – Moderate Harm Potential
2024-12-05Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2024-12-05Pharmacy Service DeficienciesEnsure that residents are free from significant medication errors.D – Moderate Harm Potential
2024-12-05Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.D – Moderate Harm Potential
2024-12-05Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential
2023-06-29Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.G – Actual Harm
2023-06-29Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.F – Moderate Harm Potential
2023-06-29Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.E – Moderate Harm Potential
2023-06-29Nursing and Physician Services DeficienciesEnsure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being.E – Moderate Harm Potential
2023-06-29Freedom from Abuse, Neglect, and Exploitation DeficienciesProtect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.D – Moderate Harm Potential
2023-06-29Resident Assessment and Care Planning DeficienciesCoordinate assessments with the pre-admission screening and resident review program; and referring for services as needed.D – Moderate Harm Potential
2023-06-29Quality of Life and Care DeficienciesProvide activities to meet all resident's needs.D – Moderate Harm Potential
2023-06-29Quality of Life and Care DeficienciesAssist a resident in gaining access to vision and hearing services.D – Moderate Harm Potential
2023-06-29Quality of Life and Care DeficienciesProvide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.D – Moderate Harm Potential
2023-06-29Pharmacy Service DeficienciesImplement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.D – Moderate Harm Potential
2019-08-06Administration DeficienciesConduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations (including nights and weekends) and emergencies.F – Moderate Harm Potential
2019-08-06Pharmacy Service DeficienciesEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.E – Moderate Harm Potential
2019-08-06Resident Rights DeficienciesHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.D – Moderate Harm Potential
2019-08-06Resident Rights DeficienciesImmediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.D – Moderate Harm Potential
2019-08-06Quality of Life and Care DeficienciesEnsure residents do not lose the ability to perform activities of daily living unless there is a medical reason.D – Moderate Harm Potential
2019-08-06Quality of Life and Care DeficienciesEnsure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.D – Moderate Harm Potential
2019-08-06Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential

Fire Safety Citation History

15 fire safety citations on record

DateCategoryDescriptionSeverity
2024-12-05Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.F – Moderate Harm Potential
2024-12-05Gas, Vacuum, and Electrical Systems DeficienciesMeet requirements for the use and maintenance of medical gas equipment.F – Moderate Harm Potential
2023-06-29Emergency Preparedness DeficienciesList the names and contact information of those in the facility.F – Moderate Harm Potential
2023-06-29Emergency Preparedness DeficienciesImplement emergency and standby power systems.F – Moderate Harm Potential
2023-06-29Construction DeficienciesInstall a two-hour-resistant firewall separation.F – Moderate Harm Potential
2023-06-29Smoke DeficienciesProvide properly protected cooking facilities.F – Moderate Harm Potential
2023-06-29Gas, Vacuum, and Electrical Systems DeficienciesHave generator or other power source capable of supplying service within 10 seconds.F – Moderate Harm Potential
2023-06-29Smoke DeficienciesProperly select, install, inspect, or maintain portable fire extinguishes.E – Moderate Harm Potential
2019-08-06Emergency Preparedness DeficienciesEstablish policies and procedures for medical documentation.F – Moderate Harm Potential
2019-08-06Smoke DeficienciesHave approved installation, maintenance and testing program for fire alarm systems.E – Moderate Harm Potential
2019-08-06Gas, Vacuum, and Electrical Systems DeficienciesHave generator or other power source capable of supplying service within 10 seconds.E – Moderate Harm Potential
2019-08-06Egress DeficienciesKeep aisles, corridors, and exits free of obstruction in case of emergency.D – Moderate Harm Potential
2019-08-06Egress DeficienciesInstall emergency lighting that can last at least 1 1/2 hours.D – Moderate Harm Potential
2019-08-06Smoke DeficienciesEnsure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.D – Moderate Harm Potential
2019-08-06Gas, Vacuum, and Electrical Systems DeficienciesEnsure proper usage of power strips and extension cords.D – Moderate Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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