Adara Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Broomfield, Colorado.
- Location
- 12975 Sheridan Blvd, Broomfield, Colorado 80020
- CMS Provider Number
- 065379
- Inspections on file
- 25
- Latest survey
- December 8, 2025
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Adara Living during CMS and state inspections, most recent first.
Two residents were administered other residents' medications due to failures in verifying patient identity and following medication administration protocols. One resident was hospitalized after receiving antihypertensives and an opioid not prescribed to her, while another became lethargic after receiving his roommate's medications following a room switch that was not updated in the EMR. Both incidents were linked to staff not properly confirming resident identity and not adhering to established procedures.
A resident with severe cognitive and physical impairments, requiring a mechanical lift and two-person assistance for transfers, was improperly transferred by a new CNA who attempted a stand-pivot transfer alone after being misinformed about the resident's needs. This resulted in a fall and a significant skin tear. The CNA did not consult the care plan or nursing staff prior to the transfer, and staff interviews revealed communication gaps and limited access to care plan details.
Two residents experienced sexual abuse from another resident with a known history of sexually inappropriate behavior. Despite care plans outlining interventions such as 1:1 staff monitoring and frequent checks, these measures were not effectively implemented, resulting in repeated incidents where the perpetrator inappropriately touched other residents. Staff and resident interviews confirmed that the facility did not adequately identify or address the risk, leading to substantiated abuse events.
The facility failed to maintain sanitary conditions in nourishment refrigerators, as observed in five instances where food items were not labeled with resident names or expiration dates. Med-Pass containers, energy drinks, and other food items were improperly stored, and a sticky substance with hair was found in one refrigerator. Staff interviews revealed inadequate labeling practices and monitoring of refrigerator contents.
The facility failed to implement its policy on food storage brought by visitors, leading to unsafe conditions in resident refrigerators. Observations showed missing thermometers and improper temperature monitoring, with no corrective actions documented. Staff interviews revealed confusion over responsibilities, and resident interviews highlighted unclean conditions and undated food items.
The facility failed to provide annual training on abuse prevention and dementia management to 46 and 42 staff members, respectively. The transition to a new training platform did not ensure completion of mandatory training, as revealed by interviews with the NHA and DON. Despite efforts to audit training records, the facility could not confirm all staff had completed the necessary training.
A facility failed to protect residents from abuse, leading to multiple physical altercations. A resident with a history of traumatic brain injury and dementia slapped another during a wheelchair collision. Another resident with Alzheimer's and PTSD was involved in several altercations, including striking a resident and pushing another to the ground. Despite interventions like 15-minute checks, the facility's investigations often unsubstantiated abuse due to lack of intent to harm, highlighting inadequate monitoring and personalized care plans.
A resident with schizophrenia and PTSD was left exposed while using the restroom, as both the room and bathroom doors were open, making him visible from the hallway. Staff members failed to ensure privacy, with one CNA walking past without closing the door and another leaving the room with a trash bag, leaving the door open. Interviews revealed that staff were trained to ensure privacy, but this was not consistently applied.
A resident with multiple allergies experienced issues with laundry services at an LTC facility. Despite the resident's wife's request to handle the laundry due to allergy concerns, the facility failed to consistently store the resident's laundry for her. This led to missing clothing and the use of inappropriate detergents, risking the resident's health. Staff turnover and communication issues contributed to the deficiency.
A facility failed to accurately reflect a resident's hospice status in the MDS assessment. The resident, with COPD and heart failure, was incorrectly coded as receiving hospice care, despite no supporting documentation in the EMR. The MDSC acknowledged the error and corrected it during the survey.
The facility failed to provide adequate respiratory care for two residents using CPAP machines. One resident had no cleaning schedule or care plan for their CPAP, while another had a non-functional machine due to a missing power cord and improper storage of the mask and tubing. Staff interviews revealed confusion about cleaning responsibilities and storage methods.
A facility failed to follow proper procedures before using bed rails for a resident with quadriplegia, leading to a deficiency. The resident was observed with half bed rails up without a signed consent or a PT/OT safety evaluation. The facility did not document attempts to use alternatives or obtain a physician's order for the bed rails. Staff interviews revealed a lack of awareness and adherence to policies, as the resident had arranged for a new bed from the VA without notifying the DON and NHA.
The facility failed to provide meals in accordance with mechanically altered diet restrictions, serving residents on a mechanical soft diet oven-roasted potatoes with skins, contrary to the facility's diet manual. This occurred due to a lack of adherence to dietary protocols and inconsistent communication among staff.
A facility failed to maintain accurate medical records for a resident, specifically regarding wound treatment orders. The resident had a left buttock pressure injury, but the treatment administration record incorrectly documented treatment for a right buttock wound. Despite nurses being aware of the correct wound location, the error in documentation persisted until the survey.
Failure to Prevent Significant Medication Errors
Penalty
Summary
Two residents experienced significant medication errors due to failures in medication administration procedures. One resident with diagnoses including dementia, respiratory failure, and thrombocytopenia was given another resident's medications, which included antihypertensives and an opioid, resulting in acute changes in condition such as low blood pressure, decreased responsiveness, and lethargy. The resident attempted to alert the nurse that the medication cup did not have her name, but the nurse insisted the medications were correct. The resident subsequently took the medications, became increasingly lethargic, and was sent to the hospital, where she was treated for accidental overdose and recovered after receiving Narcan. Another resident, with a history of malnutrition, hypertensive heart disease, and traumatic brain injury, received his roommate's medications after the two switched sides of their shared room without the change being updated in the electronic medical record (EMR). The nurse administering medications did not verify the residents' identities using updated photos or other identifiers, resulting in the resident receiving the wrong medications. This resident became unusually lethargic and was monitored closely after the error was discovered. The error was identified when the roommate reported that the nurse had attempted to give him morphine, which he did not take, and that his roommate had received a large number of pills. In both cases, the medication errors were directly linked to failures in verifying resident identity and following established medication administration protocols. Staff interviews confirmed that the nurses involved did not consistently use the required checks, such as confirming the resident's name, photo, or other identifiers, before administering medications. The errors were further compounded by issues such as pre-pouring medications and not updating room assignments in the EMR, which contributed to the confusion and subsequent administration of incorrect medications.
Failure to Prevent Accident Due to Improper Transfer
Penalty
Summary
The facility failed to prevent an accident involving a resident who required a mechanical lift and two-person assistance for transfers due to severe cognitive impairment, left hemiplegia, and other significant medical conditions. According to the care plan and physician orders, the resident was to be transferred using a Sara lift with the help of two staff members. However, a certified nurse aide (CNA) who was new to the facility attempted to transfer the resident alone using a stand-pivot method after being informed by a registered nurse (RN) that the resident was a one-person assist and able to stand and pivot. The CNA was unaware of the resident's actual transfer requirements and did not review the care plan or consult with nursing staff prior to the transfer. During the transfer, the resident fell, resulting in a 7 cm skin tear on the left lower leg with active bleeding. The incident report identified gait imbalance as a predisposing factor and noted that the CNA was not aware that a mechanical lift and additional assistance were required. The resident's care plan, which documented the need for a Sara lift and two-person assistance, was not accessed or referenced by the CNA prior to the transfer. The CNA also reported that the resident refused the mechanical lift and requested a stand-pivot transfer, which was performed without proper authorization or support. Interviews with staff revealed gaps in communication and access to care plan information. The director of nursing (DON) stated that transfer statuses and mechanical lift requirements were documented in care plans, but CNAs did not have full access to these documents and were expected to ask nurses for clarification. The DON also indicated that the CNA did not seek guidance before performing the transfer. The incident highlighted a breakdown in communication regarding the resident's transfer needs and a lack of adherence to established protocols for safe resident handling.
Failure to Prevent Sexual Abuse Between Residents
Penalty
Summary
The facility failed to protect two residents from sexual abuse by another resident, resulting in substantiated incidents of abuse. In the first incident, a resident with a history of sexually inappropriate behaviors and a diagnosis of severe traumatic brain injury grabbed another resident's shirt and upper chest area, attempting to touch her breast. Multiple staff and a dietary aide witnessed the event, and the victim reported feeling unsafe and uncertain about the perpetrator's intentions. The care plan for the perpetrator included interventions such as one-to-one staff monitoring and frequent checks, but these measures were not effectively implemented prior to the incident. In a separate incident, the same resident touched another resident's breast twice while she was assisting him with pudding. The victim, who had severe cognitive impairments and a diagnosis of dementia, reported the incident to the nursing home administrator. The perpetrator admitted to the behavior, and staff confirmed that the two residents had been interacting at the time. Prior to this event, the facility was aware of the perpetrator's history of sexual behaviors but had not implemented more restrictive interventions to prevent further incidents. Interviews with staff and residents confirmed that the facility's interventions were insufficient to prevent the abuse. The facility's abuse policy required maintaining an environment free from abuse and ensuring staff distribution and knowledge to meet residents' needs. However, the facility did not adequately identify or address the risk posed by the resident with a history of sexually inappropriate behavior, leading to repeated incidents of sexual abuse involving vulnerable residents.
Facility Fails to Maintain Sanitary Conditions in Nourishment Refrigerators
Penalty
Summary
The facility failed to ensure food was prepared, distributed, and served under sanitary conditions in five nourishment refrigerators. Observations revealed that the facility did not label Med-Pass containers with an opened or expiration date according to the product's handling instructions. Additionally, a Monster energy drink was found without a resident's information to differentiate it from staff food. A sticky light brown substance with long black hair was also observed at the bottom of one refrigerator. Further observations showed that a refrigerator on the second floor contained a Med-Pass container that was not labeled with an opened or expiration date. On the third floor, three Nestle Boost supplements were found with a use-by date, and a secure unit freezer contained an unlabeled and uncovered medication cup with a frozen white substance. Another refrigerator on the third floor secure unit contained several items, including a Med-Pass container, fresh blueberries, coffee mate creamer, hand sanitizer, salsa, a Starbucks cup, and a Red Bull can, none of which were labeled with resident names or expiration dates. Interviews with staff revealed that dietary aides and CNAs were responsible for labeling food items brought in by residents' families. The NHA and DON stated that both dietary and nursing staff monitored refrigerator temperatures and checked for expired products. However, the Med-Pass supplement was not widely used, and opened containers were typically placed in refrigerators without proper labeling. The NHA emphasized that staff food or drinks found in resident refrigerators would be discarded, as these refrigerators were designated for resident food only.
Failure to Implement Food Storage Policy in Resident Refrigerators
Penalty
Summary
The facility failed to implement its policy regarding the use and storage of foods brought to residents by family and other visitors, leading to unsafe and unsanitary conditions on two of three floors. Observations revealed that personal refrigerators in residents' rooms lacked internal thermometers, and temperatures were not consistently monitored or recorded. Some refrigerators were found to have temperatures above the acceptable range of 41 degrees Fahrenheit, with no corrective actions documented. Additionally, food items in these refrigerators were not properly labeled with the resident's name and date, as required by the facility's policy. Interviews with staff, including a certified nurse aide and the nursing home administrator, indicated a lack of clarity and consistency in monitoring the temperatures of residents' personal refrigerators. The housekeeping staff was responsible for recording temperatures during room cleaning, but there was confusion about who was responsible for monitoring and taking corrective actions when temperatures were out of range. The environmental services director mentioned that thermometers were recently ordered to address the issue, but it was unclear if staff had been adequately trained on the policy. Resident interviews and observations further highlighted the deficiencies. One resident reported that her refrigerator had not been cleaned since she moved in two years ago, and observations confirmed the presence of food spills and ice build-up. Another refrigerator was found with undated food items and no thermometer inside. These findings demonstrate a failure to ensure safe and sanitary storage of food items in residents' personal refrigerators, as required by both the facility's policy and state regulations.
Deficiency in Staff Training on Abuse and Dementia Care
Penalty
Summary
The facility failed to provide mandatory annual training on abuse prevention and dementia management to a significant portion of its staff. Specifically, 46 out of 212 staff members did not complete the required annual abuse prevention training, and 42 out of 212 staff members did not complete the annual dementia management training. This deficiency was identified through a review of training records and staff interviews, which revealed that the facility's previous electronic education platform was not effectively utilized by staff, leading to incomplete training. The facility had recently transitioned to a new training platform, but the transition did not ensure that all staff members completed the necessary training. Interviews with the Nursing Home Administrator (NHA) and Director of Nursing (DON) highlighted that the facility had identified issues with training completion and had implemented a performance improvement plan (PIP) for human resources. However, this PIP did not address the annual abuse and dementia education. The NHA acknowledged the importance of ensuring all staff are trained to recognize signs of abuse and manage dementia care effectively. Despite efforts to audit and update training records, the facility was unable to provide documentation confirming that all staff had completed the required training.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect several residents from abuse, resulting in multiple incidents of resident-to-resident physical altercations. Resident #98, with a history of traumatic brain injury and dementia, exhibited physically aggressive behaviors towards others, including slapping Resident #16 during a wheelchair collision. Despite interventions such as 15-minute checks and behavior monitoring, the facility's investigation unsubstantiated the abuse due to Resident #98's poor impulse control, although the slap was acknowledged. Resident #127, diagnosed with Alzheimer's disease and PTSD, was involved in multiple altercations. On one occasion, Resident #127 struck Resident #67 after becoming agitated by obscenities, resulting in a laceration above Resident #67's eyebrow. Another incident involved Resident #106, who wandered into Resident #127's room and was pushed to the ground by Resident #127. The facility's investigations often concluded that abuse was unsubstantiated due to lack of intent to harm or absence of serious injury, despite evidence of physical altercations. The facility's failure to implement effective interventions and personalized care plans contributed to these incidents. Residents with known aggressive behaviors and cognitive impairments were not adequately monitored or separated to prevent conflicts. The facility's investigations frequently cited overstimulation and lack of intent as reasons for unsubstantiating abuse, overlooking the need for proactive measures to ensure resident safety and prevent further incidents.
Failure to Ensure Resident Privacy During Restroom Use
Penalty
Summary
The facility failed to ensure the dignity and privacy of a resident while using the restroom. The resident, who is over 65 years old and has diagnoses including schizophrenia and PTSD, was observed sitting on the toilet with both the room and bathroom doors open, making him visible from the hallway. Despite being cognitively intact and requiring assistance for toileting hygiene, the resident was left exposed, and staff members did not take appropriate actions to ensure his privacy. During the incident, an unidentified CNA walked past the resident's room without closing the door or checking on the resident. Another CNA exited the resident's room with a trash bag, leaving the door open, further exposing the resident. Interviews with CNAs revealed that they were trained to ensure privacy by closing doors unless the resident had specific needs, such as claustrophobia. The DON confirmed that the resident was generally comfortable with the bathroom door open unless visitors were present, indicating a lack of consistent privacy measures.
Failure to Honor Resident's Laundry Preferences Due to Allergies
Penalty
Summary
The facility failed to honor a resident's choice for laundry services, specifically for a resident with multiple allergies. The resident's wife had requested that the resident's dirty laundry be stored and saved for her to launder due to his allergies to most commercial laundry products. Despite this request, the facility did not consistently ensure that the resident's laundry was saved for his wife, leading to instances where the resident's clothes were missing or mixed with other residents' clothing. The resident, who was severely cognitively impaired and had a history of exposure to Agent Orange, suffered from multiple allergies, including allergies to certain laundry detergents. His wife reported that he had developed rashes in the past when the wrong soap or detergent was used. The facility's failure to consistently store the resident's laundry for his wife to launder was a significant oversight, especially given the resident's allergy-related health concerns. Interviews with facility staff revealed that there was a lack of consistent communication and adherence to the resident's laundry preferences. Although signs were posted in the resident's room to indicate his wife's preference to do his laundry, staff turnover and communication issues contributed to the failure to honor this request. The facility's policy on promoting resident self-determination was not effectively implemented in this case, as evidenced by the resident's missing clothing and the lack of documentation addressing his allergies and laundry preferences in his electronic medical record.
Inaccurate MDS Assessment for Hospice Services
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) assessment accurately reflected the status of a resident, specifically regarding hospice services. Resident #83, a 66-year-old individual with diagnoses of chronic obstructive pulmonary disease (COPD) and heart failure, was reported in the MDS assessment as receiving hospice care. However, a comprehensive review of the resident's electronic medical record (EMR) did not reveal any physician's order for hospice, progress notes, or care-planned interventions indicating that hospice services were being provided. Interviews with facility staff revealed that the MDS Coordinator (MDSC) was responsible for completing the MDS assessments and acknowledged that the coding error occurred. The MDSC stated that she typically assessed residents in their rooms and consulted with staff to complete the MDS assessments. She admitted that the hospice services were incorrectly coded for Resident #83 and that the error was corrected once it was brought to her attention during the survey. The MDSC also mentioned that she planned to be more cautious in reviewing alerts in the future to prevent similar errors.
Inadequate Respiratory Care for Residents Using CPAP Machines
Penalty
Summary
The facility failed to provide adequate respiratory care for two residents who required the use of CPAP machines. Resident #45 did not have a routine cleaning schedule for their CPAP machine, and there was no care plan in place that included the route of administration, oxygen supplementation, storage, cleaning, and machine settings. The resident reported that they had to clean their CPAP machine themselves, indicating a lack of staff involvement in maintaining the equipment. Resident #95's CPAP machine was non-functional due to a missing power cord, which had not been replaced despite being ordered a month prior. The resident had not used the CPAP machine in two to three years and reported that the machine and mask had not been cleaned since moving into the facility. Observations showed the CPAP mask and tubing were improperly stored, often found on the floor or under a fan, which could lead to contamination. Interviews with staff revealed a lack of clarity and adherence to the facility's policies regarding the cleaning and maintenance of CPAP machines. The night nurses were reportedly responsible for cleaning the equipment, but there was confusion about the frequency and proper storage methods. The director of nursing was unaware of the non-functional status of Resident #95's CPAP machine and the potential risks associated with improper use and maintenance of the equipment.
Failure to Follow Bed Rail Procedures for Resident
Penalty
Summary
The facility failed to ensure proper procedures were followed before the use of bed rails for a resident, leading to a deficiency. The resident, who was under 65 years old and diagnosed with quadriplegia and pressure ulcers, was observed with half bed rails in the up position on multiple occasions. Despite the resident's cognitive intactness, as indicated by a BIMS score of 15 out of 15, the facility did not obtain a signed consent from the resident or their representative prior to the initiation of the side rails. Additionally, there was no evidence of a physical therapy or occupational therapy safety evaluation conducted before the use of the half bed rails on a new bed. The facility's policy required a comprehensive assessment and documentation of least restrictive alternatives before using physical restraints like bed rails. However, the facility did not document attempts to use alternatives or discussions about the potential elimination of the side rails. The resident was totally dependent on staff for bed mobility, contradicting the facility's documentation that the bed rails were not a restraint because the resident was paralyzed. Furthermore, the facility failed to obtain a physician's order for the use of bed rails, as the existing order did not specify the bed rails' position when staff was not repositioning the resident. Interviews with staff revealed a lack of awareness and adherence to the facility's policies regarding bed rail use. The NHA was unaware that bed rails were being used for the resident, and the DON stated that the facility did not practice using bed rails. The resident had arranged for a new bed from the VA, which was delivered and used without notifying the DON and NHA. The facility's failure to follow its policies and procedures for bed rail use, including obtaining necessary consents, evaluations, and orders, led to the deficiency identified during the survey.
Failure to Adhere to Mechanically Altered Diet Restrictions
Penalty
Summary
The facility failed to ensure that residents who were prescribed mechanically altered diets received food prepared according to their specific dietary needs. During meal service observations, it was noted that residents on a mechanical soft diet were served oven-roasted potatoes with skins, which were not in compliance with the dietary restrictions outlined in the facility's diet manual. The manual specifically restricted potato skins for residents on mechanically altered diets, yet the meal trays included potatoes with skins. The facility's policy on Therapeutic Diet Orders mandates that residents receive food in the appropriate form as prescribed by a physician or assessed by the interdisciplinary team. However, during the meal service, the dietary staff did not adhere to these guidelines, resulting in the improper preparation and serving of meals. The human resources director, who was previously the dietary manager, acknowledged the error and noted that potatoes without skins were served in other dining rooms, indicating a lapse in consistency and oversight in meal preparation. Interviews with the dietary manager and the nursing home administrator revealed a lack of clarity and communication regarding the dietary restrictions for mechanically altered diets. The speech therapist was consulted but provided conflicting information about the acceptability of potato skins for residents on a mechanical soft diet. Despite the facility's diet manual clearly restricting potato skins, the oversight led to the serving of inappropriate food items to residents, highlighting a breakdown in adherence to dietary protocols.
Inaccurate Wound Documentation for a Resident
Penalty
Summary
The facility failed to maintain accurately documented medical records for a resident, specifically regarding wound orders and treatment records. The resident, over 65 years old, was admitted with diagnoses including post-surgical aftercare of the skin and multiple pressure ulcers. The resident was cognitively intact and required varying levels of assistance for daily activities. A discrepancy was found in the resident's electronic medical record (EMR) where a skin/wound note documented a right upper buttock unstageable pressure injury, but later corrected to a left buttock unstageable pressure injury. Despite this correction, the treatment administration record continued to reflect treatment for a right buttock wound until updated during the survey. The director of nursing (DON) confirmed that the nurses responsible for the resident's wound care were aware of the correct wound location on the left buttock but did not recognize the error in the treatment orders. The admission wound location chart, which was undated, incorrectly documented a wound on the right buttock. This inconsistency in documentation and failure to update the treatment orders in a timely manner led to the deficiency identified during the survey.
Latest citations in Colorado
A resident with severe dementia, hallucinations, delusions, and chronic pain, who was independent with mobility and at risk for wandering, was struck in the face by another cognitively impaired resident known to exhibit verbal and physical aggression and to be highly protective of her room. An RN heard a commotion, saw the victim outside the aggressor’s room, and attempted to intervene but witnessed the aggressor hit the victim before reaching them, resulting in a lip laceration and bruise. The aggressor’s care plan noted use of a doorway stop sign or closed door and the need to redirect others away from her room, but she often refused these measures. At the time of the incident, only one CNA and one nurse were on the memory care unit due to an unfilled CNA call-in, and staff reported it was difficult to manage when two CNAs were not present. The facility investigation substantiated the event as abuse and identified that both residents may have had increased pain contributing to agitation before the altercation.
A resident with severe cognitive impairment and multiple chronic conditions intentionally slid from a wheelchair to sit on the floor and refused assistance to return to the chair. An LPN directed two CNAs to place a blanket under the resident and drag the resident across the floor, onto an elevator, and to another floor, rather than allowing the resident to remain seated on the floor as requested. The resident later reported trying to resist and stated dislike of the experience. Documentation by the LPN omitted how the resident was actually moved between floors, despite care plan goals for dignity and autonomy and a facility policy requiring residents be treated with dignity and respect and that their choices and preferences be honored.
Surveyors found that staff repeatedly failed to follow hand hygiene and Enhanced Barrier Precautions (EBP) requirements. CNAs and an LPN provided direct care, including incontinence care, use of a mechanical lift sling, and gastric tube feeding, without performing hand hygiene before or after care and without using required gowns for residents on EBP. One CNA handled a soiled lift sling, touched his hair and face, used a touchscreen to document care, and then assisted another resident without cleaning his hands. Another CNA entered an EBP room wearing only gloves, not a gown, and did not perform hand hygiene after removing gloves. An LPN handled a feeding tube and provided care to residents on EBP without hand hygiene or gown use. A resident’s representative reported seeing staff work with a feeding tube without gloves or a gown, while staff interviews and facility policy described correct practices that were not followed in practice.
A resident with severe cognitive impairment and multiple serious diagnoses had a physician-appointed health care proxy who reported that the facility did not inform her when the resident’s condition changed or when an antibiotic was started, and that her calls were not returned for days. Another representative for the same resident stated that calls went to a general voicemail and were rarely or very slowly returned. Grievance records documented repeated concerns about delayed communication, lack of notification about new medications, and difficulty reaching staff. Other residents’ representatives similarly reported that calls to check on residents or report suspected verbal abuse went to voicemail and were returned late or not at all, while staff acknowledged that calls often went to voicemail and that several calls from representatives were missed or delayed.
The facility failed to investigate an allegation of verbal abuse and threats between two cognitively impaired roommates after a family member, who was on the phone with one resident, reported hearing the other resident yelling loudly and making threats. The resident’s representative could not reach staff by phone and contacted EMS, which responded to the facility, yet no investigation or documentation of the altercation, alleged threats, or EMS involvement was found in either resident’s record. Staff acknowledged loud yelling and arguing and initiated a room change, but the RN did not fully inform the DON, the SSD—who was not present—dismissed the event as a simple argument, and the NHA did not treat or report it as abuse, contrary to facility policies requiring identification, investigation, and reporting of possible verbal or mental abuse by other residents.
Unsafe food handling and kitchen sanitation practices were observed in the dining room and main kitchen. Staff handled ready-to-eat foods with bare hands, failed to wash hands between tasks and after bathroom use, and touched food, dishes, and meal tickets while plating and serving meals. The facility also kept moldy croissants in dry storage, used a pencil to prop up a hood drip pan, and allowed a dietary aide with artificial nails and multiple bracelets to serve residents.
The facility failed to maintain and document safe food temperatures during meal service, resulting in cold foods being held and served within the temperature danger zone and incomplete temperature logs on multiple days. During a lunch service observation, various forms of chicken salad were held at 45–55°F, yet plates were assembled and sent out, and a resident reported that meals delivered to the room were always cold and often not eaten. Staff interviews showed inconsistent understanding of required hot and cold holding temperatures and confirmed that temperature logs were sometimes not completed as required.
Failure to Honor Residents’ Choice of Attending Physician: Three cognitively intact residents said they were not allowed to choose their own attending physician and were required to see the facility MD instead. EMR and admission agreement review showed no documentation that they were offered a choice of physician, despite one resident wanting to continue with a community PCP. The NHA stated residents could choose their attending physician, but also said the facility had only one physician available for residents to choose from.
Psychotropic Medication Documentation and PRN Behavior Monitoring Deficiencies Survey review found that several residents had psychotropic medications ordered without documented physician rationale, resident-specific target behaviors, or individualized non-pharmacological interventions. Generic behavior-monitoring orders were used instead of approaches tied to each resident’s history, interests, and identified behaviors, and one resident’s PRN antipsychotic was administered multiple times without documentation of attempted non-pharmacological interventions before use. The EMR also showed notes of stability or no unwanted behaviors for some residents, yet the records still lacked rationale supporting continued psychotropic treatment.
Failure to Address Suicidal Ideation and Individualized Psychosocial Needs: The facility did not adequately address suicidal statements, trauma-related needs, or individualized behavioral interventions for multiple residents. One resident with dementia, anxiety, and PTSD made a suicidal threat, but the record did not show ongoing safety monitoring or documented follow-up. Another resident with PTSD, depression, and a history of trauma and suicide attempts had ongoing depressive symptoms, but the care plan and orders did not reflect the PASRR-identified need for therapeutic support, psychiatric oversight, coping skills, or a safety plan. A third resident with autism and mood disturbance had inappropriate sexual behavior toward the DON, but the care plan was not updated with person-centered interventions specific to that behavior.
Failure to Prevent Resident-to-Resident Physical Abuse on Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. On the date of the incident, an RN heard a commotion in the hallway outside the alleged assailant’s room and observed that resident strike another resident, causing the victim’s lip to bleed. The RN had seen both residents near the medication cart a few minutes earlier without concern and attempted to intervene when she saw the victim standing outside the assailant’s room, but was unable to reach them before the strike occurred. The two residents were then separated, and frequent checks were initiated. The victim was a younger-than-65 resident with vascular dementia (severe, with agitation), Alzheimer’s disease, Lewy body disease, bipolar disorder, and chronic pain. Her MDS showed short- and long-term memory problems, hallucinations, delusions, and physical and verbal behaviors toward others, with moderately impaired cognition and impaired decision-making. She was independent with mobility and had a care plan for wandering and dementia that identified her as pleasantly confused and easily redirected, with interventions to identify wandering patterns, offer diversions, and assess for pain or toileting needs when agitated. Documentation on the day of the incident noted her involvement in a resident-to-resident altercation, a small laceration to the middle of her upper lip, and a small bruise below her lower lip. The assailant was an older resident with severe vascular dementia with agitation, memory deficit after intracranial hemorrhage, and recurrent depressive disorder. Her MDS documented short- and long-term memory problems, fluctuating disorganized thinking, and verbal behaviors directed toward others that could significantly intrude on others’ privacy or disrupt the environment. Her behavior/dementia care plan identified verbal aggression (yelling/screaming), physical aggression (hitting), refusal of care, withdrawal, tearfulness, and negative statements, and noted that she was protective of her room and became upset if others entered or tried to enter. The care plan included use of a velcro stop sign across her doorway or keeping her door closed, but also documented that she often declined having the door closed, requiring staff to redirect other residents away from her room. Staff statements indicated that at the time of the incident there was one CNA and one nurse on the memory care unit, that one CNA had called in and was not replaced, and that it was hard when there were not two CNAs on the unit. The facility’s investigation substantiated the incident as abuse and identified that both residents may have been experiencing increased pain leading up to the altercation, with pain, constipation, and urinary retention noted as contributing factors for the victim and hand contracture pain and refusal of interventions noted for the assailant.
Resident Dragged on Blanket Instead of Honoring Request to Sit on Floor
Penalty
Summary
The deficiency involves a failure to honor a resident’s right to dignity and self-determination when staff did not allow the resident to remain seated on the floor per his wishes and instead dragged him on a blanket between floors. Late at night, the resident, who lived on the second floor, was in his wheelchair on the first floor and intentionally slid out of his wheelchair to sit on the ground according to his own wishes. When staff offered assistance to help him back into his wheelchair, he refused. Despite this refusal, an LPN directed two CNAs to move the resident from the first floor back to the second floor. Following the resident’s refusal to get back into his wheelchair, the LPN instructed the CNAs to place a blanket underneath the resident so he could be dragged while lying on it. The CNAs and the LPN maneuvered the blanket under the resident by moving him from side to side. One CNA positioned herself behind the resident and placed her arms under his armpits, while the other CNA held the resident’s pants at his ankles. The LPN then pulled on the blanket with the resident on it. Together, the three staff members dragged the resident on the blanket across the floor and onto the elevator, transported him to the second floor, and then dragged him off the elevator onto the second floor hallway. Once on the second floor, the resident agreed to have two staff members assist him back into his wheelchair, and a two-person transfer was performed to lift him from the floor into the chair. The resident later reported that he remembered being pulled on the blanket, stated that he "tried to fight them like crazy," and said he did not like what had been done. The nursing progress note written by the LPN the following morning documented that the resident had remained on the first floor until late at night, refused to talk with staff, refused care, and declined snacks, fluids, and redirection, but the note did not document how he was actually relocated to the second floor. The resident’s records showed he had severe cognitive impairment with a BIMS score of 3/15, diagnoses including Parkinson’s disease, depression, unspecified intellectual disabilities, traumatic brain injury, seizures, and chronic kidney disease stage 3, and care plan goals that included being treated with dignity and autonomy. The facility’s dignity policy stated that residents are to be treated with dignity and respect at all times, that their choices and preferences are to be honored, and that demeaning practices are prohibited, which was not followed in this incident.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to hand hygiene and adherence to Enhanced Barrier Precautions (EBP) on all four units. The facility’s own policies require hand hygiene before and after direct patient care and the use of gowns and gloves during high-contact care activities for residents on EBP. CDC guidance cited in the report emphasizes that hand hygiene protects both healthcare personnel and patients, and that EBP requires targeted gown and glove use during high-contact resident care activities, particularly for residents with wounds, indwelling devices, or MDRO colonization or infection. Surveyors observed multiple instances where staff did not follow these requirements. An unidentified CNA exited a room of a resident on EBP without wearing a gown while providing care. On another occasion, a CNA exited a resident’s room carrying a soiled mechanical lift sling without gloves, failed to perform hand hygiene, touched his hair and face, used a touchscreen to document care, and then entered another resident’s room to answer a call light and assist with a request without performing hand hygiene before or after assisting that resident. Another CNA entered the room of a resident on EBP, donned only gloves without a gown, provided incontinence care, then left the room with soiled linens and trash properly disposed of, removed gloves, but did not perform hand hygiene before caring for another resident. Additional observations showed an LPN entering the room of a resident on EBP for gastric tube feeding, setting up and handling the feeding tube without performing hand hygiene beforehand and without wearing a gown. The same LPN later entered another EBP room, provided care, and left without performing hand hygiene. A resident’s representative reported seeing staff work with the resident’s feeding tube without gloves or a gown. In interviews, CNAs and nursing staff described correct hand hygiene and EBP practices, including washing hands for about 20 seconds and using gowns and gloves for residents on EBP, and the DON stated she expected staff to perform hand hygiene when entering and exiting rooms and to follow EBP procedures requiring gown and glove use. These stated practices conflicted with the observed failures in hand hygiene and EBP adherence documented by surveyors.
Failure to Notify Health Care Proxy and Return Calls Regarding Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to inform a resident’s physician-appointed health care proxy of changes in the resident’s condition and new treatments, and to return the proxy’s calls in a timely manner. Facility policy on Notification of Changes required informing the resident, consulting with the physician, and notifying the family member or legal representative when there was a change requiring such notification, and specified that when residents were incapable of making their own decisions, the representative would make necessary decisions. Resident #1 was under 65, admitted with diagnoses including paralysis and weakness following a stroke, respiratory failure, cognitive communication deficit, and encephalopathy, and was documented as severely cognitively impaired with a BIMS score of 0/15, indicating reliance on the health care proxy for decision-making. The health care proxy reported that the facility made it very difficult to contact the resident, stating that staff did not return calls for days and that she was not informed when the resident developed an infection and was started on an antibiotic until after the medication had already been initiated. She stated she had several questions about the medication and was not consulted on the medical decision prior to its start. Another representative reported that calls to the facility went to a general voicemail and that her messages were either not returned or took several days for a response. Grievance records showed repeated concerns from the resident’s representatives about delays in speaking with the resident, delays in return calls, and lack of notification about new medications and changes in condition. Additional interviews with other residents’ representatives supported a broader pattern of delayed or absent communication. One representative of another resident reported that his call to check on a newly admitted resident went to voicemail and was not returned for two days. Another resident’s representative and a secondary witness reported that when they attempted to report suspected verbal abuse, their calls to the facility and to the SSD went to voicemail and were never returned. Staff interviews confirmed that calls first went to the front desk and then to the nurses’ stations, that calls often went to voicemail when nurses were unable to answer, and that voicemail messages were expected to be returned within 24 hours. The NHA acknowledged that several calls from the resident’s representatives went to voicemail and that calls were often made during shift change when it was harder to reach the nurse on duty, but there was no documentation to support the claimed regular communication with the health care proxy.
Failure to Investigate Alleged Verbal Abuse Between Cognitively Impaired Roommates
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of verbal abuse and threats between two cognitively impaired residents after a family member reported overhearing the incident. Facility policy on abuse, neglect, exploitation, and misappropriation requires that all possible incidents of abuse, including verbal and mental abuse by other residents, be identified, investigated, and reported within required timeframes, with residents protected from further harm during investigations. The policy on identifying types of abuse specifies that yelling or hovering over a resident with intent to intimidate is an example of mental and verbal abuse. Despite these policies, the facility did not initiate or document an investigation into a reported verbal altercation that included alleged threats. One resident, under age 65, with dysphagia, left-sided hemiplegia, attention and concentration deficit, delusional disorder, and major depressive disorder, had moderate cognitive impairment and was dependent on staff for most ADLs. He reported that he and his roommate yelled back and forth at each other after the roommate told him to “shut the [expletive],” but he did not recall the specific words used and denied any physical contact. His guardian stated that he later reported being fearful of his roommate after the incident. Another representative, who was on the phone with him during the event, reported hearing the roommate yelling loudly and making threats toward him, then hearing a nurse enter to calm the situation. This representative attempted to call the facility to report the yelling and threatening behavior, was sent to voicemail without a return call, and subsequently contacted emergency services. The roommate, an older resident with dementia, cognitive communication deficit, depression, and insomnia, also had moderate cognitive impairment and required staff assistance for most ADLs. He did not recall the incident, and his representative only learned of it the following day and was told it involved yelling about loud phone use. A review of both residents’ medical records revealed no documentation of the verbal altercation, the alleged threats, or related concerns, and no investigation documents were produced when requested. Staff interviews confirmed there had been loud yelling and arguing, that EMS responded to the facility, and that a room change was initiated due to the incident, but the RN who responded did not report the EMS involvement to the DON. The SSD, who was not present during the incident, characterized it as just an argument and stated there were no threats, and the NHA stated the event was not reported as abuse because they believed no threats were made. No contemporaneous interviews with the residents were documented, and no inquiry was made by facility staff into why EMS had been called in relation to the altercation, resulting in a failure to investigate the allegation of verbal abuse as required by facility policy.
Unsafe Food Handling and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the main kitchen and dining areas. During meal service observations, staff repeatedly handled ready-to-eat foods with bare hands and did not perform hand hygiene when changing tasks, after touching dirty dishes, after using the bathroom, or before serving food. An LPN cut a resident’s patty melt and handed pieces to the resident with her bare hand without sanitizing her hands. A DA passed drinks by touching the rims of cups, and another DA tore a resident’s patty melt into smaller pieces with bare hands and handed food to the resident. During a later observation, kitchen staff continued to work without washing hands between tasks and while handling food, dishes, and meal tickets. A DA entered the kitchen from the dishroom and did not wash his hands before putting away snacks. A cook did not wash her hands after working at the sink, after touching dirty dishes, after exiting the bathroom in the kitchen, or before serving room trays. She was observed touching shrimp, corn bread, rice, squash, cheese, and frozen fries with bare hands while plating and preparing meals, and she also handled fryer baskets and food items without washing her hands. Another cook wiped her hands on her clothing, handled meal tickets, and touched ready-to-eat foods with bare hands while assembling plates and serving meals. The facility also failed to discard expired or spoiled food, maintain equipment in good repair, and prevent staff from wearing prohibited items while preparing or serving food. A plastic bag of croissants in dry storage contained bread-like food covered in dark green and black fuzz and remained on the bread rack on two separate observations. In the kitchen hood system above the grill, a half wooden pencil was being used to hold up the grease drip pan on two observations. In addition, a dietary aide taking meal orders, passing drinks, and serving meals had artificial nails approximately half an inch long and multiple fabric bracelets on her wrists while working with residents.
Failure to Maintain and Document Safe Food Temperatures During Meal Service
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner by not maintaining appropriate food temperatures during meal service and by not consistently documenting food temperatures as required. During a continuous observation of lunch meal service, chicken salad, including soft and bite-sized and pureed versions, was found on the steam table at temperatures of 55°F and 45°F, which were within the documented temperature danger zone and below the required cold-holding standard. Despite these temperatures, plates with wedge chicken salad and a Hawaiian roll were assembled and placed on the meal cart for service. A resident reported that meals delivered to his room were always cold, leading him not to eat them and to attempt to obtain food from outside the facility. Review of the facility’s April 2026 food temperature logs showed multiple instances where temperatures were not documented for breakfast, lunch, and dinner services on numerous dates. Staff interviews revealed inconsistent understanding and application of proper holding temperatures, with the cook and dietary manager providing varying temperature thresholds that did not align with the facility policy or the Colorado Retail Food Establishment Rules and Regulations. The cook acknowledged that the wedge chicken salad should not have been served at 55°F and attributed difficulty maintaining proper temperatures to a hot room with inadequate ventilation, while the dietary manager stated that cooks sometimes forgot to complete the temperature logs.
Failure to Honor Residents’ Choice of Attending Physician
Penalty
Summary
The facility failed to ensure three cognitively intact residents were allowed to choose their own attending physician. Resident #15, Resident #28, and Resident #30 each stated during a group interview that they did not have a choice in who their physician could be while in the facility and that they had to see the facility’s MD. Resident #15 said she had a primary care physician in town that she wanted to continue seeing, but she was told she could not see that physician. Resident #28 and Resident #30 each said they were required to see the facility’s MD instead of choosing their own physician. Record review for each of the three residents, including the admission agreement and EMR, showed no documentation that they were provided a choice of attending physician. Resident #15 had diagnoses including COPD, cirrhosis of the liver, and osteoarthritis, and her MDS showed she was cognitively intact with a BIMS score of 15. Resident #28 had diagnoses including type 2 diabetes mellitus, asthma, osteoarthritis, and TIA/cerebral infarction, and was also cognitively intact with a BIMS score of 15. Resident #30 had diagnoses including type 2 diabetes mellitus, wedge compression fracture of T11-T12 and L3, and hypertension, and his MDS likewise showed a BIMS score of 15. The NHA stated residents were able to choose their attending physician when admitted, but also said the facility had one physician residents could choose from and was not aware that these residents wanted different physicians.
Psychotropic Medication Documentation and PRN Behavior Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure four residents were free from unnecessary psychotropic medication use and chemical restraint concerns. Survey review found that the facility did not document a physician’s rationale for the continued use of psychotropic medications for three residents, did not document resident-specific care approaches with medication-specific target behaviors and person-centered interventions for those residents, and did not ensure one resident’s PRN antipsychotic use had corresponding documentation of identified behaviors and non-pharmacological interventions. For one resident with PTSD, anxiety, and depression, the record showed buspirone, Valium, duloxetine, and Lexapro orders with behavior-monitoring language, but the orders did not identify resident-specific non-pharmacological interventions for specific behaviors. The resident’s PASRR described a history of self-harm, suicidal thoughts, mood swings, loss of interest, and low energy, and recommended therapeutic interventions, coping skills, psychiatric oversight, increased socialization, and activities such as puzzles, games, and painting. The EMR review did not show documented behaviors during the review period, and it did not show a physician rationale to justify continued psychotropic use. For another resident with schizoaffective disorder, dementia, anxiety, and depression, the care plan and orders listed generic interventions and behavior targets such as screaming, hallucinations, kicking, and yelling, but the resident-specific behaviors and interests identified in the PASRR, including hearing the devil inside her head and being soothed by prayer and rosary use, were not incorporated into the behavior-monitoring orders or care plan. The record also lacked documentation of non-pharmacological interventions used for the resident’s behaviors and lacked a physician rationale for continued psychotropic use despite notes stating the resident was stable and not experiencing unwanted behaviors. A third resident with vascular dementia, anxiety, and PTSD had orders for Abilify, mirtazapine, sertraline, clonazepam, and behavior monitoring tied to verbal aggression, exit seeking, tearfulness, and hitting staff, but the orders remained generic and did not reflect the resident’s individualized approaches such as listening to 80’s rock music or watching a favorite program when crying or confused. The EMR again did not show a physician rationale for continued psychotropic use despite notes indicating pleasant mood and no unwanted behaviors. For the resident who died during the stay and had dementia and depression, the record showed Lexapro, Seroquel, and PRN injectable haloperidol ordered for behaviors such as swinging at staff and agitation. The PRN haloperidol order did not list a diagnosed specific condition, only behaviors, and the order for non-pharmacological interventions was not initiated until after the resident had already been receiving psychotropic medications. MAR and order administration notes showed multiple PRN haloperidol administrations, but several entries lacked documentation of attempted non-pharmacological interventions before the medication was given, and one note only documented encouragement to sit down without identifying the other ordered interventions or their effectiveness.
Failure to Address Suicidal Ideation and Individualized Psychosocial Needs
Penalty
Summary
The facility failed to ensure that residents with mental disorders, psychosocial adjustment difficulties, and trauma histories received appropriate treatment and services to support their mental and psychosocial well-being. For one resident with vascular dementia, anxiety, and PTSD, the record showed repeated depression screens indicating little interest, depressed mood, poor appetite, sleep problems, low energy, and feelings of worthlessness, along with notes describing chronic behaviors potentially causing harm, tearfulness, withdrawal, and anxiety. A behavior note documented that the resident stated she was going to kill herself, but the record did not show documented interventions to keep her safe afterward or ongoing monitoring for suicidal ideation. A second resident with PTSD, anxiety, depression, and a documented history of trauma, self-harm, suicidal thoughts, and numerous suicide attempts had a PASRR evaluation identifying the need for therapeutic interventions, psychiatric oversight, coping skills development, and a safety plan. The resident told staff she had previously seen a therapist at the facility, but that therapy had stopped and no new arrangements had been made. She also reported that staff had not asked about her PTSD triggers or what interventions would help her. The record showed depression screens with ongoing depressive symptoms, but no follow-up documentation after those screenings, and the care plan and physician orders did not reflect the resident’s suicidal history or the specialized services identified in the PASRR. The facility also failed to provide individualized care approaches for a resident with autistic disorder, dementia with mood disturbance, anxiety disorder, major depressive disorder, and cognitive communication deficit. The resident had a history of inappropriate sexual behaviors and was documented as having sexually inappropriate contact with the DON when he squeezed her breast during a dining activity. Although the resident was placed on 15-minute behavior monitoring for 24 hours, the care plan was not revised to reflect a person-centered intervention specific to that sexual behavior. Staff interviews showed that interventions were inconsistently understood and that the nursing staff did not know what person-centered interventions were in place for the resident’s behaviors.
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