Amberwood Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Denver, Colorado.
- Location
- 4686 E Asbury Cir, Denver, Colorado 80222
- CMS Provider Number
- 065034
- Inspections on file
- 16
- Latest survey
- April 23, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Amberwood Post Acute during CMS and state inspections, most recent first.
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.
Two residents were not protected from physical abuse when another resident, following an escalating argument involving property damage and verbal altercations, threw a wheelchair armrest that struck both individuals. The incident was not witnessed by staff, who only intervened after hearing the commotion. All residents involved had behavioral and mental health diagnoses, and staff were aware of their volatile interactions, but the abuse was not prevented.
The facility failed to manage the personal funds accounts of four Medicaid-funded residents, resulting in account balances exceeding the Medicaid eligibility limit. The Business Office Manager was aware of the issue but had not notified the residents or their representatives, and the Nursing Home Administrator was not fully informed. This oversight risked the residents' Medicaid status.
The facility failed to provide appropriate restorative nursing services for three residents with limited mobility, leading to deficiencies in maintaining or improving their range of motion. One resident did not receive any restorative services despite being listed on a program, another reported infrequent services, and a third was not restarted on services after hospital discharge, risking contractures.
The facility experienced a medication error rate of 14.63%, with errors including unprimed insulin administration, failure to check blood pressure before giving Amlodipine, incorrect Senna-Docusate dosage, and misinterpretation of Metamucil instructions. Interviews highlighted the need for adherence to proper procedures and clarity in physician orders.
The facility failed to secure treatment and medication carts, leaving them unlocked and unattended. Observations revealed that two treatment carts and one medication cart were left unlocked, with residents and staff passing by. Interviews with staff, including an agency nurse and the DON, confirmed that carts should be locked when unattended to prevent access to dangerous items. The facility did not provide the medication storage policy during the survey.
The facility failed to provide necessary dental services to three residents, including one who was edentulous and seeking dentures, another with chipped teeth and tooth pain, and a third who was not notified of a dental visit. Despite care plans and requests for dental care, the residents were not referred or seen by a dentist due to scheduling and communication issues.
The facility failed to maintain an effective infection control program, with deficiencies in housekeeping procedures, resident hand hygiene before meals, and cleaning of glucometers. Housekeepers did not perform hand hygiene or use separate cleaning materials for different areas, and residents were not assisted with hand hygiene before meals. An LPN used personal hygiene wipes instead of alcohol wipes for cleaning, and staff did not properly don PPE during wound care.
A resident with schizoaffective disorder and bipolar disorder was discharged without proper documentation or notification. The facility did not provide a 30-day or immediate discharge notice, nor did they inform the resident of their right to appeal. Staff interviews confirmed the facility's inability to meet the resident's needs, but the required discharge process was not followed.
A facility failed to reassess a resident's status after a hospital transfer, directing the hospital to discharge her to a sister facility without proper documentation or communication. The resident, with schizoaffective disorder, exhibited challenging behaviors, but the facility did not develop a discharge care plan or reassess her needs post-hospitalization. Staff interviews confirmed the lack of documentation and communication regarding the discharge process.
The facility failed to implement PASRR Level II recommendations for two residents, delaying therapy initiation and lacking documentation of behavioral health services. One resident with schizophrenia experienced a three-week delay in counseling referral, while another with bipolar disorder had no evidence of receiving recommended services. The social service director cited workload challenges, and the DON was unaware of these deficiencies.
A facility failed to ensure PRN pain medications for a resident had specific parameters related to pain severity. The resident, with diagnoses including schizoaffective disorder and diabetes, had PRN orders for Oxycodone, Tramadol, and Tylenol without specified pain levels on a 1-10 scale. Staff interviews confirmed the expectation for such parameters, but the orders, initially from an emergency department physician, lacked this detail.
A facility failed to provide proper discharge notifications and develop a collaborative discharge plan for a resident with severe cognitive impairment and behavioral issues. The discharge planning process was not documented in the resident's EMR or comprehensive care plan, contrary to facility policy. Staff interviews confirmed the lack of documentation and adherence to discharge procedures.
A resident with Parkinson's disease and COPD, requiring substantial assistance with ADLs, was found with long and dirty fingernails, contrary to the facility's policy for maintaining personal hygiene. Despite the care plan's directives for regular nail care, staff interviews revealed a failure to adhere to these guidelines, resulting in inadequate grooming for the resident.
A resident with lymphedema did not receive timely treatment due to a missing physician's order for leg wraps. Despite a referral and request by an NP, the order was not entered into the EMR, delaying the treatment. The resident's care plan lacked interventions for edema, and the facility faced challenges in obtaining specialized measurements for the wraps.
A resident with hemiplegia and a need for corrective lenses did not receive timely optometry services due to the facility's failure to arrange a referral. Despite the resident's request for a vision referral shortly after admission, there was no documentation of a referral, and consent for vision services was delayed. Interviews with staff revealed challenges in scheduling ancillary services, with the SSD struggling to keep up with referrals and the DON and NHA recognizing the need for timely scheduling.
A facility failed to supervise a resident with a history of self-inflicted burns and a smoking habit. Despite being cognitively intact, the resident, diagnosed with schizophrenia and possessing a lighter, was allowed to smoke independently without a comprehensive care plan addressing the risks. Staff interviews revealed a lack of awareness and communication about the resident's smoking status and the need for supervision, posing a risk to the resident and others.
A resident with type 2 diabetes did not receive a properly administered dose of insulin due to an LPN's failure to prime the insulin pen before injection. The facility's policy requires priming to ensure accurate dosing, but this step was missed, resulting in a significant medication error.
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.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident. The incident began when one resident entered the shared room of two others, leading to an argument in which food was thrown. The situation escalated when the first resident, after discovering his property had been damaged, returned and threw a wheelchair armrest at one of the residents, which then struck both individuals. This altercation was not witnessed by staff, but staff responded after hearing the commotion and separated the residents. No injuries were reported, but the event involved physical aggression and property damage. The residents involved had documented histories of behavioral and mental health issues, including anxiety, depression, and, in one case, schizoaffective disorder. Assessments indicated that at least one resident had a history of verbal behavioral symptoms directed toward others, and care plans noted the potential for physical aggression related to anger and poor impulse control. Despite these known risks, the altercation occurred without staff intervention until after the physical abuse had taken place. Staff interviews confirmed that the residents had a history of volatile interactions, described as similar to a sibling rivalry, and that staff were aware of the need to monitor their interactions. However, the incident was not prevented, and staff only intervened after the situation had escalated to physical abuse. The facility's policy required the protection of residents from abuse by anyone, including other residents, but this policy was not effectively implemented in this instance, resulting in a failure to prevent physical abuse.
Failure to Manage Resident Personal Funds Accounts
Penalty
Summary
The facility failed to manage the personal funds accounts of four Medicaid-funded residents accurately, leading to account balances exceeding the Medicaid eligibility limit. Specifically, the facility did not notify the residents or their legal representatives when their personal funds accounts reached $200 less than the eligibility resource limit for one person. Record reviews revealed that the account balances for these residents were significantly over the $2000 Medicaid eligibility limit, with amounts ranging from $585.18 to $1,575.87 over the limit. Interviews with the Business Office Manager (BOM) and the Nursing Home Administrator (NHA) highlighted a lack of communication and oversight regarding the management of these accounts. The BOM, who started working at the facility in August 2024, acknowledged awareness of the over-limit accounts but had not yet notified the residents or their responsible parties. The NHA was only aware of one resident's account being over the limit and was not informed about the other three accounts. This oversight put the residents at risk of losing their Medicaid status due to exceeding the allowable personal funds limit.
Deficiency in Restorative Nursing Services for Residents with Limited Mobility
Penalty
Summary
The facility failed to provide appropriate care for three residents with limited mobility, leading to deficiencies in maintaining or improving their range of motion (ROM). Resident #43, who was cognitively intact and dependent on staff for various activities of daily living (ADLs), did not receive restorative nursing services despite being listed on a restorative program. There was no documentation of restorative services being provided, and the resident's care plan did not include a focus on restorative services. Resident #51, also cognitively intact and dependent on staff for dressing and personal hygiene, reported that her restorative program was not conducted as frequently as required. The facility had reduced the frequency of restorative services, and documentation showed only two sessions over a 30-day period. Like Resident #43, there were no physician's orders or care plan focus for restorative services for Resident #51. Resident #66, who had severe cognitive impairment and required total assistance for ADLs, was identified as needing occupational therapy to assess for a restorative nursing program. However, there was no documentation of restorative services being provided. The MDS coordinator acknowledged that Resident #66 should have been restarted on restorative services after returning from the hospital, but this was not done, leading to a risk of contractures.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with an observed error rate of 14.63%, equating to six errors out of 41 opportunities. During medication administration observations, several errors were noted. An LPN administered insulin to a resident without priming the insulin pen, which is necessary to ensure the correct dosage is delivered. Another LPN failed to check a resident's blood pressure before administering Amlodipine Besylate, as required by the physician's order, and administered an incorrect dosage of Senna-Docusate Sodium. Additionally, a different LPN misinterpreted the packaging instructions for Metamucil, leading to an incorrect dosage being given, and administered aspirin in a chewable form instead of the prescribed oral capsule. Interviews with staff revealed a lack of adherence to proper medication administration procedures. The DON confirmed the importance of priming insulin pens and following physician orders precisely to prevent potential harm. The RCC acknowledged the need for clarity in physician orders, especially for bulk medications like Metamucil, to prevent dosage errors. These findings indicate a significant lapse in medication administration practices, contributing to the high error rate observed during the survey.
Failure to Secure Treatment and Medication Carts
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were properly stored in accordance with accepted professional standards. Specifically, two of three treatment carts and one of three medication carts were found unlocked and unattended during the survey. On multiple occasions, treatment carts on both the south and north halls were observed to be unlocked and unattended, with residents and staff walking past them. The treatment cart on the south hall was left unlocked for an extended period until a nurse was notified and locked it. Similarly, the medication cart on the south hall was found unlocked and unattended, with staff, including the DON, passing by without noticing its status. Interviews with staff revealed a lack of adherence to the facility's policy regarding the locking of treatment and medication carts. An agency nurse acknowledged that the treatment cart should be locked when unattended to prevent residents from accessing its contents. The DON confirmed that both treatment and medication carts should be locked when unattended, as they contained items such as scissors and medications that could be dangerous to residents, particularly those with mental health issues and wandering behaviors. Despite these acknowledgments, the facility's failure to provide the medication storage policy by the end of the survey further highlights the deficiency in ensuring proper storage of drugs and biologicals.
Failure to Provide Dental Services to Residents
Penalty
Summary
The facility failed to assist residents in obtaining routine or emergency dental services as needed for three residents. Resident #18, who was edentulous and had expressed a desire to see a dentist for dentures, had not been referred to a dentist since his admission. Despite a signed consent for dental services, there was no documentation of a referral being made. The resident's care plan indicated a potential risk for altered nutritional intake due to being edentulous, yet no action was taken to address his request for dental services. Resident #32, who had chipped teeth and reported tooth pain, had been seeking dental care since his admission. Although there were notes indicating the need for a dental appointment due to tooth pain, the resident was not seen by the dentist. The resident was placed on a reserve list for dental treatment but was not seen due to time constraints during the dentist's visit. The resident's care plan included interventions for dental issues, but these were not effectively implemented. Resident #51 requested to see the dentist but was not notified or taken to the dentist when they visited the facility. Despite being placed on a reserve list for the next dental visit, there was no documentation of her being scheduled. The facility's staff interviews revealed issues with scheduling and communication regarding dental services, contributing to the residents not receiving the necessary dental care.
Infection Control Deficiencies in Housekeeping, Resident Hygiene, and Equipment Cleaning
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by multiple deficiencies observed during a survey. Housekeeping staff did not adhere to proper infection control procedures when cleaning resident rooms. Specifically, housekeepers were observed not performing hand hygiene before starting cleaning tasks or between glove changes. They also failed to use separate cleaning materials for different areas of the room and did not allow disinfectants to remain on surfaces for the required contact time. Additionally, high-touch surfaces were not adequately cleaned, and the cleaning process did not follow the recommended sequence from cleaner to dirtier areas. The facility also failed to ensure residents were assisted with hand hygiene prior to meals. During meal service observations, residents were not offered hand hygiene after touching potentially contaminated surfaces or before eating. Some residents were observed engaging in activities that could spread germs, such as folding utensils into napkins without changing gloves or performing hand hygiene after touching personal items or coughing into their gloves. Despite the availability of moist towelettes, residents were not encouraged or assisted in using them for hand hygiene before meals. Furthermore, the facility did not ensure proper cleaning of glucometers and adherence to infection control procedures during wound care. An LPN was observed using personal hygiene wipes instead of alcohol wipes to clean a resident's finger and glucometer, contrary to facility policy. Additionally, during wound care for a resident on enhanced barrier precautions, staff did not perform hand hygiene before donning PPE, and their wrists were exposed due to improper gowning. The wound care nurse also reached under his gown to retrieve a marker, compromising the protective barrier of the PPE.
Failure to Provide Appropriate Discharge Process
Penalty
Summary
The facility failed to ensure that a resident was permitted to remain in the facility and was not transferred or discharged without an appropriate process. The resident, a 65-year-old with schizoaffective disorder and bipolar disorder, exhibited behaviors such as hallucinations, delusions, and aggression. Despite these challenges, the facility did not provide the necessary documentation or notification for the resident's discharge to a sister facility. The facility's policy requires that residents be allowed to remain unless specific criteria are met, and that proper documentation and notification are provided. However, in this case, there was no documentation indicating the reason for the discharge or the anticipated date. Additionally, the resident or their representative was not notified of the immediate discharge to the hospital, nor were they informed of their right to appeal the discharge. Interviews with staff revealed that the facility's interdisciplinary team had determined they could not meet the resident's needs due to her behaviors. Despite this, the facility did not issue a 30-day or immediate discharge notice, nor did they educate the resident about the appeal process. The lack of proper discharge documentation and notification was acknowledged by the facility's administration.
Facility Fails to Reassess Resident Post-Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after a hospital transfer, violating the resident's right to remain in the facility. The facility did not reassess the resident's status upon her request to return, instead directing the hospital to discharge her to a sister facility. This decision was made without proper documentation or communication with the resident, who was her own responsible party. The resident, a 65-year-old with schizoaffective disorder and bipolar disorder, exhibited behaviors such as hallucinations, delusions, and aggression. Despite these challenges, the facility did not develop a discharge care plan or document a reassessment of her needs post-hospitalization. The facility's policy requires that residents be allowed to return unless specific criteria are met, which were not documented in this case. Interviews with staff revealed that the facility's interdisciplinary team and primary care physician decided the resident's needs could not be met at the facility. However, there was no evidence of a discharge plan being discussed with the resident or documented in her care plan. The social services director admitted to not discussing discharge planning with the resident, and the director of nursing confirmed the lack of documentation for the discharge process.
Failure to Implement PASRR Level II Recommendations
Penalty
Summary
The facility failed to incorporate the recommendations from the PASRR Level II determination and evaluation report into the assessment, care planning, and transition of care for two residents. Specifically, the facility did not initiate therapy as recommended by the PASRR Level II in a timely manner for these residents. The Behavioral Health Services policy and procedure, revised in February 2019, mandates that the facility provide behavioral health services as needed to attain or maintain the highest practicable physical, mental, and psychosocial well-being of residents. However, the facility did not adhere to this policy for the residents in question. Resident #65, who was admitted with diagnoses including schizophrenia and a history of suicidal behavior, had a PASRR Level II recommendation for psychiatric case consultation, case management, individual therapy, and a crisis intervention plan. Despite receiving the PASRR Level II notice of determination on 9/19/24, the facility delayed processing the referral for counseling until 10/10/24, three weeks later. This delay in initiating the recommended therapy was a significant oversight in the resident's care plan. Resident #43, diagnosed with bipolar disorder and other medical conditions, had a PASRR Level II recommendation for behavioral health services to address self-isolation and enhance her quality of life. Although a referral for behavioral health services was documented on 3/22/24, there was no evidence in the resident's electronic medical record that these services were provided. The social service director acknowledged the lapse in initiating a new referral after the previous behavioral health services provider vacated their position, citing an inability to keep up with responsibilities due to a lack of assistance. The director of nursing was unaware of the deficiency in providing behavioral health services to these residents.
Lack of Pain Management Parameters for PRN Medications
Penalty
Summary
The facility failed to ensure that the administration of as-needed (PRN) pain medications for a resident met professional standards of quality. Specifically, the orders for PRN pain medications, including Oxycodone, Tramadol, and Tylenol, lacked specific parameters related to the severity of the resident's pain level on a scale of 1-10. This deficiency was identified for a resident who was cognitively intact and had diagnoses including schizoaffective disorder, bipolar disorder, and diabetes mellitus. The resident's care plan indicated a risk for pain or discomfort, with a goal to relieve pain to a tolerable level, but the lack of specific pain level parameters in the medication orders did not align with this goal. Interviews with staff, including LPNs and the Director of Nursing, revealed that there was an expectation for PRN pain medications to have clear pain scale parameters. However, the orders for the resident's PRN pain medications, which were initially ordered by an emergency department physician, did not specify the pain levels for which each medication should be administered. This oversight was acknowledged by the staff, who indicated that the facility had reviewed and audited the PRN pain medication orders during the survey.
Failure to Provide Proper Discharge Notifications and Planning
Penalty
Summary
The facility failed to provide proper discharge notifications and develop a collaborative discharge plan for a resident with severe cognitive impairment and multiple diagnoses, including dementia and type 2 diabetes mellitus. The resident, who exhibited behavioral symptoms such as hallucinations and aggression, was not involved in the discharge planning process, nor was there documentation of such planning in the resident's electronic medical record (EMR) or comprehensive care plan. Despite the facility's policy requiring a post-discharge plan to be reviewed with the resident or their representative at least 24 hours before discharge, this was not adhered to. The facility's social services director (SSD) and regional clinical consultant (RCC) confirmed that the discharge planning process was not documented as required. The SSD acknowledged the lack of documentation in the resident's EMR, and the RCC emphasized that the discharge process should be part of the comprehensive care plan. The nursing home administrator (NHA) indicated that the SSD was responsible for documenting and developing the discharge plan, but this was not done, leading to a deficiency in the facility's discharge procedures.
Failure to Maintain Resident's Personal Hygiene
Penalty
Summary
The facility failed to ensure that a resident who was unable to carry out activities of daily living (ADL) independently received the necessary services to maintain good grooming and personal hygiene. Specifically, the facility did not ensure that the resident's fingernails were trimmed and clean. The resident, who was cognitively intact and required substantial assistance with various ADLs, was observed with long and dirty fingernails, which he expressed a desire to have cut. The facility's policy required that residents unable to perform ADLs independently receive appropriate care to maintain hygiene, including nail care. The resident's care plan included interventions for bathing, showering, and nail care, but these were not adequately implemented. Interviews with staff, including an LPN and the DON, revealed that nail care should be performed as needed and checked during bathing. However, the resident's fingernails were not maintained according to these guidelines, indicating a lapse in the facility's adherence to its own policies and procedures for resident care.
Delayed Treatment for Lymphedema Due to Missing Physician's Order
Penalty
Summary
The facility failed to provide timely treatment for a resident with lymphedema, a condition characterized by swelling due to lymph fluid buildup. The resident, who was over 65 years old and cognitively intact, was dependent on staff for dressing and personal hygiene. Despite a nurse practitioner's referral to a lymphedema clinic and a request for lymphedema wraps on 9/17/24, the necessary physician's order for the wraps was not entered into the resident's electronic medical record. Consequently, the resident did not receive the recommended treatment. The care plan for the resident included interventions for skin breakdown but did not address edema or the use of wraps. The director of nursing acknowledged difficulties in finding a service provider to measure the resident's legs for the wraps, as it required specialized services. The regional clinical consultant later indicated that the director of nursing had entered the physician's order and documented a progress note, but the deficiency occurred due to the initial delay in obtaining the necessary measurements and orders.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to ensure timely access to optometry services for a resident, leading to a deficiency in maintaining the resident's vision abilities. The resident, a 67-year-old individual with hemiplegia, was admitted with a need for corrective lenses and expressed a desire for a vision referral shortly after admission. Despite this, there was no documentation in the resident's electronic medical record indicating a referral to an eye doctor, and a consent for vision services was not obtained until several weeks after the resident's request. Interviews with facility staff revealed systemic issues in scheduling ancillary services, with the Social Services Director (SSD) acknowledging difficulties in keeping up with referrals. The SSD noted that while ancillary services were offered quarterly and upon admission, there had been challenges in ensuring timely referrals. The Director of Nursing (DON) and the Nursing Home Administrator (NHA) both recognized the need for timely scheduling of ancillary services, with the NHA acknowledging that the SSD required additional support to fulfill her duties effectively.
Inadequate Supervision of Resident with Smoking Habit and History of Self-Inflicted Burns
Penalty
Summary
The facility failed to ensure adequate supervision and safety measures for a resident with a history of self-inflicted injury from fire and a smoking habit. The resident, who was cognitively intact and had a history of schizophrenia, suicidal behavior, and severe burns, was assessed as being able to smoke independently without supervision. However, the facility did not have a comprehensive care plan addressing the resident's smoking habit, nor did it document a plan to monitor the resident, who possessed a lighter and smoked over ten times per day. Interviews with staff revealed a lack of awareness and communication regarding the resident's smoking status and the associated risks. The social service director and assistant director of nursing acknowledged the need for a safety plan and supervision due to the resident's history of self-inflicted burns. Despite this, the resident was allowed to smoke independently, with the nursing home administrator emphasizing the resident's autonomy. This oversight in care planning and supervision posed a risk to the resident and others in the facility.
Failure to Prime Insulin Pen Leads to Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin. The incident involved a resident over the age of 65, who was diagnosed with type 2 diabetes mellitus and was cognitively intact. During a medication administration, an LPN did not prime the insulin pen before administering a 50-unit dose of Tresiba insulin to the resident. This action was contrary to the professional guidelines provided by the Tresiba product information, which requires the pen to be primed by dialing to two units and expelling the insulin before administering the prescribed dose. The facility's policy on administering medications emphasizes the importance of following prescriber orders and ensuring safe medication practices. However, the LPN failed to adhere to these guidelines, as confirmed by the director of nursing and the regional clinical consultant. They acknowledged that priming the insulin pen is crucial to ensure the resident receives the full dose of insulin. This oversight was documented during an observation and interview process, highlighting a significant medication error in the facility's administration practices.
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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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