Atlas Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Pueblo, Colorado.
- Location
- 2611 Jones Ave, Pueblo, Colorado 81004
- CMS Provider Number
- 065232
- Inspections on file
- 32
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Atlas Post Acute during CMS and state inspections, most recent first.
A resident with chronic pain, osteoarthritis, contractures, and lower leg wounds had orders for scheduled and PRN oxycodone, with a care plan directing that pain medications be administered as ordered. Over several days, multiple doses of the resident’s scheduled immediate-release oxycodone were not given, with documentation indicating the drug was on order or not on hand and no documented notification to the provider when it was unavailable. The resident reported missing pain doses several times, experiencing increased pain and withdrawal-like symptoms, and being told staff were waiting for the pharmacy. Staff interviews revealed inconsistent understanding and execution of the medication re-ordering and provider-notification process, and facility leadership later acknowledged that one missed dose occurred despite adequate stock and without documented reason or provider contact.
A resident with multiple medical conditions was administered Midodrine for hypotension without consistent adherence to physician-ordered BP parameters. The medication was given multiple times without a BP check or when BP readings were outside the prescribed range, and was also withheld when it should have been administered. Staff interviews confirmed confusion about the medication parameters and failure to follow required procedures.
The facility failed to honor dietary preferences for three residents, leading to deficiencies in meal service. A resident with diabetes did not receive hard boiled eggs as requested, another resident requiring small portions due to dental issues was served regular portions, and a third resident with malnutrition did not receive double portions of preferred foods. Staff interviews and record reviews confirmed these lapses in adhering to documented preferences.
The facility failed to properly label and store medications on two medication carts, with insulin pens and inhalers lacking open dates. An LPN confirmed that insulin should be dated upon opening to ensure timely disposal, while another LPN found insulin pens past their 28-day usage period. The DON acknowledged the importance of labeling medications with open dates to maintain their effectiveness.
A resident with dementia and muscle weakness was observed with long, dirty fingernails despite needing assistance with ADLs. The facility's policy required regular nail care to prevent infections and skin issues, but the resident's nails were not trimmed or cleaned for months. Staff interviews confirmed the resident's dependency on staff for nail care and the associated risks of neglecting this care.
A facility failed to ensure proper monitoring and care planning for a resident using a continuous glucose monitor (CGM). The resident, with Type I diabetes, was not effectively monitored for CGM changes, and staff lacked training on its use. The care plan did not address the CGM, and physician's orders were incomplete. Interviews revealed staff confusion and lack of training, with the DON acknowledging the need for better tracking and care planning.
A resident with multiple health conditions was observed receiving oxygen at 4 LPM, contrary to the physician's order of 3 LPM. Staff interviews revealed that CNAs were informed of oxygen rates but did not adjust settings, which was the responsibility of licensed nurses. An LPN confirmed the discrepancy and the DON emphasized the importance of following physician orders to prevent medical complications.
Failure to Administer Ordered Pain Medication and Notify Provider When Medication Unavailable
Penalty
Summary
The deficiency involves the facility’s failure to provide pain medication as ordered and to notify the provider when a resident’s ordered pain medication was unavailable. Resident #2, who was cognitively intact and dependent on staff for transfers, toileting, bathing, and dressing, had diagnoses including protein calorie malnutrition, contractures of both knees, chronic pain syndrome, generalized osteoarthritis, and open wounds to both lower legs. Physician orders included scheduled extended-release oxycodone (Oxycontin) twice daily, scheduled immediate-release oxycodone (Roxicodone) every four hours for chronic pain, and PRN oxycodone for breakthrough pain, along with an order to monitor and document pain levels and use non-pharmacological interventions before PRN medication. The resident’s pain care plan identified him as at risk for pain or discomfort due to wounds and disease processes, with interventions to administer medications as ordered. Record review showed that multiple doses of the resident’s scheduled Roxicodone were not administered. On one day in January, four of six scheduled doses were not given, and another scheduled dose was not given on a later date, with the MAR indicating “other/see nurses notes” for several missed doses. Nursing progress notes documented that Roxicodone was on order and that nurses were unable to access the pyxis, and that there was none of the medication on hand despite reports that it had been reordered. One note also documented that the resident refused an offer to get up for an hour daily because he had no pain medication. For the missed dose on the later January date, there was no documentation in the nursing progress notes explaining why the medication was not administered. Interviews further described the circumstances around the missed pain medication. Resident #2 reported that he had missed his pain medication three or four times since admission, that missing his immediate-release oxycodone led to increased leg pain and withdrawal-like symptoms, and that staff told him the facility was waiting for the medication from the pharmacy when it was unavailable. An LPN stated she reordered medications when the card reached a certain level and relied on providers being present on weekdays, and she was unsure of the process on weekends or overnight. The DON and regional clinical resource stated that if a medication was unavailable, they expected nurses to notify the provider to consider a substitute or hold the medication and document the communication, and later acknowledged they were unsure why a dose was not administered on the later January date and that there was sufficient stock at that time. Staff interviews also confirmed that the resident frequently complained of pain and relied on timely administration of his pain medications, while the facility did not document provider notification when the ordered pain medication was unavailable.
Failure to Follow Medication Administration Parameters for Hypotension Medication
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of Midodrine, a medication prescribed for hypotension. According to physician orders, Midodrine was to be administered only if the resident's blood pressure (BP) was below 100/60 mmHg, and a BP reading was required prior to each dose. However, the medication administration records revealed that the resident received Midodrine multiple times without a BP being taken beforehand, and on several occasions, the medication was administered when the resident's BP was outside the prescribed parameters. There were also instances where the medication was not given when it should have been, according to the physician's orders. The resident involved was over 65 years old, had diagnoses including unspecified cirrhosis of the liver, muscle weakness, acute respiratory failure with hypoxia, and chronic hepatic failure, and was cognitively intact. The resident required significant assistance with activities of daily living and had a goal to discharge into the community. The medication errors occurred over several days, with the medication being given when the BP was above the threshold or withheld when it should have been administered, as documented in the medication administration records. Interviews with staff confirmed that the required BP checks were not consistently performed prior to administering the medication, and that the parameters for administration were not always followed. Nursing staff acknowledged confusion regarding the medication parameters and the necessity of BP measurement before administration. The facility's policy required medications to be administered as prescribed, including adherence to any parameters and documentation of medication errors, but these procedures were not followed in this case.
Failure to Honor Resident Dietary Preferences
Penalty
Summary
The facility failed to provide food that accommodated resident preferences for three residents, leading to deficiencies in dietary services. Resident #38, who was on a therapeutic diet due to diabetes, consistently did not receive hard boiled eggs with his meals as per his preference. Despite his requests and the inclusion of this preference on his meal ticket, the staff failed to provide the eggs, indicating a breakdown in communication and adherence to dietary preferences. Interviews with staff revealed that the dietary manager and other staff were aware of the resident's preferences, but these were not consistently honored. Resident #18, who required a mechanically altered diet and preferred small meal portions due to dental issues, was served regular portions instead of the small portions she preferred. This discrepancy was observed during meal preparation and was not aligned with the resident's documented preferences on her meal ticket. The dietary manager acknowledged the oversight but was unaware of the specific incident, highlighting a lapse in ensuring that meal preferences were accurately followed. Resident #23, who had multiple health issues including severe protein-calorie malnutrition, had preferences for certain foods like biscuits and gravy, which were not consistently provided in double portions as requested. The resident's representative had communicated these preferences to the facility, but they were not documented on the meal ticket, leading to inconsistencies in meal service. The facility's failure to document and adhere to the resident's dietary preferences contributed to the deficiency, as confirmed by staff interviews and record reviews.
Improper Labeling and Storage of Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were stored and labeled properly on two medication carts. Specifically, insulin pen injection devices and inhaler medications were not labeled with open dates, which is necessary to determine their expiration and ensure safe administration. During an observation, a Fluticasone inhaler and a Humalog insulin pen were found without open dates on the 400 hall medication cart. The LPN responsible for this cart acknowledged that insulin medications should be dated when opened to determine when they need to be discarded, and confirmed that the Fluticasone inhaler was not dated, making it unclear when it was opened. On the 500 hall medication cart, a Humalog insulin pen and a Lantus insulin pen were found with open dates that indicated they should have been disposed of, as they were beyond the 28-day usage period. The LPN responsible for this cart confirmed that these insulin pens were only good for 28 days after opening and acknowledged the potential danger of administering expired medication. The DON also confirmed that medications like insulin and inhalers should be labeled with the resident's name and the date they were opened, as some medications are only effective for a certain number of days after opening.
Failure to Provide Adequate Fingernail Care
Penalty
Summary
The facility failed to provide adequate fingernail care for a resident who required assistance with activities of daily living (ADL). The resident, who was over 65 years old and had diagnoses including dementia, muscle weakness, and anoxic brain damage, was observed multiple times with long, untrimmed, and visibly soiled fingernails. Despite the facility's policy requiring daily cleaning and regular trimming of nails to prevent infections and skin problems, the resident's fingernails were found to be approximately one inch long with dark debris underneath them on several occasions. The comprehensive care plan for the resident, which was revised earlier in the year, indicated a risk for skin breakdown and self-inflicted scratches due to long fingernails. However, the electronic medical record did not show documentation of nail care being provided since early February, despite the resident's need for assistance with ADLs. Interviews with staff, including a CNA and an LPN, confirmed the resident's dependency on staff for nail care and the potential risks associated with neglecting this care. The deficiency was identified through observations and staff interviews, highlighting a lapse in the facility's adherence to its own policies and procedures regarding nail care.
Deficiency in Monitoring and Care Planning for Continuous Glucose Monitor
Penalty
Summary
The facility failed to ensure that a resident with a continuous glucose monitor (CGM) received the highest practicable treatment and care in accordance with professional standards and the comprehensive person-centered care plan. The resident, who was cognitively intact and had a diagnosis of Type I diabetes mellitus, was using a Freestyle Libre 2 CGM. However, the facility did not effectively monitor the frequency of CGM changes, train staff on the use of the CGM, or include the use of the CGM in the resident's care plan. The care plan did not address the use of the CGM, and the physician's orders did not specify the frequency of CGM changes or the requirement for the resident to report blood glucose levels to the nurse. Interviews with staff revealed a lack of training and awareness regarding the CGM. An LPN stated she had not received training on the CGM and was unsure about the frequency of changes, mistakenly believing it to be every eight days. The Director of Nursing acknowledged that the facility should have tracked the frequency of CGM changes and that an assessment confirming the resident's ability to change the monitor independently was conducted late. The DON also admitted that the care plan should have included the use of the CGM, and staff training on the Freestyle Libre 2 was necessary.
Failure to Adhere to Physician's Order for Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care and services consistent with professional standards of practice for a resident who required oxygen therapy. The resident, who had diagnoses including dementia, anxiety disorder, lung cancer, chronic obstructive pulmonary disease, and type two diabetes, was observed receiving oxygen at 4 liters per minute (LPM) via nasal cannula on multiple occasions. However, the physician's order specified that the resident should receive oxygen at 3 LPM continuously to maintain oxygen saturation at or above 90%. Despite this, the medication administration record inaccurately documented that the resident received 3 LPM of oxygen. Interviews with staff revealed that the certified nurse aides were informed of the oxygen rates but did not adjust the settings, which were the responsibility of the licensed nurses. A licensed practical nurse confirmed that the resident was receiving 4 LPM instead of the ordered 3 LPM and acknowledged the need to follow physician orders as written. The director of nursing emphasized the importance of adhering to physician orders and obtaining new orders if changes were necessary, highlighting the potential for medical complications if orders were not followed.
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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