Brookdale Greenwood Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Greenwood Village, Colorado.
- Location
- 6450 S Boston St, Greenwood Village, Colorado 80111
- CMS Provider Number
- 065376
- Inspections on file
- 17
- Latest survey
- April 9, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Brookdale Greenwood Village during CMS and state inspections, most recent first.
A resident with sepsis, Alzheimer’s disease, repeated falls, and documented need for at least contact guard or stand‑by assist with a walker was allowed to ambulate outside unaccompanied. The care plan identified fall risk and general fall precautions but did not specify the required supervision level for ambulation, and therapy notes showed the resident was not cleared for independent ambulation, especially on uneven surfaces or outdoors. Staff interviews revealed inconsistent understanding of the resident’s mobility status, incomplete special instructions regarding fall risk and assistance needs, and conflicting statements about whether the resident was considered safe to walk alone. The resident went outside alone, was later found on the ground near the parking lot with a newspaper and her walker nearby, reported tripping and falling, and was noted to have oral bleeding and pain with movement; hospital imaging confirmed facial bone and coccyx fractures.
The facility failed to provide adaptive dining equipment for three residents who required it. One resident with dysphagia and Alzheimer's disease used cups without handles, another with dysphagia and dementia used glass goblets and a soda can, and a third with multiple sclerosis was observed without a plate guard. The registered dietician confirmed the shortage of Kennedy cups and makeshift solutions being used.
The facility failed to store, prepare, distribute, and serve food in a sanitary manner. Observations revealed improperly labeled and dated food items and inappropriate handling of ready-to-eat foods by a dietary aide, who did not perform hand hygiene or change gloves as required.
The facility failed to maintain an effective infection control program, leading to deficiencies in housekeeping protocols, isolation precautions, and hand hygiene practices. Housekeeping staff did not follow proper cleaning protocols, and staff did not use PPE correctly or offer hand hygiene to residents before meals. Additionally, the facility's water management plan was outdated and incomplete.
The facility failed to offer choices to two residents for their bathing schedules, assigning shower days based on room numbers rather than individual preferences. Both residents expressed discomfort and lack of autonomy in their bathing routines, and staff interviews confirmed that the schedules were pre-determined by the facility.
The facility failed to provide necessary personal hygiene services for two residents. One resident had long, soiled fingernails despite needing assistance, and another resident did not receive required help with oral hygiene, with no proper documentation in place.
The facility failed to ensure that two residents received care according to professional standards and their care plans. One resident did not have blood pressure and heart rate consistently assessed before administering Metoprolol, and another resident's weights were not obtained as ordered, with no reweigh conducted after a significant weight change.
The facility failed to provide proper foot care for two residents, one with severely overgrown and discolored toenails and another with an overgrown toenail, despite documented needs and requests for care. Staff were unclear about responsibilities and procedures for addressing these needs.
The facility failed to ensure an environment free from accident hazards for two residents at risk for falls by not maintaining their beds in the lowest position when they were in bed. Both residents were repeatedly found in high bed positions without staff present, despite being identified as fall risks and members of the Falling Star Program. The care plans for both residents did not document the need for the bed to be in the lowest position.
The facility failed to provide effective pain management for a resident, as they did not complete comprehensive pain assessments, document the resident's pain management goals, or consistently administer and evaluate the effectiveness of pain medications. The resident reported significant pain in her left knee, which was not adequately addressed in her care plan.
The facility failed to ensure residents were free from significant medication errors by not following physician-ordered parameters for midodrine administration for a resident. Despite orders to hold the medication if the systolic blood pressure (SBP) was above 120 mmHg, the medication was administered 26 times when the SBP was above this threshold, including three instances where the SBP was above 140 mmHg.
The facility failed to ensure medication carts were locked when unattended, as observed on two occasions. Medication carts were found unlocked with keys inserted, and no nurse was visible nearby. Staff interviews confirmed that carts should be locked at all times, and the DON acknowledged the issue and indicated steps were being taken to prevent future lapses.
The facility failed to ensure adequate hydration and provide the correct consistency of thickened liquids for two residents. One resident, with significant cognitive impairment, was given nectar thick liquids instead of honey thick liquids and had fluids out of reach, leading to dehydration. Another resident, with a history of aspiration problems, was given regular consistency water instead of nectar thick liquids. Staff interviews revealed a lack of understanding and adherence to the prescribed liquid consistencies.
The facility failed to administer the pneumococcal vaccination to a resident after consent was provided. The resident's electronic medical record indicated that the vaccination was not given, and the consent form was signed as verbal, indicating refusal, which contradicted the resident representative's interview. The infection preventionist and director of nursing confirmed the discrepancy and planned to contact the resident's representative to clarify their wishes.
The facility failed to post nurse staffing information in a prominent place accessible to residents and visitors. Observations revealed no staffing information posted on the third floor, and the Director of Nursing confirmed that the information was kept in binders behind the nurses' stations, restricted to facility and agency staff only.
Failure to Supervise High-Risk Resident During Ambulation Outside
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and appropriate use of assistive devices to prevent accidents for a resident with known fall risk and mobility impairments. The resident was admitted with diagnoses including sepsis, unsteadiness on feet, generalized muscle weakness, repeated falls, and Alzheimer’s disease. A recent MDS showed moderate cognitive impairment, need for a walker, substantial to maximal assistance with toilet transfers, and partial to moderate assistance with walking 50 feet, with walking on uneven surfaces and curbs not attempted. The facility’s falls management policy required evaluation of fall risk and implementation of an IDT fall prevention plan for high‑risk residents, but the resident’s care plan, while identifying fall risk and listing general fall interventions, did not specify the level of supervision required for ambulation. Facility records and therapy documentation showed that the resident required at least contact guard or stand‑by assistance for ambulation and transfers and was not safe to ambulate independently, particularly on uneven surfaces or outside. A functional assessment documented use of a front‑wheel walker with contact guard assist on level surfaces and dependence on staff for uneven surfaces. PT notes described gait training with a front‑wheel walker and contact guard assist, need for verbal cueing for posture and step placement, impulsive transfer behavior despite maximal cues, and toilet transfers requiring minimal assistance and constant cueing. A social services note stated the resident required contact guard assist for all mobility. The director of rehabilitation later confirmed that the resident was not independent with ambulation, had not been cleared to walk independently in hallways or outside, and that therapy had not worked with her on uneven surfaces or curbs. On the day of the fall, documentation and interviews indicated the resident had been working with PT on gait training with stand‑by assist earlier in the evening. Nursing notes indicated the resident had a history of getting up unassisted, walking with her walker or holding onto furniture, and required frequent reminders that staff needed to be with her when walking; she was placed on frequent room checks for this behavior. That evening, staff last recalled seeing the resident near the nurses’ station before she went outside unaccompanied. She was later found on her back on the ground outside near the parking lot, approximately 30 feet from the front door, fully clothed with shoes on and holding a newspaper, with her walker nearby. She reported that she had tripped and fallen forward, hitting her head, and complained of pain when attempts were made to move her. She was noted to be bleeding from her mouth, and subsequent hospital imaging documented fractures of facial bone sockets and a closed coccyx fracture. The facility’s post‑event analysis identified that the resident went outside unaccompanied and was not using an assistive device at the time of the fall, with being unaccompanied outside listed as a contributing factor, despite her documented need for assistance and lack of clearance for independent ambulation, especially outdoors. Interviews with multiple staff members further demonstrated inconsistency and lack of clarity regarding the resident’s ambulation status and supervision needs. Some staff, including CNAs and LPNs, stated the resident was a one‑person assist and was not supposed to go outside alone, while the director of rehabilitation was initially documented in the facility’s investigation as saying the resident was safe to ambulate alone and go outside alone near the patio table, a statement later contradicted by therapy records and her own subsequent interview. The IDT post‑event analysis inaccurately documented that the resident ambulated with no problems with the use of a device. CNAs also reported that special instructions in the computer system did not always indicate fall risk status or required assistance level. The investigation interviews lacked documented dates and times, and there were discrepancies between RN accounts regarding whether one RN left the resident briefly with another family before obtaining additional help. Collectively, these documented actions and omissions show that the resident, known to be at high risk for falls and requiring at least stand‑by or contact guard assistance, was allowed to ambulate outside unaccompanied without clearly defined and communicated supervision parameters, resulting in a fall with fractures.
Failure to Provide Adaptive Dining Equipment
Penalty
Summary
The facility failed to provide accessible dining equipment and utensils for three residents who required adaptive equipment. Resident #22, diagnosed with dysphagia and Alzheimer's disease, was observed using cups without handles and a straw, contrary to the care plan that specified the use of a nosey cup and two-handled mug. Similarly, Resident #18, diagnosed with dysphagia, parkinsonism, and dementia, was observed using glass goblets and a soda can with a straw instead of the prescribed Kennedy cups and plate guard. The care plan for Resident #18 included occupational therapy screening and providing adaptive equipment as needed, which was not adhered to during the observations. Resident #1, diagnosed with multiple sclerosis, was observed without a plate guard during lunch service, despite the care plan indicating the need for a plate guard and handled cups. The registered dietician (RD) confirmed that both dietary and nursing staff were responsible for ensuring residents received the necessary equipment. The RD also mentioned that the facility was running low on Kennedy cups and had been using makeshift solutions like plastic wrap over cups with straws. These observations and interviews indicate a failure to provide the required adaptive dining equipment as per the residents' care plans.
Failure to Maintain Sanitary Food Handling Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner in two satellite kitchens. Specifically, the facility did not ensure that food was labeled, dated, and disposed of in a timely manner. Observations revealed an opened carton of soy milk with an expiration date of 1/21/24 and two opened Hormel thick and Easy Clear thickener drinks without any date of opening. The dietary manager discarded these items after review. The registered dietitian confirmed that opened containers should have an open-by and use-by date and that the soy milk should have been discarded by 1/21/24. Additionally, the facility failed to handle ready-to-eat foods appropriately. During the noon meal service, a dietary aide was observed placing serving utensils into pans with bare hands, failing to perform hand hygiene before donning gloves, and using the same gloved hands to handle various food items without changing gloves. The dietary manager confirmed that ready-to-eat foods should be handled with utensils or clean gloves.
Infection Control and Hygiene Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection control program, leading to several deficiencies across two units. Housekeeping staff did not follow proper cleaning protocols, such as cleaning from cleaner to dirtier areas and changing gloves and performing hand hygiene between cleaning the bathroom and bedroom. Observations revealed that the housekeeping supervisor cleaned the toilet before the sink and did not change gloves or perform hand hygiene after cleaning the bathroom and before handling other cleaning supplies. Interviews with the housekeeping supervisor and the infection preventionist confirmed these lapses in protocol, which could potentially spread bacteria or viruses within the facility. The facility also failed to ensure proper isolation precautions and the appropriate use of personal protective equipment (PPE). Observations showed that a certified nurse aide (CNA) did not don an N95 mask before entering a COVID-19 positive resident's room, and another staff member wore a surgical mask under an N95 mask, contrary to CDC guidelines. Interviews with the infection preventionist confirmed that staff should wear an N95 mask before entering a COVID-19 positive room and should not wear a surgical mask underneath. Additionally, the facility did not ensure that staff performed hand hygiene or offered it to residents before meals. Observations in the dining room and resident rooms showed that staff did not offer hand hygiene to residents before serving meals. The dietary manager and the director of nursing acknowledged that hand hygiene should be performed before meals and that hand wipes were previously used but had been discontinued. Furthermore, the facility's water management plan was outdated and lacked specific details, such as the current staff responsible for the plan and a complete diagram of the water system. Interviews with the nursing home administrator and interim maintenance director revealed that the plan had not been reviewed or updated to reflect the current staff and facility layout.
Failure to Offer Resident Choice in Bathing Schedule
Penalty
Summary
The facility failed to offer choices to residents for activities of daily living (ADL), specifically in ensuring that two residents received showers according to their preferred frequency. Resident #1, who has multiple sclerosis, respiratory failure, and neuromuscular dysfunction of the bladder, reported that she did not have a choice of when she bathed and had to take her bed bath when it was offered or it would not be done. The resident's bath days were pre-determined by the facility and not re-offered if missed. Similarly, Resident #23, who has heart failure, respiratory failure, cataracts, and arthritis, stated that her shower days were assigned to her and she did not have any choice about her shower preferences, which were dependent on staff workload rather than her own preferences. Both residents expressed discomfort with the current shower assignments and felt they lacked autonomy in their bathing schedules. Staff interviews corroborated the residents' statements, revealing that bathing schedules were assigned based on room numbers and not individual resident preferences. CNA #2 and CNA #3 confirmed that residents did not choose their shower days, which were scheduled upon admission based on room assignments. The Director of Nursing (DON) claimed that residents had choices for when they bathed and that the shower assignment sheet was merely a guideline. However, the evidence from resident and staff interviews indicated that the facility's practice did not align with the DON's statement, as residents' shower days and times were indeed assigned according to their room numbers, limiting their ability to exercise self-determination in their daily care routines.
Failure to Provide Necessary Personal Hygiene Services
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for two residents. Resident #49, a 77-year-old with diagnoses including alcohol abuse and adult failure to thrive, required partial to moderate assistance with activities of daily living (ADL). Observations revealed that Resident #49's fingernails were long, discolored, and visibly soiled with a dark substance under several nails. Despite the resident's attempts to trim his own nails and the comprehensive care plan indicating the need for nail care, staff did not offer assistance. Interviews with CNAs and an LPN confirmed that Resident #49's nails were overgrown and unclean, and the facility's nail care policy was not provided for review. Resident #23, over the age of 65 with diagnoses including heart failure, respiratory failure, cataracts, and arthritis, required substantial assistance with oral hygiene. The resident reported needing help with setting up oral care supplies and stated that staff often forgot to assist with brushing her teeth. The comprehensive care plan did not document the resident's oral care assistance needs, and there was no documentation in the electronic medical record indicating that the resident received the necessary assistance. Interviews with a CNA, an LPN, and the DON confirmed the lack of proper documentation and assistance for Resident #23's oral care.
Failure to Monitor Vitals and Obtain Weights
Penalty
Summary
The facility failed to ensure that two residents received treatment and care in accordance with professional standards of practice and their comprehensive person-centered care plans. For Resident #47, the facility did not consistently assess and document blood pressure and heart rate prior to administering Metoprolol, a beta-blocker medication. This failure occurred on multiple occasions in March 2024, and there was no documentation indicating that the resident's vitals were assessed before the medication was held on one occasion. Interviews with staff revealed that the electronic charting system did not prompt nurses to document the resident's vitals due to incorrect input of the physician's order, and there was a lack of proper documentation by CNAs as well. For Resident #16, the facility did not obtain weights according to the physician's orders. The resident, who had multiple comorbidities including hemiplegia, diabetes, and heart failure, was supposed to be weighed weekly for three weeks following admission. However, weights were not consistently documented, and there was no reweigh conducted when a significant weight change was noted. Additionally, there was no documentation that the provider or registered dietitian was notified about the missed weights or the weight change. Interviews with the Director of Nursing (DON) and the Registered Dietitian (RD) confirmed that the facility's policy required weights to be obtained and documented, and any refusals or discrepancies should be addressed promptly. The RD emphasized the importance of accurate weight monitoring for understanding the resident's health status. The failure to follow these protocols led to deficiencies in the care provided to both residents.
Failure to Provide Proper Foot Care
Penalty
Summary
The facility failed to ensure proper foot care for two residents, Resident #49 and Resident #16, as per the standards of practice. Resident #49, a 77-year-old male with diagnoses including alcohol abuse and adult failure to thrive, had severely overgrown and discolored toenails, with one toenail curving completely over the toe pad. Despite being signed up for podiatry services, there was no documentation of him receiving these services, and staff interviews revealed uncertainty about whether he had been offered additional podiatry services after initially refusing them. The care plan and physician notes indicated a need for nail care, but this was not adequately addressed by the facility staff. Resident #16, who had multiple diagnoses including hemiplegia, hemiparesis, diabetes mellitus type two, and severe cognitive impairment, also did not receive proper foot care. Her left big toenail was observed to be significantly overgrown, and despite her expressing a desire for nail care, there was no documentation in her electronic medical record indicating that her nail care needs were addressed. Staff interviews revealed a lack of awareness about her condition and a misunderstanding of responsibilities regarding nail care for diabetic residents. The facility's policy and procedure for foot care were requested but not provided, and there was a general lack of clarity among staff about the process for identifying and addressing residents' need for podiatry services. The Director of Nursing acknowledged the deficiencies and indicated that assessments for ancillary services were done at least annually, but this did not translate into timely and effective care for the residents in question.
Failure to Maintain Bed Position for Fall-Risk Residents
Penalty
Summary
The facility failed to ensure an environment free from accident hazards for two residents, both of whom were at risk for falls. Specifically, the facility did not maintain the beds of Resident #6 and Resident #41 in the lowest position when the residents were in bed, as required by the facility's Falls Management and Falling Star Program policies. Observations revealed that both residents were repeatedly found in beds that were in a high position without staff present, despite being identified as fall risks and members of the Falling Star Program. Resident #6, who had severe cognitive impairment and required substantial assistance with daily activities, was observed on multiple occasions lying in bed with the bed in a high position. The resident's care plan, which identified the resident as a fall risk and a member of the Falling Star Program, did not document the need for the bed to be in the lowest position when the resident was in bed. The DON confirmed that the bed should have been in the lowest position and adjusted it accordingly during the survey. Similarly, Resident #41, who had moderate cognitive impairment and required substantial assistance with daily activities, was also observed lying in bed with the bed in a high position on multiple occasions. The resident's care plan identified the resident as a fall risk and a member of the Falling Star Program but failed to document the need for the bed to be in the lowest position. Staff interviews revealed a lack of consistent understanding and adherence to the facility's protocol for maintaining bed positions for fall-risk residents.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide an effective pain management regime for a resident, identified as Resident #216, who required such services. The facility did not complete a comprehensive pain assessment that identified the onset, presence, and duration of the resident's pain. Additionally, the resident's goal for pain management and acceptable level of pain were not documented. The care plan did not specify the location of the resident's pain or include non-pharmacological interventions to help alleviate the pain. The resident reported significant pain in her left knee, which was not adequately addressed in her care plan or pain assessments. The medication administration record (MAR) revealed inconsistencies in the administration of pain medications. Oxycodone was not administered on several occasions, and there was no documentation explaining why the medication was not given or if the physician was notified. The resident's pain levels were not consistently assessed before or after the administration of acetaminophen and oxycodone, and there was no follow-up to determine the effectiveness of these medications. The resident's pain levels were frequently above five out of ten, indicating that the pain management interventions were not effective. Interviews with staff, including an LPN and the DON, highlighted gaps in the facility's pain management practices. The LPN acknowledged that the resident was in pain and that the pain was primarily in her left knee. However, the pain medication orders were not updated to reflect this. The DON confirmed that pain assessments should be completed every shift and should cover various aspects of the resident's pain, but these assessments were not adequately documented for Resident #216. The DON also noted that the facility had an emergency medication stock, but it was unclear why the resident did not receive her prescribed oxycodone on certain days.
Failure to Follow Physician-Ordered Parameters for Midodrine Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of midodrine for Resident #265. The resident, who was over the age of 65 and had diagnoses including myelodysplastic syndrome, orthostatic hypotension, and high cholesterol, was prescribed midodrine to be administered three times a day with the condition that it should be held if the systolic blood pressure (SBP) was above 120 mmHg. However, the February medication administration record (MAR) documented 26 instances where midodrine was administered despite the resident's SBP being above the physician-ordered parameter, including three instances where the SBP was above 140 mmHg. Interviews with facility staff, including an LPN, the DON, the pharmacist, and the medical director, confirmed that medication orders, including blood pressure parameters, should always be followed. The staff acknowledged the importance of adhering to these parameters to prevent adverse effects, such as elevated blood pressure. The failure to follow the physician's orders for midodrine administration led to significant medication errors, as documented in the report.
Medication Cart Security Lapses
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were properly stored in accordance with professional standards on two of six medication carts. Specifically, the medication carts were left unlocked when unattended. On one occasion, a medication cart in the middle hallway of the third floor was observed with keys inserted and dangling from the lock in the unlocked position, with no nurse visible nearby. This situation persisted for several minutes until an LPN returned, acknowledged the mistake, and secured the cart. On another occasion, a medication cart in the left hallway of the third floor was also found unlocked and unattended for several minutes until another LPN returned and locked it. Interviews with staff confirmed that medication carts should be locked at all times and keys should never be left in the carts. The LPNs involved admitted to the lapses, and the Director of Nursing (DON) reiterated the policy that medication carts must be properly secured and that nurses should always have the keys in their possession. The DON indicated that steps were being taken to prevent such occurrences in the future.
Failure to Ensure Adequate Hydration and Correct Liquid Consistency
Penalty
Summary
The facility failed to ensure adequate hydration for two residents, Resident #31 and Resident #266, by not encouraging fluid intake and not providing the correct consistency of thickened liquids as per physician's orders. Resident #31, who had significant cognitive impairment and required maximum assistance with eating and drinking, was observed with fluids out of reach and was given nectar thick liquids instead of the prescribed honey thick liquids. This resident had a history of dehydration and was receiving IV fluids for suspected dehydration, yet her fluid intake was not adequately monitored or recorded in the medical record. Staff interviews revealed a lack of understanding of the differences between nectar and honey thick liquids, and the resident's fluid intake was not properly tracked or encouraged as per the facility's policy. The resident's representative also noted that the resident needed fluids within reach, which was not consistently done. Resident #266, who had moderate cognitive impairment and a history of aspiration problems, was observed with regular consistency water and an Ensure nutritional shake instead of the prescribed nectar thick liquids. Staff interviews confirmed that the resident required nectar thick liquids, but there was a failure to provide the correct consistency, posing a risk of aspiration. The speech language pathologist's evaluation and physician's orders clearly indicated the need for nectar thick liquids, yet this was not adhered to by the facility staff. The facility's policies on thickened liquids and hydration were not followed, leading to these deficiencies. The director of nursing and registered dietitian acknowledged the importance of providing the correct liquid consistency to prevent aspiration and the need for monitoring fluid intake, but there was a lack of proper implementation and communication among the staff. The facility's failure to ensure residents received the correct consistency of liquids and adequate hydration resulted in potential health risks for the residents involved.
Failure to Administer Pneumococcal Vaccination
Penalty
Summary
The facility failed to implement policies and procedures related to pneumococcal immunizations for one of the five residents reviewed for immunizations. Specifically, the facility did not administer the pneumococcal vaccination to Resident #6 after consent was provided. According to the CDC's Recommended Immunization Schedule for Adults, individuals over the age of 65 should receive one dose of PCV15 followed by PPSV23 or one dose of PCV20 if they lack documentation of vaccination or evidence of past infection. Resident #6, who was over the age of 65 and had diagnoses including chronic kidney disease, osteoporosis, and gout, did not receive the pneumococcal vaccination despite the resident representative's desire for the resident to be up to date on all vaccinations. The resident's electronic medical record revealed that the pneumococcal vaccination was not administered, and the consent form was signed as verbal, indicating refusal, which contradicted the resident representative's interview stating they wanted the resident to receive the vaccination. The infection preventionist (IP) and director of nursing (DON) were interviewed and confirmed that it was unclear who refused the vaccines on the consent form. The IP, who started working at the facility in January 2024, stated that the nurse was responsible for offering the necessary immunizations and obtaining consent. If a resident was eligible for a vaccine but did not want it, they would sign the consent indicating refusal. However, in this case, the consent form for Resident #6 was not signed by the family representative, leading to confusion about the resident's vaccination status. The IP and DON acknowledged the discrepancy and planned to contact the resident's representative to confirm their wishes regarding the vaccinations.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to ensure that nurse staffing information was posted in a prominent place, readily accessible to residents and visitors. Observations on 3/26/24 at 4:01 p.m. revealed no nurse staff posting on the third floor, where a binder labeled 'staffing information' was found but restricted to facility and agency staff only. The Director of Nursing (DON) confirmed on 3/28/24 at 10:07 a.m. that the staffing information was typically posted at the nurses' station or on a board near the nurses' station, but it was currently in binders located behind the nurses' stations on the second and third floors. The DON was unsure why the binder was restricted and acknowledged that the nursing staffing schedule was not posted in a visible area for residents and visitors to view.
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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