Castle Peak Senior Life And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Eagle, Colorado.
- Location
- 195 Freestone Rd, Eagle, Colorado 81631
- CMS Provider Number
- 065420
- Inspections on file
- 16
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Castle Peak Senior Life And Rehabilitation during CMS and state inspections, most recent first.
A resident with cognitive impairment and documented visual deficits requested very hot tea, which a PTA dispensed from a hot beverage machine and then further heated in a microwave, contrary to facility policy prohibiting reheating of facility-provided drinks. The PTA secured a lid on the cup and placed it at the bedside. Due to visual impairment, the resident could not locate the drinking opening, attempted to remove the lid independently, and spilled the hot liquid onto an arm and thigh, sustaining second-degree partial thickness burns over approximately 6% TBSA. Nursing and NP assessments documented bright red, blanchable burns with blistering and subsequent healing, and staff interviews confirmed that the beverage had been overheated and that the resident’s visual impairment and lack of appropriate supervision and adaptive equipment contributed to the accident.
A resident with CVA-related left-sided hemiplegia, who used a wheelchair and was cognitively intact, was moved to a different room after reporting strong chemical odors and refusing to return to the original room. Facility policy stated that staff would assist with packing and unpacking belongings for room changes, and staff reported that environmental services, nursing, or maintenance typically helped move items. In this case, however, staff repeatedly told the resident they could not move her belongings and would only escort her while she attempted to move them herself, despite her physical limitations. The NHA communicated by email that, due to prior disputes about handling of personal property, the resident was responsible for arranging family or third-party movers at her own expense, while staff would only provide access and oversight. As a result, most of the resident’s personal items remained in the original room for an extended period after she agreed to the permanent room change.
A resident with a history of CVA, left-sided hemiplegia, and behavioral symptoms reported that the DON confronted her during a room-move, stood in a confrontational posture, argued with her about moving her own belongings despite her physical limitations, raised her voice, and mocked her request for written communication and her disabilities. The resident emailed the NHA with a recording and written statement, later stating she felt the DON’s behavior was verbally abusive. The NHA reviewed the recording and statements, consulted with corporate staff, and concluded the allegation was not substantiated, and therefore did not report the resident’s abuse allegation to the State Agency, contrary to the facility’s occurrence reporting policy requiring all abuse allegations to be reported within specified time frames.
A resident with CVA-related left-sided hemiparesis and a history of behavioral symptoms alleged that the DON verbally abused and mocked her during a heated argument about moving her belongings to a new room, after she had requested assistance as an accommodation and asked that communication occur in writing. The resident reported feeling cornered and provoked, provided an audio recording and written statement to the NHA, and described the DON’s behavior as verbally abusive. The DON also emailed her account of the incident, and an RN was present during the exchange. However, the facility did not document a thorough abuse investigation as required by its policy: there was no detailed interview of the resident, no documented, substantive interview of the RN, no interviews with other staff or residents, no documented review and analysis of the audio recording, and no comprehensive written investigation findings, resulting in a deficiency for failure to thoroughly investigate an abuse allegation.
A resident was transferred or discharged without the facility ensuring that their needs and preferences were met, and without adequate preparation for a safe transition.
A resident with cognitive impairment and a history of elopement was placed on a wanderguard and moved to a secured memory care unit without continuous physician orders and without obtaining consent from the resident’s representative. The resident’s opportunities for preferred activities, such as walking and going outside, were limited, and documentation of activity participation was inconsistent. Staff interviews confirmed that required orders and consent processes were not properly followed.
Two residents experienced severe weight loss due to the facility's failure to implement timely nutritional interventions. One resident with dementia lost 18.6 pounds in a month, while another with GERD and thyroid disorder lost 8 pounds. The facility discontinued nutritional supplements without addressing the weight loss, and staff interviews revealed a lack of awareness and action regarding the residents' nutritional needs.
A resident in a memory care unit slapped another resident due to a lack of personal space, and the facility failed to conduct a thorough investigation or implement timely interventions. Both residents had severe cognitive impairments, and the incident was not reported as abuse due to the lack of willful intent. However, the facility did not interview the residents or staff adequately, nor did it update care plans promptly to prevent future incidents.
A resident experienced an unwitnessed fall and the facility failed to take immediate vital signs as required by professional standards. Despite the care plan's directive, vital signs were not recorded until two days later. Staff interviews confirmed the necessity of immediate assessment, including vital signs, to ensure resident safety.
The facility failed to ensure that two residents were free from unnecessary psychotropic medications. Both residents were prescribed Haloperidol without a stop date, and the medication was used on an as-needed basis for over 14 days without proper documentation. The medical director and director of nursing acknowledged the error, noting that as-needed psychotropic medications should have a maximum prescribing time of 14 days.
A resident with otitis externa did not receive prescribed cortisporin ear drops due to a delay in delivery from an out-of-town pharmacy. The resident experienced pain and was mistakenly given a discontinued antibiotic instead. The facility failed to notify the physician of the missed doses, and the error was not identified until later, highlighting a breakdown in communication and adherence to medication administration policies.
Burn Injury from Improperly Heated Hot Beverage and Inadequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from accident hazards and received adequate supervision when provided a hot beverage. A resident with diagnoses including a displaced intertrochanteric fracture of the left femur with routine healing, unspecified cataract, unspecified macular degeneration, disorientation, and restlessness and agitation requested very hot tea. The resident had moderate cognitive impairment with a BIMS score of 11 and was care planned as needing set-up assistance with eating and drinking. Although an MDS assessment indicated adequate vision without corrective lenses, subsequent care planning documented vision impairment related to cataracts, macular degeneration, and diplopia, and that the resident wore an eye patch and glasses. On the day of the incident, the resident asked a physical therapy assistant (PTA) to make her tea “very hot.” The PTA dispensed hot water for tea from the kitchenette coffee machine and then heated the beverage in a microwave for an additional 30 seconds at the resident’s request. The PTA then secured a lid on the cup and placed it on the resident’s bedside table. The facility’s Hot Beverage policy, in effect at the time, stated that hot beverages were to be served at a safe, palatable temperature, that hot beverage machines were to be set and maintained at manufacturer-recommended temperatures, and that microwaves were not to be used to reheat hot beverages if the temperature was not considered palatable; instead, a fresh cup was to be poured. The policy also directed staff to report safety or decline in managing hot beverages to the IDT or therapy for review and possible care plan updates. After the PTA placed the lidded cup at the bedside, the visually impaired resident attempted to drink the tea but could not locate the opening in the lid due to her macular degeneration. The resident then attempted to remove the lid independently, during which the hot tea spilled onto her right forearm and right posterior thigh. Nursing assessment documented bright red, blanchable burns with a broken blister on the arm, and measurements of 8 cm by 5 cm on the arm and 12 cm by 22 cm on the thigh. The NP assessed the injuries as second-degree partial thickness burns involving approximately 6% total body surface area, with the resident reporting pain of 3 out of 10 and denying numbness, tingling, fevers, or chills. Subsequent documentation showed the wounds progressing with scabbing and epithelial tissue formation prior to the resident’s discharge home. Staff interviews confirmed that, following the incident, it was recognized that the tea had been heated beyond the temperature at which it was dispensed from the coffee machine and that the resident’s impaired vision contributed to her difficulty using the standard lidded cup. The DON and RN stated that the PTA had reheated the tea in the microwave without checking the temperature and then served it to the resident, contrary to the facility’s policy prohibiting reheating of facility-provided drinks in microwaves. The dietary manager and nursing staff also indicated that the facility’s practice was to avoid reheating hot beverages and to rely on the coffee machine settings, which were kept at or below 160°F, rather than using microwaves for additional heating. These actions and inactions led to the resident being provided an excessively hot beverage in a manner that did not account for her visual impairment, resulting in the burn injury. The facility’s failure centered on not adhering to its own Hot Beverage policy and not adequately supervising or accommodating the resident’s known visual impairment when providing a very hot beverage. The PTA’s use of the microwave to further heat the tea, the absence of a temperature check before serving, and the placement of a standard lid that the visually impaired resident could not safely manage independently all contributed to the incident. The care plan at the time identified the resident as needing set-up assistance and, after the incident, was updated to include interventions such as encouraging the resident to leave lids on hot beverages and to use the call light for assistance with lids, indicating that these precautions were not in place or not implemented at the time of the burn event.
Failure to Provide Timely Assistance With Resident Room-Change Belongings
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences during a room change, specifically by not providing timely assistance with moving the resident’s personal belongings. The facility’s Room Change policy, revised April 2025, states that environmental services staff or a designee will assist residents to pack their belongings prior to a room change, and nursing staff will assist residents to unpack belongings and get settled into the new room. The policy does not specify who will physically move the belongings between rooms, but staff interviews indicated an expectation that environmental services, nursing, or maintenance staff would typically assist with moving items or furniture. The resident involved was under age 65 and had multiple diagnoses, including CVA with left-sided hemiparesis and spastic hemiplegia, coronary artery disease, hyperlipidemia, depression, ADHD, lower back pain, and muscle weakness. The resident was cognitively intact with a BIMS score of 15, used a wheelchair for mobility, and was independent with hygiene, toileting, bathing, and dressing, but required setup and cleanup assistance with eating. The resident had documented verbal behavioral symptoms such as yelling and cursing, and a behavior care plan that included communicating via email and following up on concerns in a timely manner. The resident reported irritation of the nose and eyes and refused to return to her original room after complaining of a strong smell of ammonia and bleach, and staff assisted her into another room that night so she could sleep. Following this move, the resident requested assistance from staff to bring toiletries, a plant, and other personal items from the original room to the new room. Progress notes documented that staff told the resident they were not allowed to move her belongings and could only accompany her while she moved them herself, despite her left-sided hemiplegia and inability to move the items independently. The resident stated she was told she needed to move the items herself or arrange for someone else to move them and that she felt she should not have to pay to move her own items because the facility had offered the room change. Email communications show that the NHA characterized the room change as an accommodation requested by the resident and informed her that, due to prior concerns about staff handling her property, her belongings should be moved by family, an authorized representative, or a third-party mover at her own expense, with staff only providing access and oversight. The resident agreed to permanently move to the new room, but most of her belongings remained in the previous room, and staff continued to only escort her to retrieve items herself. Staff interviews confirmed that, in typical room changes, families or staff would assist with moving belongings, and that in this case the facility did not expect the resident to move her own items but also did not provide direct assistance or documented resources for moving services. The permanent move of the resident’s belongings did not occur until 39 days after she agreed to the room transfer, during which time the majority of her personal items remained in the original room.
Failure to Report Resident’s Verbal Abuse Allegation Involving DON
Penalty
Summary
The deficiency involves the facility’s failure to report an allegation of verbal abuse to the State Agency as required by its own policy and federal regulations. The facility’s Occurrence Reporting–Vulnerable Adult policy, revised in October 2022, requires all alleged violations and substantiated incidents involving abuse, neglect, exploitation, mistreatment, injuries of unknown origin, or misappropriation of resident property to be reported immediately, but no later than two hours if abuse or serious bodily injury is involved, or within 24 hours if not. Despite this policy, an allegation by a resident that the DON had been verbally abusive was not reported to the State Agency. The resident involved was under age 65 and had multiple diagnoses, including CVA (stroke), hemiparesis, spastic hemiplegia of the left side, coronary artery disease, hyperlipidemia, depression, ADHD, lower back pain, and muscle weakness. A recent MDS assessment documented that the resident was cognitively intact with a BIMS score of 15/15 and exhibited verbal behavioral symptoms such as yelling and cursing. The resident was independent in most ADLs, used a wheelchair for mobility, and had a behavior care plan addressing yelling and inappropriate language, as well as an abuse prevention care plan noting risk for abuse or neglect and the ability to report suspected abuse. On the evening in question, the DON went to the resident’s room to oversee the move of facility-provided furniture to a new room. According to the resident’s interview and emails, the DON stood between the resident and the door with hands on hips, told the resident that staff would move only facility furniture and that the resident must move personal belongings, and argued with the resident when the resident stated she could not move her items due to left-sided paralysis. The resident reported feeling cornered, mocked, and provoked, and stated that the DON repeatedly demanded to know if she would move her belongings, raised her voice, and mocked the resident’s request for written communication and disabilities. The resident emailed the NHA that evening with a recording and written statement, stating she felt mocked and provoked, and the following morning explicitly stated she felt the DON’s behavior was verbally abusive. The NHA received emails from both the resident and the DON describing the argument and reviewed the resident’s audio recording and written statements from the resident and the DON. The NHA also spoke with an RN who had been present and involved corporate personnel in reviewing the materials. After this internal review, the NHA, regional corporate director, and corporate compliance officer concluded that verbal abuse was not substantiated. Based on that conclusion, the NHA did not report the resident’s allegation of abuse to the State Agency. The NHA stated she believed that because she had already investigated and decided the allegation was not substantiated, she did not need to report it, resulting in the facility’s failure to report an allegation of verbal abuse as required by policy and regulation.
Failure to Thoroughly Investigate Resident’s Verbal Abuse Allegation Against DON
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate an allegation of verbal abuse made by a cognitively intact resident against the DON, as required by the facility’s Occurrence Reporting–Vulnerable Adult policy. That policy directed that all suspected or alleged abuse be promptly and thoroughly investigated, including private interviews with the reporter, the alleged victim, the alleged perpetrator, and potential witnesses, as well as documentation of the investigation results. In this case, the resident, who had a history of CVA with left-sided hemiparesis and spastic hemiplegia, depression, ADHD, and other conditions, reported feeling verbally abused and mocked by the DON during an argument related to moving her belongings to a new room. The resident had a BIMS score of 15, was cognitively intact, and had an abuse prevention care plan indicating she was able to report suspected abuse. On the evening in question, the resident had arranged via email with the NHA for assistance moving to a new room, stating she was not physically able to move her belongings and needed help as an accommodation. The resident reported that no one came to her room at the agreed time, later learning the DON had been waiting in the hallway. When the DON and an RN entered the room, the resident stated that the DON stood between her and the door with hands on her hips, told her staff would move only facility-provided furniture, and insisted the resident move her own personal belongings despite her left-sided paralysis. The resident described feeling cornered and provoked, and reported that the interaction escalated into both parties talking over each other and yelling. She stated that when she requested communication in writing, the DON repeatedly asked if she was going to move her belongings and mocked her request, including questioning whether she could hear, which the resident perceived as demeaning and mocking of her disabilities. The resident emailed the NHA that evening with a recording of the argument and a written statement, stating she felt mocked and provoked by the DON and describing the DON’s behavior as verbally abusive. The DON also emailed the NHA summarizing the encounter, acknowledging that she repeatedly asked the resident if she was going to move that night and that the conversation became louder as they talked over each other. The NHA later stated she listened to the audio recording, reviewed the written statements from both the resident and the DON, and spoke with the RN who was present, but there was no documentation of these investigative steps. The only written follow-up in the record was a brief statement that the RN confirmed he was present and had nothing to add to the DON’s email; there was no documentation of specific questions asked of him, no documented interview of the resident about the incident, no interviews with other residents regarding their interactions with the DON, and no interviews with other staff to determine if anyone overheard the incident. Additionally, despite the resident explicitly stating she felt verbally abused, the allegation was not reported to the State Agency, and the facility could not produce documentation showing that a thorough investigation consistent with its abuse policy and investigation checklist was completed at the time of the allegation. The NHA acknowledged that she did not conduct an in-person interview with the resident, stating that the resident’s written statement served as the interview, and that she did not pursue additional interviews with other staff or residents because, after internal review with corporate personnel, they did not substantiate the event as verbal abuse. The DON, who had experience with other abuse investigations and was aware that terms such as “intimidated” or “provoked” should prompt further inquiry, stated she documented her recollection and later listened to the audio with the NHA, but again, no contemporaneous documentation of these steps was available. Review of the resident’s EMR and email correspondence revealed no additional investigation notes or follow-up communication with the resident regarding her abuse claim. As a result, the facility lacked documentation of a prompt, thorough investigation as required by its own policy, including the absence of detailed interviews, witness statements, and analysis of the audio recording, leading to the cited deficiency for failure to thoroughly investigate an allegation of verbal abuse.
Failure to Ensure Safe and Resident-Centered Transfer/Discharge
Penalty
Summary
The facility failed to ensure that the transfer or discharge process met the resident's needs and preferences, and did not adequately prepare the resident for a safe transfer or discharge. The report notes that the necessary steps to assess and address the resident's individual requirements and preferences during the transfer or discharge process were not completed. As a result, the resident was not properly prepared for a safe transition to the next care setting.
Failure to Obtain Physician Orders and Consent for Use of Wanderguard and Secured Unit Placement
Penalty
Summary
The facility failed to ensure that a resident was free from the use of physical restraints except as required for medical treatment, as evidenced by the use of a wanderguard and placement in a secured memory care unit without proper physician orders and without obtaining consent from the resident’s representative. The resident, who had diagnoses including Parkinson’s disease, unspecified dementia, Alzheimer’s disease, and anxiety disorder, was cognitively impaired but valued independence and outdoor activities. After an elopement incident, the facility placed a wanderguard on the resident and moved him to the secured unit during the day, but did not have a continuous physician’s order for the device, and the order that was present was only for a single day. The resident continued to wear the wanderguard for an extended period without appropriate orders, and documentation of the device’s use was inconsistent with the resident’s actual status. The facility also failed to obtain consent from the resident’s representative or power of attorney before moving the resident to the secured memory care unit, which restricted his ability to participate in activities that were important to him, such as walking and going outside. Both the resident’s representative and POA expressed concerns that the move was made without their agreement and that the resident was not assessed for the appropriateness of the secured unit. The representative noted that the resident was not provided with personalized activities and that his opportunities for walks and outdoor activities were limited, despite these being identified as very important to him in his care plan and activity assessments. Documentation and staff interviews revealed that the resident’s participation in preferred activities was sporadic and not consistently offered or recorded. Nursing and activity records showed limited engagement in walks and other activities, and there were instances where the resident requested walks but was not accommodated. Staff interviews confirmed that the wanderguard was used as an intervention prior to placement in the secured unit, but the required physician orders and consent processes were not properly followed, leading to the deficiency.
Failure to Address Severe Weight Loss in Residents
Penalty
Summary
The facility failed to ensure adequate nutritional care for two residents, leading to severe weight loss. Resident #10, admitted with dementia, stroke, and seizure disorder, experienced a significant weight loss of 18.6 pounds (12.8%) from July 30, 2024, to August 27, 2024. Despite this severe weight loss, the facility did not implement timely or effective nutritional interventions. Observations revealed that Resident #10 was not offered alternative food options during meals, and the care plan lacked updated interventions to address the weight loss. Resident #35, diagnosed with GERD, arthritis, and a thyroid disorder, also experienced severe weight loss. The resident lost 8 pounds (7%) from August 6, 2024, to September 10, 2024. The facility discontinued the resident's oral nutritional supplement due to perceived weight gain, despite evidence of weight loss. The care plan did not reflect any new interventions to address the resident's nutritional needs after the weight loss was identified. Interviews with staff, including a registered dietitian and the director of nursing, highlighted a lack of awareness and action regarding the residents' weight loss. The dietitian did not expect the nutritional plan to be updated for weight loss and was unaware of interventions for Resident #10. The director of nursing acknowledged discrepancies in documentation and the failure to identify Resident #35 as at risk in the nutrition committee. These oversights contributed to the facility's inability to provide necessary nutritional care for the residents.
Failure to Prevent Resident-to-Resident Altercation
Penalty
Summary
The facility failed to protect a resident from abuse, specifically failing to prevent one resident from slapping another. The incident involved two residents in the memory care unit, both with severe cognitive impairments and dementia. Resident #22 slapped Resident #23 on the hand in the dining room after Resident #23 got too close to her belongings. The facility's investigation determined that the action was not willful harm due to Resident #22's dementia, and no physical injury or psychological harm was noted for Resident #23. The facility's investigation into the incident was incomplete. It did not include interviews with the involved residents to assess their feelings of safety, nor did it involve interviews with other residents or staff members to gather additional insights or concerns about potential abuse. The investigation also lacked documentation of what the residents were doing before the altercation and whether staff attempted to redirect them prior to the incident. The care plans for both residents were reviewed, but no new interventions were put in place for Resident #23 to prevent future altercations. The facility's policy required thorough investigations and the development of interventions to prevent further occurrences, but these steps were not adequately followed. The facility's response to the incident, including behavior monitoring and staff communication, was delayed and insufficient, as noted by the lack of immediate documentation and follow-up actions.
Failure to Conduct Immediate Post-Fall Assessment
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice following an unwitnessed fall. Specifically, the facility did not take the resident's vital signs immediately after the fall, which is a critical step in post-fall assessment as per professional nursing standards. The resident, who was under 65 years old and had diagnoses including hypertension, renal insufficiency, and COPD, was found sitting on the floor in her bathroom with pain in her coccyx. Despite the fall care plan requiring vital signs to be checked after a fall, the facility did not record the resident's vital signs until two days later. Interviews with staff, including an LPN, the director of rehabilitation, a CNA, and the DON, confirmed that the standard procedure following a fall is to assess the resident immediately, including taking vital signs. The DON emphasized the importance of obtaining vital signs to rule out causes such as low blood pressure or heart rate. However, the fall report for the resident did not include any documentation of vital signs being taken immediately after the fall, indicating a lapse in following the established care plan and professional standards.
Failure to Ensure Stop Dates for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that two residents were free from unnecessary psychotropic medications, as required by their policy. Resident #14, who had moderate cognitive impairments and was dependent on staff for daily activities, was prescribed Haloperidol without a stop date, and the medication was used on an as-needed basis for over 14 days without proper documentation from a physician. Similarly, Resident #37, who had severe cognitive impairments and required assistance with daily activities, was also prescribed Haloperidol without a stop date, and the medication was used on an as-needed basis for over 14 days without appropriate documentation. The medical director acknowledged that as-needed psychotropic medications should have a maximum prescribing time of 14 days and admitted that the orders for both residents were incorrect as they lacked stop dates. The director of nursing confirmed that as-needed psychotropic medications cannot be ordered for more than 14 days. The failure to include stop dates for these medications led to the deficiency, as it did not align with the facility's policy and the regulatory requirements for prescribing psychotropic medications.
Significant Medication Error Due to Delayed Delivery and Incorrect Administration
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of antibiotics. The resident, who was over 65 years old and had diagnoses including chronic obstructive pulmonary disease and otitis externa, was supposed to receive cortisporin ear drops for an ear infection. However, the medication was not administered as ordered due to a delay in delivery from an out-of-town pharmacy. The resident did not receive the prescribed antibiotic on the scheduled dates, and there was no documentation indicating that the physician was notified of the missed doses. The resident reported experiencing ear pain over the weekend and had to request pain relief medication. Despite the physician's order for cortisporin ear drops, the medication was not available until several days later. During this period, the resident was mistakenly given a discontinued antibiotic, neomycin-polymyxin ear drops, instead of the prescribed cortisporin. This error occurred because the discontinued medication was not removed from the medication cart, leading to the administration of the wrong antibiotic. Interviews with staff revealed a lack of communication and documentation regarding the delay in medication delivery and the administration of the incorrect antibiotic. The Director of Nursing (DON) was not informed of the medication delay or the administration error until after the fact. The facility's policies on medication administration and physician notification were not followed, contributing to the significant medication error experienced by the resident.
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A resident with severe dementia, hallucinations, delusions, and chronic pain, who was independent with mobility and at risk for wandering, was struck in the face by another cognitively impaired resident known to exhibit verbal and physical aggression and to be highly protective of her room. An RN heard a commotion, saw the victim outside the aggressor’s room, and attempted to intervene but witnessed the aggressor hit the victim before reaching them, resulting in a lip laceration and bruise. The aggressor’s care plan noted use of a doorway stop sign or closed door and the need to redirect others away from her room, but she often refused these measures. At the time of the incident, only one CNA and one nurse were on the memory care unit due to an unfilled CNA call-in, and staff reported it was difficult to manage when two CNAs were not present. The facility investigation substantiated the event as abuse and identified that both residents may have had increased pain contributing to agitation before the altercation.
A resident with severe cognitive impairment and multiple chronic conditions intentionally slid from a wheelchair to sit on the floor and refused assistance to return to the chair. An LPN directed two CNAs to place a blanket under the resident and drag the resident across the floor, onto an elevator, and to another floor, rather than allowing the resident to remain seated on the floor as requested. The resident later reported trying to resist and stated dislike of the experience. Documentation by the LPN omitted how the resident was actually moved between floors, despite care plan goals for dignity and autonomy and a facility policy requiring residents be treated with dignity and respect and that their choices and preferences be honored.
Surveyors found that staff repeatedly failed to follow hand hygiene and Enhanced Barrier Precautions (EBP) requirements. CNAs and an LPN provided direct care, including incontinence care, use of a mechanical lift sling, and gastric tube feeding, without performing hand hygiene before or after care and without using required gowns for residents on EBP. One CNA handled a soiled lift sling, touched his hair and face, used a touchscreen to document care, and then assisted another resident without cleaning his hands. Another CNA entered an EBP room wearing only gloves, not a gown, and did not perform hand hygiene after removing gloves. An LPN handled a feeding tube and provided care to residents on EBP without hand hygiene or gown use. A resident’s representative reported seeing staff work with a feeding tube without gloves or a gown, while staff interviews and facility policy described correct practices that were not followed in practice.
A resident with severe cognitive impairment and multiple serious diagnoses had a physician-appointed health care proxy who reported that the facility did not inform her when the resident’s condition changed or when an antibiotic was started, and that her calls were not returned for days. Another representative for the same resident stated that calls went to a general voicemail and were rarely or very slowly returned. Grievance records documented repeated concerns about delayed communication, lack of notification about new medications, and difficulty reaching staff. Other residents’ representatives similarly reported that calls to check on residents or report suspected verbal abuse went to voicemail and were returned late or not at all, while staff acknowledged that calls often went to voicemail and that several calls from representatives were missed or delayed.
The facility failed to investigate an allegation of verbal abuse and threats between two cognitively impaired roommates after a family member, who was on the phone with one resident, reported hearing the other resident yelling loudly and making threats. The resident’s representative could not reach staff by phone and contacted EMS, which responded to the facility, yet no investigation or documentation of the altercation, alleged threats, or EMS involvement was found in either resident’s record. Staff acknowledged loud yelling and arguing and initiated a room change, but the RN did not fully inform the DON, the SSD—who was not present—dismissed the event as a simple argument, and the NHA did not treat or report it as abuse, contrary to facility policies requiring identification, investigation, and reporting of possible verbal or mental abuse by other residents.
Unsafe food handling and kitchen sanitation practices were observed in the dining room and main kitchen. Staff handled ready-to-eat foods with bare hands, failed to wash hands between tasks and after bathroom use, and touched food, dishes, and meal tickets while plating and serving meals. The facility also kept moldy croissants in dry storage, used a pencil to prop up a hood drip pan, and allowed a dietary aide with artificial nails and multiple bracelets to serve residents.
The facility failed to maintain and document safe food temperatures during meal service, resulting in cold foods being held and served within the temperature danger zone and incomplete temperature logs on multiple days. During a lunch service observation, various forms of chicken salad were held at 45–55°F, yet plates were assembled and sent out, and a resident reported that meals delivered to the room were always cold and often not eaten. Staff interviews showed inconsistent understanding of required hot and cold holding temperatures and confirmed that temperature logs were sometimes not completed as required.
Failure to Honor Residents’ Choice of Attending Physician: Three cognitively intact residents said they were not allowed to choose their own attending physician and were required to see the facility MD instead. EMR and admission agreement review showed no documentation that they were offered a choice of physician, despite one resident wanting to continue with a community PCP. The NHA stated residents could choose their attending physician, but also said the facility had only one physician available for residents to choose from.
Psychotropic Medication Documentation and PRN Behavior Monitoring Deficiencies Survey review found that several residents had psychotropic medications ordered without documented physician rationale, resident-specific target behaviors, or individualized non-pharmacological interventions. Generic behavior-monitoring orders were used instead of approaches tied to each resident’s history, interests, and identified behaviors, and one resident’s PRN antipsychotic was administered multiple times without documentation of attempted non-pharmacological interventions before use. The EMR also showed notes of stability or no unwanted behaviors for some residents, yet the records still lacked rationale supporting continued psychotropic treatment.
Failure to Address Suicidal Ideation and Individualized Psychosocial Needs: The facility did not adequately address suicidal statements, trauma-related needs, or individualized behavioral interventions for multiple residents. One resident with dementia, anxiety, and PTSD made a suicidal threat, but the record did not show ongoing safety monitoring or documented follow-up. Another resident with PTSD, depression, and a history of trauma and suicide attempts had ongoing depressive symptoms, but the care plan and orders did not reflect the PASRR-identified need for therapeutic support, psychiatric oversight, coping skills, or a safety plan. A third resident with autism and mood disturbance had inappropriate sexual behavior toward the DON, but the care plan was not updated with person-centered interventions specific to that behavior.
Failure to Prevent Resident-to-Resident Physical Abuse on Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. On the date of the incident, an RN heard a commotion in the hallway outside the alleged assailant’s room and observed that resident strike another resident, causing the victim’s lip to bleed. The RN had seen both residents near the medication cart a few minutes earlier without concern and attempted to intervene when she saw the victim standing outside the assailant’s room, but was unable to reach them before the strike occurred. The two residents were then separated, and frequent checks were initiated. The victim was a younger-than-65 resident with vascular dementia (severe, with agitation), Alzheimer’s disease, Lewy body disease, bipolar disorder, and chronic pain. Her MDS showed short- and long-term memory problems, hallucinations, delusions, and physical and verbal behaviors toward others, with moderately impaired cognition and impaired decision-making. She was independent with mobility and had a care plan for wandering and dementia that identified her as pleasantly confused and easily redirected, with interventions to identify wandering patterns, offer diversions, and assess for pain or toileting needs when agitated. Documentation on the day of the incident noted her involvement in a resident-to-resident altercation, a small laceration to the middle of her upper lip, and a small bruise below her lower lip. The assailant was an older resident with severe vascular dementia with agitation, memory deficit after intracranial hemorrhage, and recurrent depressive disorder. Her MDS documented short- and long-term memory problems, fluctuating disorganized thinking, and verbal behaviors directed toward others that could significantly intrude on others’ privacy or disrupt the environment. Her behavior/dementia care plan identified verbal aggression (yelling/screaming), physical aggression (hitting), refusal of care, withdrawal, tearfulness, and negative statements, and noted that she was protective of her room and became upset if others entered or tried to enter. The care plan included use of a velcro stop sign across her doorway or keeping her door closed, but also documented that she often declined having the door closed, requiring staff to redirect other residents away from her room. Staff statements indicated that at the time of the incident there was one CNA and one nurse on the memory care unit, that one CNA had called in and was not replaced, and that it was hard when there were not two CNAs on the unit. The facility’s investigation substantiated the incident as abuse and identified that both residents may have been experiencing increased pain leading up to the altercation, with pain, constipation, and urinary retention noted as contributing factors for the victim and hand contracture pain and refusal of interventions noted for the assailant.
Resident Dragged on Blanket Instead of Honoring Request to Sit on Floor
Penalty
Summary
The deficiency involves a failure to honor a resident’s right to dignity and self-determination when staff did not allow the resident to remain seated on the floor per his wishes and instead dragged him on a blanket between floors. Late at night, the resident, who lived on the second floor, was in his wheelchair on the first floor and intentionally slid out of his wheelchair to sit on the ground according to his own wishes. When staff offered assistance to help him back into his wheelchair, he refused. Despite this refusal, an LPN directed two CNAs to move the resident from the first floor back to the second floor. Following the resident’s refusal to get back into his wheelchair, the LPN instructed the CNAs to place a blanket underneath the resident so he could be dragged while lying on it. The CNAs and the LPN maneuvered the blanket under the resident by moving him from side to side. One CNA positioned herself behind the resident and placed her arms under his armpits, while the other CNA held the resident’s pants at his ankles. The LPN then pulled on the blanket with the resident on it. Together, the three staff members dragged the resident on the blanket across the floor and onto the elevator, transported him to the second floor, and then dragged him off the elevator onto the second floor hallway. Once on the second floor, the resident agreed to have two staff members assist him back into his wheelchair, and a two-person transfer was performed to lift him from the floor into the chair. The resident later reported that he remembered being pulled on the blanket, stated that he "tried to fight them like crazy," and said he did not like what had been done. The nursing progress note written by the LPN the following morning documented that the resident had remained on the first floor until late at night, refused to talk with staff, refused care, and declined snacks, fluids, and redirection, but the note did not document how he was actually relocated to the second floor. The resident’s records showed he had severe cognitive impairment with a BIMS score of 3/15, diagnoses including Parkinson’s disease, depression, unspecified intellectual disabilities, traumatic brain injury, seizures, and chronic kidney disease stage 3, and care plan goals that included being treated with dignity and autonomy. The facility’s dignity policy stated that residents are to be treated with dignity and respect at all times, that their choices and preferences are to be honored, and that demeaning practices are prohibited, which was not followed in this incident.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to hand hygiene and adherence to Enhanced Barrier Precautions (EBP) on all four units. The facility’s own policies require hand hygiene before and after direct patient care and the use of gowns and gloves during high-contact care activities for residents on EBP. CDC guidance cited in the report emphasizes that hand hygiene protects both healthcare personnel and patients, and that EBP requires targeted gown and glove use during high-contact resident care activities, particularly for residents with wounds, indwelling devices, or MDRO colonization or infection. Surveyors observed multiple instances where staff did not follow these requirements. An unidentified CNA exited a room of a resident on EBP without wearing a gown while providing care. On another occasion, a CNA exited a resident’s room carrying a soiled mechanical lift sling without gloves, failed to perform hand hygiene, touched his hair and face, used a touchscreen to document care, and then entered another resident’s room to answer a call light and assist with a request without performing hand hygiene before or after assisting that resident. Another CNA entered the room of a resident on EBP, donned only gloves without a gown, provided incontinence care, then left the room with soiled linens and trash properly disposed of, removed gloves, but did not perform hand hygiene before caring for another resident. Additional observations showed an LPN entering the room of a resident on EBP for gastric tube feeding, setting up and handling the feeding tube without performing hand hygiene beforehand and without wearing a gown. The same LPN later entered another EBP room, provided care, and left without performing hand hygiene. A resident’s representative reported seeing staff work with the resident’s feeding tube without gloves or a gown. In interviews, CNAs and nursing staff described correct hand hygiene and EBP practices, including washing hands for about 20 seconds and using gowns and gloves for residents on EBP, and the DON stated she expected staff to perform hand hygiene when entering and exiting rooms and to follow EBP procedures requiring gown and glove use. These stated practices conflicted with the observed failures in hand hygiene and EBP adherence documented by surveyors.
Failure to Notify Health Care Proxy and Return Calls Regarding Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to inform a resident’s physician-appointed health care proxy of changes in the resident’s condition and new treatments, and to return the proxy’s calls in a timely manner. Facility policy on Notification of Changes required informing the resident, consulting with the physician, and notifying the family member or legal representative when there was a change requiring such notification, and specified that when residents were incapable of making their own decisions, the representative would make necessary decisions. Resident #1 was under 65, admitted with diagnoses including paralysis and weakness following a stroke, respiratory failure, cognitive communication deficit, and encephalopathy, and was documented as severely cognitively impaired with a BIMS score of 0/15, indicating reliance on the health care proxy for decision-making. The health care proxy reported that the facility made it very difficult to contact the resident, stating that staff did not return calls for days and that she was not informed when the resident developed an infection and was started on an antibiotic until after the medication had already been initiated. She stated she had several questions about the medication and was not consulted on the medical decision prior to its start. Another representative reported that calls to the facility went to a general voicemail and that her messages were either not returned or took several days for a response. Grievance records showed repeated concerns from the resident’s representatives about delays in speaking with the resident, delays in return calls, and lack of notification about new medications and changes in condition. Additional interviews with other residents’ representatives supported a broader pattern of delayed or absent communication. One representative of another resident reported that his call to check on a newly admitted resident went to voicemail and was not returned for two days. Another resident’s representative and a secondary witness reported that when they attempted to report suspected verbal abuse, their calls to the facility and to the SSD went to voicemail and were never returned. Staff interviews confirmed that calls first went to the front desk and then to the nurses’ stations, that calls often went to voicemail when nurses were unable to answer, and that voicemail messages were expected to be returned within 24 hours. The NHA acknowledged that several calls from the resident’s representatives went to voicemail and that calls were often made during shift change when it was harder to reach the nurse on duty, but there was no documentation to support the claimed regular communication with the health care proxy.
Failure to Investigate Alleged Verbal Abuse Between Cognitively Impaired Roommates
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of verbal abuse and threats between two cognitively impaired residents after a family member reported overhearing the incident. Facility policy on abuse, neglect, exploitation, and misappropriation requires that all possible incidents of abuse, including verbal and mental abuse by other residents, be identified, investigated, and reported within required timeframes, with residents protected from further harm during investigations. The policy on identifying types of abuse specifies that yelling or hovering over a resident with intent to intimidate is an example of mental and verbal abuse. Despite these policies, the facility did not initiate or document an investigation into a reported verbal altercation that included alleged threats. One resident, under age 65, with dysphagia, left-sided hemiplegia, attention and concentration deficit, delusional disorder, and major depressive disorder, had moderate cognitive impairment and was dependent on staff for most ADLs. He reported that he and his roommate yelled back and forth at each other after the roommate told him to “shut the [expletive],” but he did not recall the specific words used and denied any physical contact. His guardian stated that he later reported being fearful of his roommate after the incident. Another representative, who was on the phone with him during the event, reported hearing the roommate yelling loudly and making threats toward him, then hearing a nurse enter to calm the situation. This representative attempted to call the facility to report the yelling and threatening behavior, was sent to voicemail without a return call, and subsequently contacted emergency services. The roommate, an older resident with dementia, cognitive communication deficit, depression, and insomnia, also had moderate cognitive impairment and required staff assistance for most ADLs. He did not recall the incident, and his representative only learned of it the following day and was told it involved yelling about loud phone use. A review of both residents’ medical records revealed no documentation of the verbal altercation, the alleged threats, or related concerns, and no investigation documents were produced when requested. Staff interviews confirmed there had been loud yelling and arguing, that EMS responded to the facility, and that a room change was initiated due to the incident, but the RN who responded did not report the EMS involvement to the DON. The SSD, who was not present during the incident, characterized it as just an argument and stated there were no threats, and the NHA stated the event was not reported as abuse because they believed no threats were made. No contemporaneous interviews with the residents were documented, and no inquiry was made by facility staff into why EMS had been called in relation to the altercation, resulting in a failure to investigate the allegation of verbal abuse as required by facility policy.
Unsafe Food Handling and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the main kitchen and dining areas. During meal service observations, staff repeatedly handled ready-to-eat foods with bare hands and did not perform hand hygiene when changing tasks, after touching dirty dishes, after using the bathroom, or before serving food. An LPN cut a resident’s patty melt and handed pieces to the resident with her bare hand without sanitizing her hands. A DA passed drinks by touching the rims of cups, and another DA tore a resident’s patty melt into smaller pieces with bare hands and handed food to the resident. During a later observation, kitchen staff continued to work without washing hands between tasks and while handling food, dishes, and meal tickets. A DA entered the kitchen from the dishroom and did not wash his hands before putting away snacks. A cook did not wash her hands after working at the sink, after touching dirty dishes, after exiting the bathroom in the kitchen, or before serving room trays. She was observed touching shrimp, corn bread, rice, squash, cheese, and frozen fries with bare hands while plating and preparing meals, and she also handled fryer baskets and food items without washing her hands. Another cook wiped her hands on her clothing, handled meal tickets, and touched ready-to-eat foods with bare hands while assembling plates and serving meals. The facility also failed to discard expired or spoiled food, maintain equipment in good repair, and prevent staff from wearing prohibited items while preparing or serving food. A plastic bag of croissants in dry storage contained bread-like food covered in dark green and black fuzz and remained on the bread rack on two separate observations. In the kitchen hood system above the grill, a half wooden pencil was being used to hold up the grease drip pan on two observations. In addition, a dietary aide taking meal orders, passing drinks, and serving meals had artificial nails approximately half an inch long and multiple fabric bracelets on her wrists while working with residents.
Failure to Maintain and Document Safe Food Temperatures During Meal Service
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner by not maintaining appropriate food temperatures during meal service and by not consistently documenting food temperatures as required. During a continuous observation of lunch meal service, chicken salad, including soft and bite-sized and pureed versions, was found on the steam table at temperatures of 55°F and 45°F, which were within the documented temperature danger zone and below the required cold-holding standard. Despite these temperatures, plates with wedge chicken salad and a Hawaiian roll were assembled and placed on the meal cart for service. A resident reported that meals delivered to his room were always cold, leading him not to eat them and to attempt to obtain food from outside the facility. Review of the facility’s April 2026 food temperature logs showed multiple instances where temperatures were not documented for breakfast, lunch, and dinner services on numerous dates. Staff interviews revealed inconsistent understanding and application of proper holding temperatures, with the cook and dietary manager providing varying temperature thresholds that did not align with the facility policy or the Colorado Retail Food Establishment Rules and Regulations. The cook acknowledged that the wedge chicken salad should not have been served at 55°F and attributed difficulty maintaining proper temperatures to a hot room with inadequate ventilation, while the dietary manager stated that cooks sometimes forgot to complete the temperature logs.
Failure to Honor Residents’ Choice of Attending Physician
Penalty
Summary
The facility failed to ensure three cognitively intact residents were allowed to choose their own attending physician. Resident #15, Resident #28, and Resident #30 each stated during a group interview that they did not have a choice in who their physician could be while in the facility and that they had to see the facility’s MD. Resident #15 said she had a primary care physician in town that she wanted to continue seeing, but she was told she could not see that physician. Resident #28 and Resident #30 each said they were required to see the facility’s MD instead of choosing their own physician. Record review for each of the three residents, including the admission agreement and EMR, showed no documentation that they were provided a choice of attending physician. Resident #15 had diagnoses including COPD, cirrhosis of the liver, and osteoarthritis, and her MDS showed she was cognitively intact with a BIMS score of 15. Resident #28 had diagnoses including type 2 diabetes mellitus, asthma, osteoarthritis, and TIA/cerebral infarction, and was also cognitively intact with a BIMS score of 15. Resident #30 had diagnoses including type 2 diabetes mellitus, wedge compression fracture of T11-T12 and L3, and hypertension, and his MDS likewise showed a BIMS score of 15. The NHA stated residents were able to choose their attending physician when admitted, but also said the facility had one physician residents could choose from and was not aware that these residents wanted different physicians.
Psychotropic Medication Documentation and PRN Behavior Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure four residents were free from unnecessary psychotropic medication use and chemical restraint concerns. Survey review found that the facility did not document a physician’s rationale for the continued use of psychotropic medications for three residents, did not document resident-specific care approaches with medication-specific target behaviors and person-centered interventions for those residents, and did not ensure one resident’s PRN antipsychotic use had corresponding documentation of identified behaviors and non-pharmacological interventions. For one resident with PTSD, anxiety, and depression, the record showed buspirone, Valium, duloxetine, and Lexapro orders with behavior-monitoring language, but the orders did not identify resident-specific non-pharmacological interventions for specific behaviors. The resident’s PASRR described a history of self-harm, suicidal thoughts, mood swings, loss of interest, and low energy, and recommended therapeutic interventions, coping skills, psychiatric oversight, increased socialization, and activities such as puzzles, games, and painting. The EMR review did not show documented behaviors during the review period, and it did not show a physician rationale to justify continued psychotropic use. For another resident with schizoaffective disorder, dementia, anxiety, and depression, the care plan and orders listed generic interventions and behavior targets such as screaming, hallucinations, kicking, and yelling, but the resident-specific behaviors and interests identified in the PASRR, including hearing the devil inside her head and being soothed by prayer and rosary use, were not incorporated into the behavior-monitoring orders or care plan. The record also lacked documentation of non-pharmacological interventions used for the resident’s behaviors and lacked a physician rationale for continued psychotropic use despite notes stating the resident was stable and not experiencing unwanted behaviors. A third resident with vascular dementia, anxiety, and PTSD had orders for Abilify, mirtazapine, sertraline, clonazepam, and behavior monitoring tied to verbal aggression, exit seeking, tearfulness, and hitting staff, but the orders remained generic and did not reflect the resident’s individualized approaches such as listening to 80’s rock music or watching a favorite program when crying or confused. The EMR again did not show a physician rationale for continued psychotropic use despite notes indicating pleasant mood and no unwanted behaviors. For the resident who died during the stay and had dementia and depression, the record showed Lexapro, Seroquel, and PRN injectable haloperidol ordered for behaviors such as swinging at staff and agitation. The PRN haloperidol order did not list a diagnosed specific condition, only behaviors, and the order for non-pharmacological interventions was not initiated until after the resident had already been receiving psychotropic medications. MAR and order administration notes showed multiple PRN haloperidol administrations, but several entries lacked documentation of attempted non-pharmacological interventions before the medication was given, and one note only documented encouragement to sit down without identifying the other ordered interventions or their effectiveness.
Failure to Address Suicidal Ideation and Individualized Psychosocial Needs
Penalty
Summary
The facility failed to ensure that residents with mental disorders, psychosocial adjustment difficulties, and trauma histories received appropriate treatment and services to support their mental and psychosocial well-being. For one resident with vascular dementia, anxiety, and PTSD, the record showed repeated depression screens indicating little interest, depressed mood, poor appetite, sleep problems, low energy, and feelings of worthlessness, along with notes describing chronic behaviors potentially causing harm, tearfulness, withdrawal, and anxiety. A behavior note documented that the resident stated she was going to kill herself, but the record did not show documented interventions to keep her safe afterward or ongoing monitoring for suicidal ideation. A second resident with PTSD, anxiety, depression, and a documented history of trauma, self-harm, suicidal thoughts, and numerous suicide attempts had a PASRR evaluation identifying the need for therapeutic interventions, psychiatric oversight, coping skills development, and a safety plan. The resident told staff she had previously seen a therapist at the facility, but that therapy had stopped and no new arrangements had been made. She also reported that staff had not asked about her PTSD triggers or what interventions would help her. The record showed depression screens with ongoing depressive symptoms, but no follow-up documentation after those screenings, and the care plan and physician orders did not reflect the resident’s suicidal history or the specialized services identified in the PASRR. The facility also failed to provide individualized care approaches for a resident with autistic disorder, dementia with mood disturbance, anxiety disorder, major depressive disorder, and cognitive communication deficit. The resident had a history of inappropriate sexual behaviors and was documented as having sexually inappropriate contact with the DON when he squeezed her breast during a dining activity. Although the resident was placed on 15-minute behavior monitoring for 24 hours, the care plan was not revised to reflect a person-centered intervention specific to that sexual behavior. Staff interviews showed that interventions were inconsistently understood and that the nursing staff did not know what person-centered interventions were in place for the resident’s behaviors.
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