Colorow Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Olathe, Colorado.
- Location
- 885 S Hwy 50 Business Loop, Olathe, Colorado 81425
- CMS Provider Number
- 065354
- Inspections on file
- 21
- Latest survey
- April 30, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Colorow Care Center during CMS and state inspections, most recent first.
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 cognitive impairment and agitation struck another resident following an episode of verbal agitation and intrusion into personal space. Staff were not present to witness the incident, and both residents had known behavioral triggers that were not fully addressed in their care plans. The event occurred without injuries, but the lack of supervision and incomplete care planning led to a failure to prevent physical abuse.
Multiple residents with severe cognitive and behavioral impairments were subjected to physical abuse by another resident with a history of unpredictable and escalating aggression. Despite individualized care plans and staff interventions, repeated altercations occurred in common areas, resulting in physical harm such as bruises and a skin tear. Staff and facility investigations confirmed the incidents, citing environmental overstimulation and challenges in redirecting the aggressive resident as contributing factors.
A resident was subjected to physical restraints without a documented medical necessity, in violation of regulations requiring that restraints only be used for medical treatment.
Multiple residents with cognitive impairments and behavioral issues were involved in repeated physical altercations, including pushing, slapping, and falls, with staff and other residents witnessing the events. Care plans did not consistently identify abuse risk or include timely interventions, and measures such as frequent checks did not prevent further incidents. Injuries and behavioral triggers were not always clearly documented or addressed, resulting in ongoing resident-to-resident abuse.
A resident with severe dementia and multiple care needs was found to have bruising and discoloration on her arms, which was documented by nursing staff on two occasions. Despite facility policy requiring immediate reporting and investigation of injuries of unknown origin, there was no evidence that the cause of the bruising was investigated or that abuse was ruled out. The NHA and DON were unaware of the injuries until after the fact, and no timely action was taken to determine how the injuries occurred.
A resident was hospitalized after being administered another resident's medications, including pregabalin and metoprolol, leading to cardiac dysrhythmia, hypotension, and bradycardia. The error occurred due to a failure in adhering to medication administration standards.
The facility failed to store, prepare, distribute, and serve food in a sanitary manner, including improper labeling of food items, incorrect cleaning of thermometers, and failure to maintain appropriate temperatures in refrigerators and freezers. Cold foods were not held at 41°F or below before serving residents.
The facility failed to address grievances regarding call light response times, leading to significant delays in care. Despite consistent complaints from residents over several months, the facility did not document or implement effective interventions. Staff interviews revealed a lack of proper follow-up and accountability in the grievance process.
The facility failed to protect three residents from physical abuse by another resident with severe cognitive impairment and behavioral disturbances. Incidents included slapping and hitting, which were not prevented despite existing care plans and interventions.
The facility failed to provide an environment free from accident hazards and ensure residents received adequate supervision and assistance to prevent accidents for two residents. One resident did not have a timely baseline fall care plan, and another experienced multiple falls due to inadequate fall interventions and lack of anti-tip brakes on her wheelchair.
The facility failed to maintain the emergency response equipment in safe operating condition, including an unsecured oxygen cylinder and expired medical supplies on the emergency response cart. The RN was not trained on the use of the oxygen cylinder, and the facility lacked a comprehensive policy and checklist for the emergency response cart.
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.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. On the date of the incident, a maintenance assistant witnessed one resident lightly hitting another on the cheek after an exchange involving incomprehensible speech and agitation. The maintenance assistant intervened by separating the residents and notifying nursing staff. No injuries were observed on the resident who was struck, and there was no notable change in her baseline mood or cognition following the event. Prior to the incident, both residents involved had documented histories of cognitive impairment and behavioral issues. The resident who initiated the physical contact had diagnoses including Alzheimer's disease, dementia, and agitation, and was known to become irritated when others entered her personal space or when exposed to noise. She also had a history of pain and agitation related to ingrown toenails, which was not addressed prior to the incident due to her inability to consistently verbalize discomfort. The other resident had severe dementia with mood disturbance, exhibited wandering and intrusive behaviors, and was known to disrupt other residents' privacy or activities. Staff interviews revealed that both residents were known to have interactions that could lead to agitation, with one being intrusive and the other sensitive to personal space. Staff attempted to monitor and redirect both residents but did not provide extra supervision or specific interventions to prevent such altercations. At the time of the incident, staff were not present to witness the event, and there was a lack of clear documentation or awareness of the residents' whereabouts immediately prior to the altercation. The care plans for both residents did not fully address the specific triggers or risks associated with their behaviors, contributing to the failure to prevent the abusive incident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse, resulting in several substantiated incidents involving resident-to-resident altercations. Four residents were directly affected, with repeated episodes of physical aggression primarily involving one resident with a history of severe cognitive impairment, aggressive behaviors, and complex psychiatric diagnoses. This resident exhibited unpredictable and escalating behaviors, including yelling, hitting, pushing, and slapping other residents, as well as self-injurious actions such as hitting herself and pulling her own hair. The care plans for this resident identified a history of trauma, severe dementia, and behavioral disturbances, with interventions in place for both pharmacological and non-pharmacological management. Despite these interventions, the resident continued to engage in aggressive acts toward others, including dumping water, slapping, pushing, and grabbing, which resulted in physical harm to other residents, such as bruises and a skin tear. Other residents involved in these incidents also had significant cognitive impairments and behavioral symptoms, with care plans outlining interventions for managing aggression and agitation. In several cases, altercations occurred in common areas under staff supervision, but staff were unable to prevent or effectively de-escalate the situations before physical contact occurred. The facility's own investigations substantiated the allegations of abuse, documenting that the aggressive resident was the primary assailant in multiple incidents. Environmental factors, such as overstimulation in the memory care unit and busy periods after meals, were identified as contributing to the escalation of aggressive behaviors. Staff interviews confirmed the unpredictability of the aggressive resident's actions and the challenges in redirecting her, even with individualized interventions and education provided to staff. The facility's abuse policy emphasized the importance of providing a safe environment and preventing abuse by anyone, including other residents. However, the repeated incidents of physical abuse, the inability to prevent resident-to-resident altercations, and the failure to consistently implement effective interventions led to multiple residents being subjected to physical harm. The documentation and interviews revealed that staff were aware of the risks and had attempted various strategies, but these were not sufficient to prevent the substantiated episodes of abuse.
Improper Use of Physical Restraints
Penalty
Summary
A deficiency was identified regarding the use of physical restraints on residents. The report notes that residents were not consistently free from the use of physical restraints, except when required for medical treatment. This indicates that physical restraints were used in situations where they were not medically necessary, contrary to regulatory requirements.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by other residents, resulting in several resident-to-resident altercations involving four out of six sampled residents. Incidents included one resident being pushed and slapped by another, a resident being pushed to the floor after a dispute over a shoe, and repeated altercations between two residents who both exhibited cognitive impairments and behavioral disturbances. In each case, the residents involved were either unable to recall the incidents due to cognitive deficits or were non-verbal, and staff or other residents witnessed the altercations. The care plans for the residents involved did not consistently identify them as being at risk for abuse or as having been victims of physical abuse, even after multiple incidents had occurred. Updates to care plans and the implementation of new interventions were delayed, with some changes not made until after several additional altercations had taken place. For example, one resident's care plan was not updated to reflect her risk for abuse or to include new interventions until after she had been involved in three more altercations following the initial incident. Despite the facility's policy stating a commitment to preventing abuse and providing a safe environment, the measures in place, such as 15-minute checks and staff education, did not prevent further incidents. The documentation also revealed that some injuries, such as bruising, were not clearly accounted for in the medical record, and the interventions implemented did not effectively reduce the frequency of resident-to-resident abuse. The facility's failure to promptly and adequately address the risk factors and behavioral triggers for these residents contributed to ongoing physical altercations and a lack of protection from abuse.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate an allegation of abuse and neglect for one resident out of a sample of six, specifically not completing thorough and timely investigations when the resident sustained injuries of unknown origin. According to the facility's abuse policy, any suspicion of abuse, neglect, or injury of unknown source must be reported immediately and investigated, including interviews with relevant staff, residents, or family members. However, documentation showed that bruising and discoloration on the resident's forearms were noted in nursing records, but there was no evidence that these injuries were investigated or that their origin was determined. The resident involved was over 65 years old, diagnosed with Alzheimer's disease with late onset, severe dementia with agitation, lack of coordination, and anxiety disorder. The resident required staff assistance with most activities of daily living and had care plans in place for dementia, ADL support, and skin care, which directed staff to observe and report any skin changes such as bruises or cuts. Despite these directives, nursing documentation on two separate occasions identified bruising and discoloration on the resident's arms, but there was no follow-up to determine the cause or to rule out abuse, as required by facility policy. Interviews with the NHA and DON revealed that they were unaware of the documented bruising and that no investigation had been initiated at the time the injuries were first observed. The NHA acknowledged that bruises and injuries of unknown origin should have been investigated and that she should have been notified to start an investigation. The lack of documentation and investigation into the origin of the bruising constituted a failure to respond appropriately to alleged violations, as required by the facility's own policies.
Resident Hospitalized Due to Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in the administration of another resident's medications. This incident involved a resident who was cognitively intact and required partial assistance with self-care. The resident was mistakenly given 200 mg of pregabalin and 25 mg of metoprolol, which were not prescribed to her. As a result of this error, the resident experienced nausea and was sent to the hospital for monitoring. The hospital records indicated that the resident suffered from cardiac dysrhythmia, hypotension, and bradycardia following the medication error. The nursing home administrator confirmed that the nurse responsible for the error resigned after the incident. The report highlights that the facility did not adhere to the professional standards of medication administration, which include verifying the right patient and medication, among other checks, to prevent such errors.
Food Storage and Temperature Control Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen and two kitchenettes. Specifically, dented canned foods were found stored in the pantry, and food items were not labeled with use-by dates. Large plastic containers were observed with dates that were not specified as being an opening date or a use-by date, and some containers were not labeled as to what the item was inside. Additionally, a prepared container of food in the walk-in cooler was not labeled or dated. The dietary manager was unaware of these issues and acknowledged the need to address the labeling system to ensure clarity and compliance with regulations. The facility also failed to appropriately clean thermometers before obtaining temperatures from ready-to-eat foods. A dietary aide was observed using alcohol wipes incorrectly to clean the thermometer probe, by poking the thermometer through the middle of the wipe without fully opening it. This improper cleaning method was repeated multiple times during lunch service. The dietary manager demonstrated the correct method of cleaning the thermometer but was unaware that the dietary aide was not following the proper procedure. Furthermore, the facility did not maintain appropriate temperatures in kitchen refrigerators and freezers. Several thermometers were missing or broken, and the digital thermometer in the walk-in cooler was not displaying the temperature. Additionally, cold foods were not held at 41 degrees Fahrenheit or below before serving residents. Individual bowls of fresh mixed fruit were observed sitting on the counter without being on ice, and the temperature of the fruit was found to be 63.6 degrees Fahrenheit after lunch service. The dietary manager admitted that maintaining the correct temperature of meals had been a continuous issue and did not check the temperature of the fruit during or after lunch service.
Failure to Address Resident Grievances on Call Light Response Times
Penalty
Summary
The facility failed to address and act promptly upon grievances and recommendations raised during resident council meetings, specifically regarding call light response times. Residents reported waiting up to 45 minutes for assistance, leading to accidents and significant delays in receiving care. Despite these concerns being raised consistently from December 2023 through March 2024, the facility did not document or implement effective interventions to resolve the issue. The resident council minutes repeatedly noted the unresolved nature of the grievances, and there was no evidence of a completed grievance form for these concerns. Interviews with staff revealed that the grievance process was not being followed correctly. The Social Services Director (SSD) acknowledged that grievances were not being followed up on or resolved by the responsible departments. The Nursing Home Administrator (NHA) admitted to not reviewing resident council minutes regularly and identified a lack of accountability and understanding among new management team members regarding the importance of addressing grievances timely and accurately. The NHA also noted that the grievance system needed to be revamped to ensure proper follow-up and resolution. The facility's policy required grievances to be investigated and resolved within specific timeframes, but this was not adhered to. The SSD and NHA recognized the deficiencies in the grievance process and the need for improved oversight. Despite a staff in-service on call light times, residents continued to report unresolved issues, indicating that the interventions were ineffective. The facility's failure to address these grievances promptly and adequately resulted in ongoing dissatisfaction and unmet care needs among residents.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to ensure that three residents were free from abuse, specifically physical resident-to-resident altercations involving Resident #42. On one occasion, Resident #42 slapped Resident #23 in the face after attempting to take her hat while she was sleeping on a couch in the common area. This incident was witnessed by a CNA who intervened but not before the altercation occurred. Resident #42 had refused her medications throughout the day and was agitated at the time of the incident. Both residents were assessed and found to have no injuries, and neither recalled the incident afterward. Resident #42 had a history of behavioral disturbances, including physical and verbal aggression, and was on a care plan that included frequent checks and pain management interventions, which were not effectively implemented to prevent the altercation. In another incident, Resident #42 smacked Resident #36 on the back of the head with an open palm while she was participating in a group activity. This incident was also witnessed by staff, and no injuries were reported. Resident #42 was agitated and pacing before the incident, and attempts to redirect her were ineffective. The resident was later administered her medication, which helped to calm her down. Resident #42 had a history of severe cognitive impairment, behavioral disturbances, and chronic pain, which were identified as potential contributing factors to her aggressive behavior. The care plan for Resident #42 included monitoring for pain and constipation, as well as providing one-on-one support and redirecting her to less stimulating environments, but these measures were not sufficient to prevent the altercation. The facility's failure to effectively implement and monitor the care plans for Resident #42, including ensuring she received her medications and addressing her pain and behavioral needs, led to the physical altercations with Residents #23 and #36. The staff's inability to anticipate and manage Resident #42's needs and behaviors resulted in a failure to protect the residents from abuse, as required by the facility's abuse policy. The incidents highlight deficiencies in the facility's ability to provide a safe environment for its residents, particularly those with severe cognitive impairments and behavioral disturbances.
Failure to Implement Effective Fall Interventions
Penalty
Summary
The facility failed to provide an environment free from accident hazards and ensure residents received adequate supervision and assistance to prevent accidents for two residents. Resident #52, who was assessed to be at high risk for falls upon admission, did not have a baseline fall care plan implemented in a timely manner. Following a fall from his recliner, the facility did not implement appropriate fall interventions to prevent future falls from the recliner. Despite being identified as a high fall risk, the facility failed to include specific interventions related to the recliner in Resident #52's care plan. Resident #50, who had a history of falls and severe cognitive impairment, experienced multiple falls due to inadequate fall interventions. The resident's wheelchair did not have anti-tip brakes, which contributed to her falls. Observations revealed that the resident frequently attempted to stand from her wheelchair, and staff did not consistently implement interventions to prevent falls. The facility's care plan for Resident #50 did not include timely and effective fall interventions, and staff were not consistently implementing the interventions that were in place. Interviews with facility staff, including the DON, ADON, and clinical consultant, revealed gaps in the implementation and updating of fall care plans. The ADON was unable to provide a baseline care plan for Resident #52, and the DON acknowledged that interventions to prevent falls from the recliner were not included in the care plan. For Resident #50, the lack of anti-tip brakes on her wheelchair and the failure to update the care plan with effective interventions were identified as contributing factors to her repeated falls. Staff interviews indicated a need for better education and adherence to fall management policies to ensure resident safety.
Emergency Response Equipment Deficiency
Penalty
Summary
The facility failed to maintain the emergency response equipment in safe operating condition for one of two emergency response carts. Specifically, the oxygen cylinder on the south emergency response cart was not secured properly and was observed hanging loosely by the oxygen regulator. The registered nurse (RN) responsible for the cart was not familiar with the cylinder, had not been trained on its use, and was unable to verify the oxygen level. The daily checklist for the emergency cart did not include the requirement to inspect and check the oxygen cylinder, and the RN indicated that in an emergency, she would rely on oxygen supplies from resident rooms or assistance from city emergency response teams. Additionally, the facility failed to remove expired medical supplies from the emergency response cart. During an inspection, a plastic pencil box labeled for emergency use was found to contain a glucometer with test strips that had expired in 2021. The RN acknowledged that using expired test strips could result in incorrect blood sugar readings and immediately removed the expired items. The night shift nurse was identified as responsible for checking the supplies and should have removed the expired test strips. The Director of Nursing (DON) confirmed that the oxygen cylinder was not secured safely and that the facility would replace it with a larger cylinder. The DON also noted that the glucometer should not have been stored in the emergency response cart and observed several medical supplies that were not included on the inventory list. The facility did not have a policy for the emergency response cart, and the provided checklist did not include checks for the glucometer or the oxygen cylinder.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
