Creekside Village Rehabilitation And Nursing Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Collins, Colorado.
- Location
- 1000 E Stuart St, Fort Collins, Colorado 80525
- CMS Provider Number
- 065221
- Inspections on file
- 30
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 11 (3 serious)
Citation history
Health deficiencies cited at Creekside Village Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
A resident with Lewy body dementia, severe cognitive impairment, orthostatic hypotension, and a history of falls repeatedly exhibited wandering, pacing, agitation, paranoia, and exit-seeking behaviors, yet the facility did not develop or implement a resident-centered elopement care plan with clear, nonpharmacologic interventions or defined supervision needs. Despite multiple documented episodes of wandering and two separate elopements in which the resident left the building and had to be brought back by staff, the facility relied largely on PRN psychotropic medications and intermittent 15-minute checks that were not consistently documented or care-planned. Elopement risk assessments eventually identified the resident as high risk, but staff reported the resident often sat near an unlocked front door in a sparsely monitored lobby, demonstrating ongoing inadequate supervision to prevent further elopement.
A resident with epilepsy and renal failure on hemodialysis had a complex antiepileptic regimen including phenobarbital, lacosamide, clobazam, Depakote, later Tegretol, and PRN post-dialysis seizure medications. The facility repeatedly failed to administer multiple scheduled doses of these medications, including entire mornings when all seizure meds were omitted, and never gave the ordered PRN post-dialysis doses despite ongoing seizures. Staff followed an informal practice of holding medications when the resident was at dialysis without clarifying orders with the PCP or neurologist, and nurses missed additional Tegretol doses because they were unaware the drug was available in a separate storage area. The EMR lacked documentation that the neurologist or PCP were notified of these missed doses, while hospital records documented breakthrough seizures and subtherapeutic antiepileptic levels. An additional observation showed a nurse unable to locate an ordered inhaler for another resident and not notifying the physician or documenting the omission, illustrating broader medication administration failures.
The facility failed to provide physician‑ordered modified diet textures to several residents with dysphagia, resulting in one resident with severe cognitive impairment and a Level 5 minced and moist order being served a regular‑texture soft taco on a whole tortilla and subsequently choking, requiring repeated Heimlich attempts and supplemental O2. During later meal observations, two residents with Level 6 soft and bite‑sized orders were served regular‑texture items including a hamburger bun, whole lettuce leaf, and whole cookies. Staff interviews showed inconsistent understanding of IDDSI diet levels and reliance on meal tickets that did not always reflect appropriate textures, while the dietary manager reported being new, unaware of dietary extensions before the incident, and unsure of prior staff education. The report states that these failures to follow ordered diet textures placed residents at risk for serious harm or death if not corrected immediately.
The facility’s QAPI program failed to identify and address multiple serious quality of care and safety problems, including a choking incident when a resident on a minced and moist diet was served a regular meal, additional residents receiving incorrect diet textures, repeated elopements by a resident with wandering behaviors without effective new interventions, and a resident experiencing increased seizures and hospitalizations when seizure meds were not administered as ordered, including on dialysis days. The facility also had repeat citations for abuse on a secure unit and for significant med errors, and interviews with the MD and NHA showed that, despite awareness of some incidents, there was uncertainty about whether performance improvement plans were initiated and a lack of awareness of ongoing diet errors, demonstrating that QAPI activities did not effectively capture or correct these recurring issues.
A cognitively intact resident with a fracture and type 2 DM, who required partial to moderate assistance for hygiene, did not receive showers according to his expressed preferences and documented schedule. He reported going weeks without showers and being repeatedly told by staff on different shifts that the shower would be done later, despite his verbal complaints to nurses, CNAs, and managers. Although his EMR contained specific shower days and time preferences, his care plan lacked this information, and shower records showed only three showers in a 30-day period. Staff interviews revealed confusion about which shift was responsible, poor communication of updated shower schedules to CNAs, and uncertainty among nursing staff about the resident’s current shower schedule.
A resident with dementia and behavioral issues physically struck two other residents on a secure unit on separate occasions, causing at least one documented skin tear, while only one CNA was present on the unit at times and the assigned nurse was covering another unit. The aggressive resident had severe cognitive impairment and primarily spoke Spanish, yet staff reported difficulty communicating with him when agitated and there was no clear use of an interpreter during key interviews. Care plans for the involved residents identified behavioral risks and the need for close supervision and redirection but lacked resident‑specific redirection strategies and clearly defined alternative communication tools, and the facility’s abuse investigation did not reconcile staff reports of contact and injury with its inconclusive findings.
A resident with Lewy body dementia, parkinsonism, and anxiety received PRN lorazepam and Seroquel without the facility enforcing the 14‑day limit for PRN psychotropic orders or obtaining documented physician reevaluation and rationale for continuation beyond that period. Pharmacy reviews had recommended 14‑day stop dates and behavior tracking for psychotropics, but these were not timely implemented, and the EMR lacked consistent behavior and side‑effect monitoring orders or documentation for the resident’s lorazepam and Seroquel. Nursing and leadership staff reported that they typically monitor behaviors and side effects for psychotropic use and understood that PRN psychotropics should not exceed 14 days, yet the DON confirmed that behavior and side‑effect monitoring orders were missing for this resident and that new medication orders were not being reviewed daily.
A resident experienced a significant medication error due to a failure in the medication administration process.
The facility did not submit final reports of two separate physical abuse investigations to the State Agency within the required timeframe. In both cases, initial reports were timely, but the final investigative findings were submitted late, despite the investigations being completed. The administrator acknowledged the delay and confirmed it was not in accordance with facility policy or state requirements.
Multiple environmental deficiencies were identified, including detached and soiled ceiling tiles, improperly secured light fixtures, sagging drywall, and unsanitary swamp coolers. These issues were observed throughout the facility, with incomplete repairs and lack of maintenance documentation contributing to an unsafe and unsanitary environment for residents, staff, and the public.
Two residents with cognitive impairment were not protected from abuse by another resident, resulting in one incident of physical abuse and another of verbal abuse. In both cases, the aggressor became upset when other residents entered or approached his room, leading to physical contact and yelling that caused distress and minor injury. Staff were aware of the aggressor's behavioral triggers but were unable to prevent the incidents, and one staff member was not immediately aware of the verbal abuse event.
A resident with a history of C. difficile and multiple diagnoses did not receive a prescribed course of Fidaxomicin because the medication was not available at the facility. Staff and the DON reported the antibiotic was not in stock and attempts to obtain an alternative or clarification from the infectious disease physician were unsuccessful or undocumented. The medication was not administered as ordered, and there was no documentation of discontinuation, substitution, or anticipated delivery in the medical record.
A resident with severe cognitive impairments was kissed without consent by another resident with a history of unwanted advances. The facility failed to implement new interventions to prevent reoccurrence, contributing to the deficiency.
Two residents in the facility did not receive their scheduled showers, despite being dependent on staff for bathing. Resident #3, with moderate cognitive impairments, received only 10 out of 18 scheduled showers, with no documentation for missed showers. Resident #8, who preferred showers, received fewer than scheduled, and the care plan inaccurately reflected a preference for bed baths. Staff shortages and lack of documentation contributed to these deficiencies.
The facility failed to notify residents of a change in attending physicians and did not provide them with a choice, as required. Interviews and record reviews revealed that residents were not informed about the switch to a new provider group, and there was no documentation of notification or choice. The DON acknowledged the lack of written notice, and the RDQA confirmed the facility's responsibility to inform residents.
The facility experienced issues with serving food that was palatable, attractive, and at a safe and appetizing temperature. Residents reported dissatisfaction with the taste, temperature, and quality of meals, including complaints about cold, overcooked, and unappetizing food. Observations during a test tray evaluation confirmed that food temperatures were not within acceptable ranges. Despite a policy emphasizing the importance of conserving nutritive value, flavor, and appearance, and opportunities for resident feedback, inconsistencies in food preparation and service persisted.
The facility experienced deficiencies in maintaining sanitary conditions during food storage, preparation, distribution, and service. Observations indicated lapses in hand hygiene, glove usage, and proper handling of glassware. Food items were not consistently labeled, dated, or covered during transport, increasing the risk of contamination. Staff interviews revealed inconsistent adherence to established protocols for food safety, highlighting gaps in training and compliance.
The facility failed to provide scheduled showers for three residents, resulting in missed hygiene care. One resident with a history of trauma related to showers did not receive any showers or sponge baths for two months. Another resident, observed with disheveled and greasy hair, only received two out of 16 scheduled showers. A third resident, dependent on staff for bathing, received only one out of six scheduled bed baths. Staff were unaware of the residents' preferences and schedules, and documentation did not reflect any interventions for missed showers.
The facility failed to maintain the dignity of two residents by not providing timely meals and allowing staff to enter rooms without knocking or identifying themselves. One resident missed meals and had to request food, while another experienced frequent unannounced entries by staff.
A resident did not receive prescribed doses of Bisacodyl, Baclofen, Linaclotide, and Zonisamide due to medication unavailability. The facility failed to notify the provider and document the unavailability, despite in-service education on the issue.
The facility failed to provide routine dental care to a resident who had not been to a dental appointment in two years. Despite a physician order for dentist appointments as needed, there was no documentation in the resident's EMR indicating that dental care had been offered or provided. Interviews with staff revealed that the resident had not signed a consent form for dental services and that the facility did not document refusals of dental services.
The facility failed to maintain a safe, functional, and sanitary environment in the laundry area, with issues such as a non-functional exhaust fan, unfinished sheet rock, chipped paint, hanging light cover, holes in the ceiling and walls, and lint accumulation. The Environmental Services Director and Maintenance Supervisor were unaware of these issues, contributing to the deficiency.
Failure to Implement Resident-Centered Elopement Protections for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a cognitively impaired resident at high risk for elopement. The resident had Lewy body dementia, parkinsonism, orthostatic hypotension, repeated falls, and severe cognitive impairment with a BIMS score of 4/15. He required supervision to substantial assistance for most ADLs and needed supervision to touching assistance to walk ten feet. Despite these needs, an initial elopement assessment after admission concluded he was not at risk for wandering, documenting no memory or decision-making impairments and no verbalization of wanting to leave, even though he was cognitively impaired and ambulatory. Beginning in late September and throughout October and November, progress notes documented frequent wandering, pacing, agitation, paranoia, and exit-seeking behaviors. The resident was found wandering near an elevator, stated he was trying to find his way out, and had a fall associated with poor safety awareness and cognitive decline. He repeatedly required PRN lorazepam and later Seroquel for anxiety, agitation, pacing, packing and unpacking belongings, rummaging, hyper-fixation on leaving, and beliefs that he was in a hotel and needed to check out or that he needed to rescue his sister. Hospice and physician notes addressed medication management but did not address his wandering, packing, pacing, or elopement behaviors with nonpharmacologic interventions. Despite this pattern, the facility did not develop or implement a resident-centered elopement care plan that specified effective nonpharmacologic interventions or the level of supervision he consistently required. On one occasion, the resident left the building and walked with his walker toward a nearby school, stopping in the middle of a street crosswalk and asking passersby to call the police before staff redirected him back inside. An elopement risk evaluation completed that day scored him as high risk, noting dementia, memory and decision-making impairments, verbalization of wanting to leave, wandering with and without his walker, ineffective verbal redirection, and inability to find his room without hands-on assistance. The IDT reviewed this elopement and attributed it to confusion and paranoia, adding 15-minute checks, but did not document the duration of these checks or add consistent, nonpharmacologic elopement interventions to the care plan. Later, the resident again left the facility at night without his walker and was found outside at a locked back door attempting to reenter; 15-minute checks and line-of-sight observation were used temporarily, but his 15-minute check sheet for part of that time was left blank. Progress and hospice notes continued to document wandering, restlessness, and exit-seeking, and a subsequent elopement risk evaluation showed an even higher risk score, yet the facility still did not initiate a resident-centered elopement care plan or clearly define required supervision. Staff interviews further revealed that the resident often sat in the front lobby near an unlocked front door that was infrequently monitored by staff, underscoring the lack of consistent supervision in an area of easy egress.
Removal Plan
- Place Resident #13 on one-to-one supervision indefinitely.
- Review and update Resident #13's care plan to reflect current wandering and elopement risk and person-centered interventions, including implementation of a one-to-one supervisor and providing redirection as needed when wandering behaviors occur.
- Complete an audit to evaluate each resident in the facility and identify residents who are at high risk for elopement.
- Review residents identified as high risk to ensure appropriate and effective elopement prevention measures are in place and documented in their care plans.
- Educate all staff members in all departments on resident-centered interventions for residents at high risk of elopement, the facility policy on reducing wandering and elopement risk, and reporting of any increased exit-seeking behaviors prior to working their next scheduled shift.
- Provide this education to new staff members during orientation.
- Educate the interdisciplinary team (IDT) on conducting root cause analyses of significant events to ensure appropriate actions are taken to prevent reoccurrence.
- Review the Elopement and Wandering Residents policy.
- Ensure progress notes for the prior 24 hours are reviewed each day for all residents during the clinical stand-up meeting to address any changes in behavior including wandering, exit seeking, or expressions of wanting to leave the facility.
- Address identified concerns through the IDT, including non-pharmacological interventions and a care plan review.
- Reevaluate residents by the IDT quarterly and any time increased exit-seeking symptoms are noted to ensure appropriate elopement prevention measures are in place and effective.
- Inform staff of any changes through in-servicing, care plan updates, and updates to the resident's Kardex.
- Audit new admissions for elopement risk and ensure appropriate interventions are in place.
- Conduct the new-admission elopement-risk audit daily for four weeks, then five times per week for four weeks, then three times per week for four weeks, and document it on an audit form.
Failure to Administer Ordered Antiepileptic Medications and Notify Providers of Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with epilepsy and acute kidney failure requiring hemodialysis received prescribed anti-seizure medications as ordered, resulting in significant medication errors. The resident was cognitively intact but dependent on staff for all activities of daily living and had a care plan intervention to receive seizure medications as ordered and be monitored for effectiveness. The resident’s complex seizure regimen included scheduled phenobarbital, lacosamide, clobazam, and Depakote, with later addition of Tegretol, as well as PRN phenobarbital and lacosamide to be given after dialysis for breakthrough seizures. Despite these orders, the MAR and record review showed multiple missed doses of scheduled seizure medications and no administration of PRN seizure medications after dialysis, even though the resident continued to have seizures after dialysis. Record review showed that on multiple days the resident did not receive ordered doses of lacosamide, Depakote, clobazam, and phenobarbital, including entire mornings when all four scheduled seizure medications were not administered, and additional missed evening and noon doses on other days. The MAR also showed that the PRN phenobarbital and PRN lacosamide ordered to be given after dialysis for seizures were never administered, despite ongoing post-dialysis seizure activity. After a hospitalization for seizures where subtherapeutic phenobarbital and valproic acid levels were documented, the resident returned with an order to start Tegretol three times daily; however, four Tegretol doses were not given because nurses were unaware the medication was available and stored in a separate area. Subsequent MAR review after this hospitalization showed further missed Tegretol doses on multiple days. The facility’s practice contributed directly to these omissions. The DON stated it was facility practice to hold medications when a resident was at dialysis, and seizure medications and other medications scheduled on dialysis days were marked as not administered in the EMR without clarifying these orders with the PCP or neurologist. The DON also acknowledged awareness that four Tegretol doses were not administered but did not complete a full audit of the resident’s seizure medications and was not aware of additional missed doses beyond dialysis days. The DON and PCP both believed the PRN post-dialysis seizure medications were to be administered by the dialysis clinic, but the dialysis triage nurse and nephrologist reported the clinic did not administer medications from the facility’s orders and expected such medications to be given at the facility before or after dialysis. Throughout these events, the resident’s EMR did not contain documentation that the neurologist or PCP were notified of the multiple missed doses of anti-seizure medications. The resident experienced repeated seizures and multiple hospitalizations, with hospital records repeatedly referencing breakthrough seizures, subtherapeutic antiepileptic levels, and seizure activity despite reported adherence, while facility records showed that ordered antiepileptic medications were not consistently administered. In addition to the issues with this resident, an observation of another medication pass showed a nurse unable to locate a prescribed inhaler for another resident and not administering it, without notifying the physician or documenting the missed dose. This further demonstrated that medications were not consistently administered as ordered and that missed doses were not reliably communicated to providers or documented in progress notes, contributing to the identified deficiency of significant medication errors.
Removal Plan
- The DON and ADON completed an audit to ensure all residents are getting medications as ordered, including a review of each resident's medication administration record and an audit of the medication carts to ensure the medications were available.
- The DON and regional clinical resource #1 audited all residents currently on dialysis to ensure administration of medications per physician order on dialysis days.
- The Medication Administration policies were reviewed by the NHA, the DON, and regional clinical resource #1.
- The DON educated all licensed nursing staff on the Medication Administration policy, properly following physician's orders, and the process of notifying of medication errors, including notifying providers when medications conflict with scheduled dialysis days; education to be provided to all nursing staff prior to their next scheduled shift.
- The DON or designee will educate all new hire licensed nurses on medication administration and physician notification guidelines during orientation.
- The DON or designee will review MAR reports for all residents to ensure medications are administered as ordered, or the physician was notified appropriately if a medication was held.
- All licensed nurses will be observed by the DON or designee administering medications to ensure competency across shifts and with various staff members.
Failure to Provide Ordered Dysphagia Diet Textures Resulting in Choking Event and Ongoing Meal Service Errors
Penalty
Summary
The deficiency involves the facility’s failure to provide physician‑ordered modified diet textures to multiple residents with dysphagia. One resident with diagnoses including oropharyngeal dysphagia, cerebral infarction, cognitive communication deficit, and unspecified dementia had a physician’s order for a Level 5 minced and moist diet and required supervision and hands‑on assistance for meals. Despite this, the resident was served a regular‑texture soft taco on a whole tortilla instead of the ordered minced and moist texture. During this meal, the resident began choking on a piece of tortilla that became stuck in the throat. A nurse attempted the Heimlich maneuver several times without dislodging the tortilla; the resident was moving air and eventually coughed up the tortilla and then required supplemental oxygen by mask. Two additional residents with dysphagia and cognitive deficits were also not provided with the correct modified diet textures. One resident, with oropharyngeal dysphagia, hemiplegia and hemiparesis following cerebrovascular disease, and cognitive communication deficit, had a physician’s order for a Level 6 soft and bite‑sized diet. Observation of a dinner meal service showed this resident received a regular‑texture hamburger on a bun with a whole lettuce leaf and a whole cookie, despite the soft and bite‑sized order. Another resident, with diagnoses including GERD, oral‑phase dysphagia, and cognitive communication deficit, had a physician’s order for a Level 6 soft and bite‑sized diet, with documentation that this resident could have regular sandwiches and hamburgers. However, this resident was observed receiving a whole cookie, which was not consistent with the ordered soft and bite‑sized texture. Staff interviews and documentation revealed gaps in understanding and implementation of diet textures and meal ticket verification. Nursing staff and CNAs reported receiving some training on diet textures, but one CNA believed that residents on soft and bite‑sized diets could have bread and possibly cookies depending on softness, which conflicted with IDDSI guidance cited in the report. The dietary manager stated he was new to the position, had been unaware of dietary extensions prior to the choking incident, and was unsure whether dietary staff had been educated on diet textures and extensions. The registered dietitian confirmed that diet tickets were generated from the EMR and included diet orders, extensions, and specific foods, and acknowledged that the residents on soft and bite‑sized diets should not have received hamburger buns, lettuce, or cookies. The administrator later attributed one instance of incorrect items (whole cookies) on tickets to a computer program glitch, while the DON acknowledged that only limited meal audits had been occurring and that the number of residents included in those audits was insufficient. The report states that the facility’s failure to ensure residents received the physician‑ordered diet textures placed residents at risk for serious harm or death if not corrected immediately. The report also notes that, at the time of the choking incident, the nurse assigned to the secured unit where the choking resident resided was not on the unit, and another RN responded to perform the Heimlich maneuver. The event note for the choking incident identified risk factors and root causes including the resident’s dysphagia, cognitive decline, poor safety awareness, and the fact that the resident was served a regular‑texture meal including a whole tortilla despite an order for minced and moist texture. The note documented that the resident lacked insight into safety regarding food intake and that the preventative measure in place prior to the incident was simply confirming the minced and moist order. Subsequent observations during survey showed that, even after this choking event, residents with ordered soft and bite‑sized diets continued to receive regular‑texture items such as whole cookies, hamburger buns, and lettuce leaves, demonstrating ongoing failure to consistently match plated meals to physician‑ordered diet textures.
Removal Plan
- Re-educate all staff involved in meal preparation or service (IDT, nursing, dietary, activities) on diet modifications and following physician orders using IDDSI standards prior to their next scheduled shift, including a post-test to demonstrate understanding; provide this education to all new IDT/nursing/dietary/activities staff during orientation; education provided by the DON or designee.
- Re-educate all dietary staff on food preparation utilizing diet extensions and recipes to adhere to each resident's diet order prior to their next scheduled shift; provide this education to all new dietary staff during orientation.
- Have the registered dietitian (RD) conduct an audit to ensure all dietary orders, recommendations, and documentation are accurate in the medical record and match the dietary department's tray ticket information for each resident.
- Review and revise the facility's pertinent menu and therapeutic diet policies.
- Educate the IDT on conducting root cause analysis of serious events, including choking incidents, and ensuring appropriate actions are taken to prevent recurrence.
- Implement daily audits of new admissions by the dietary manager (DM) and the DON or designee to ensure dietary orders/recommendations/documentation are accurate in the medical record and match the dietary department's meal ticket information for that resident, documenting findings on an audit form.
- Have the DON or designee review all new orders to monitor for changes to diet orders; communicate any changed orders to the dietary department through a diet change communication form.
- Monitor food service at all three meals for all residents by the DON or designee, comparing the meal being served to the physician order/documentation for that resident's dietary needs; document findings on an audit form.
Failure of QAPI Program to Identify and Address Serious Quality of Care and Safety Issues
Penalty
Summary
The facility failed to maintain an effective, comprehensive, data‑driven QAPI program capable of identifying and addressing quality of care, quality of life, and resident safety concerns. Surveyors cross‑referenced multiple serious deficiencies that were not effectively captured or addressed through QAPI. These included a choking incident in which a resident on a minced and moist diet was served a regular meal, resulting in an actual choking episode that required multiple Heimlich attempts, as well as other residents being served incorrect diet textures during the survey. Additional cross‑referenced deficiencies involved two elopement incidents for a resident with wandering behaviors, where no new interventions were implemented after the first elopement and the resident later left the building without staff knowledge and was found locked outside. Another cross‑referenced deficiency involved a resident whose seizure medications were not administered as ordered on multiple occasions, including not being given at all on dialysis days, leading to increased seizures and multiple hospitalizations. The facility’s regulatory history showed repeat deficiencies that the QAPI program failed to prevent, including multiple citations for abuse prevention on the secure unit and repeated citations for significant medication errors, which escalated from potential for more than minimal harm to actual harm. The facility’s own QAPI policy required an effective, comprehensive, data‑driven program, but interviews revealed gaps in implementation. The MD reported being notified of the seizure medication error and expressed concern that seizure medications must be administered as ordered and that the neurologist should have been contacted for clarification. The NHA stated that abuse allegations were reviewed in QAPI and that he was aware of the significant seizure medication error but was unsure whether any performance improvement plans had been initiated. He also reported being aware of the choking incident but not aware that the kitchen was serving inappropriate diets, and he described the resident who eloped twice as someone for whom the facility was seeking a secured unit placement. These findings collectively demonstrated that the QAPI committee did not effectively identify, track, or address these serious and recurring quality of care and safety issues.
Failure to Honor Resident Bathing Preferences and Schedule
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s stated bathing preferences and to provide showers according to his chosen schedule. The resident, over age 65 with diagnoses including a left tibia fracture and type 2 diabetes, required partial to moderate assistance for personal hygiene and showers. He reported that from admission he went several weeks without showers, and that staff on different shifts repeatedly told him his shower would be done by the next shift, which did not occur. He stated he verbally complained to nurses, CNAs, and managers, but his shower schedule was never corrected. A manager later placed a sign in his room listing specific shower days, but the resident reported that showers still were not completed as scheduled. Record review showed the resident’s shower preferences were documented in the EMR, initially as twice weekly on specific evenings, and later updated to three times weekly on specific days before 8:00 p.m. but after lunch. However, his comprehensive care plan did not include his shower preferences or specific days. Shower records for the 30-day review period showed he received only three showers. Staff interviews revealed a CNA did not know when the resident was to receive showers and described confusion due to shower schedule updates not being communicated to CNAs. An RN acknowledged the resident’s specific time preferences and stated it was sometimes difficult to accommodate due to CNA workload and that his schedule had been changed multiple times, leaving her unsure of the current schedule. The DON stated she was unaware the resident was not receiving showers and that staff were confused about which shift was responsible for providing them.
Failure to Prevent Resident-to-Resident Physical Abuse on Secure Unit
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by another resident on a secure memory unit. Facility policy defined abuse and neglect and required identification, assessment, care planning, and monitoring of residents with behaviors that might lead to conflict, as well as deployment of sufficient, trained staff and appropriate supervision. Despite this, the facility did not prevent resident‑to‑resident altercations involving a resident with dementia and behavioral issues who physically struck two other residents. The facility’s abuse investigations, care plans, and documentation show gaps in behavioral assessment, communication support, and supervision that contributed to these incidents. In the first incident, a CNA observed a resident with severe cognitive impairment and dementia enter another resident’s room. As the CNA approached to redirect him, she heard the cognitively intact resident in the bathroom tell the intruding resident to get out, followed by a sound like a punch. When the CNA entered, she redirected the intruding resident out of the room and noted a scratch on the other resident’s neck. The victim reported that the other resident punched him three or four times and that something sharp from the assailant’s knuckles scratched him. A physician note documented that the victim had an altercation with another resident who scratched his neck, resulting in a small skin tear approximated with steri‑strips. Staff on the unit reported that contact had been made and that the injury was most likely from the assailant’s nail. The facility’s investigation concluded the allegation could not be substantiated or unsubstantiated and did not explore alternative causes for the neck injury, despite the victim’s statements and staff reports of hearing a punch and observing contact. In the second incident, a CNA was the only staff member present on the secure unit while the nurse was on another unit. She heard two male residents’ voices escalating in the hallway and, after quickly finishing care in a room, found two residents in a verbal dispute. As she positioned herself between them to deescalate, the same resident with dementia approached and swung with a closed fist, making contact with one disputing resident’s cheek. A nursing progress note documented that the resident walked by and punched the other resident in the face. The victim, who had severe cognitive impairment and dementia, denied being hit, and no apparent injuries were found on assessment. The assailant denied involvement, and there was no indication that an interpreter was used during his interview, even though his primary language was documented as Spanish and staff reported difficulty communicating with him when he was agitated. Care plans for the assailant and the victim referenced behavioral risks and the need for close supervision, frequent checks, and redirection, but did not specify effective, resident‑specific redirection techniques or clearly defined alternative communication tools for the Spanish‑speaking resident. Staffing on the secure unit routinely consisted of one nurse (also assigned to another unit) and one CNA, resulting in periods when only one staff member was present to both assist residents and monitor behaviors.
Failure to Monitor PRN Psychotropics and Enforce 14-Day Limits
Penalty
Summary
The deficiency involves the facility’s failure to adequately monitor and manage the use of psychotropic medications, specifically PRN lorazepam and Seroquel, for one resident with severe cognitive impairment and multiple neuropsychiatric diagnoses. The resident had Lewy body neurocognitive disorder, parkinsonism, and anxiety, and the MDS documented severe cognitive impairment with no recorded physical or verbal behaviors toward others during the assessment period, although the resident was receiving antipsychotic and antianxiety medications. The facility’s psychotropic care plan for this resident, initiated in November, included interventions such as administering medications as ordered and monitoring for side effects and efficacy each shift, as well as consulting with the pharmacist and physician for possible dose reductions at least quarterly. Record review showed multiple PRN lorazepam and Seroquel orders that exceeded the 14‑day limit for PRN psychotropic medications without documented physician reevaluation or rationale for continuation beyond that limit. One PRN lorazepam order in October was continued for 25 days, 11 days beyond the 14‑day limit, and a PRN Seroquel order was continued for 22 days, 8 days beyond the limit. In January, another PRN lorazepam order was continued for 23 days, 9 days beyond the 14‑day limit. The MAR documented frequent administration of PRN lorazepam over several months, including doses given during periods when the PRN orders had been continued past 14 days without documentation of reevaluation. The resident also received a PRN dose of Seroquel after the 14‑day limit had passed. There was no documentation in progress notes or hospice notes that the physician had reevaluated the PRN lorazepam to justify its use beyond 14 days. The facility also failed to ensure behavior and side‑effect monitoring for the resident’s lorazepam and Seroquel. The EMR did not show any standing orders for behavior monitoring until an order was entered during the survey, and there was no evidence of consistent behavior monitoring by nursing staff prior to that time. There were no physician orders for side‑effect monitoring for either lorazepam or Seroquel, and no documentation of consistent side‑effect monitoring. Pharmacy medication regimen reviews had previously recommended that behavior tracking be in place for all antipsychotic and anxiolytic medications, that all PRN psychotropics have a 14‑day stop date, and that PRN antipsychotics not be continued beyond 14 days without a new order and justification. These recommendations were not implemented until months later, during the survey period. Staff interviews indicated that nurses and the DON understood that psychotropic medications required behavior and side‑effect monitoring and that PRN psychotropic orders should not exceed 14 days, but the DON acknowledged that behavior and side‑effect monitoring orders were not in place for this resident’s psychotropic medications and that new medication orders were not being reviewed daily.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions leading to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Timely Submit Final Abuse Investigation Reports
Penalty
Summary
The facility failed to submit final reports of its investigations into two separate physical abuse allegations to the State Survey and Certification Agency within the required five working day timeframe, as mandated by both state law and the facility's own Abuse, Neglect and Exploitation policy. In the first incident, involving two residents, the final report was submitted two days late. In the second incident, also involving two residents, the final report was submitted twelve days after the deadline. In both cases, the initial reports were submitted on time, but the final investigative findings were not reported within the required period. The nursing home administrator confirmed during an interview that the investigations and interviews for both incidents had been completed, but acknowledged that the final reports were not submitted in a timely manner. The administrator stated that he was aware of the facility's policy and the state reporting timelines, and that the delay was due to his failure to submit the reports on time. The facility's policy requires reporting all alleged violations and the results of investigations to the appropriate authorities within specified timeframes, which was not followed in these instances.
Environmental Safety and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations revealed multiple environmental deficiencies, including detached and soiled hallway ceiling tiles with visible discoloration, frayed edges, and signs of repeated water damage. The drywall in common areas and nurses' stations showed irregular staining and discoloration, indicating potential moisture exposure and improper attachment to supporting framing, resulting in sagging and warping. Light fixtures in the foyer were partially detached from the ceiling, exposing wiring and support components in a high-traffic area. Additionally, swamp coolers in one hallway were found to be discolored and soiled with various substances. Interviews with the maintenance director and the nursing home administrator confirmed that repairs had been started but were left incomplete due to issues with external contractors and lack of staff familiarity with certain equipment, such as the swamp coolers. The maintenance director was unable to provide documentation of maintenance records, and the facility's policy for maintaining a safe and sanitary environment was not provided upon request. These actions and inactions resulted in the facility not meeting the required standards for environmental safety and cleanliness.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from abuse by another resident, resulting in both physical and verbal abuse incidents. In the first incident, a resident with severe cognitive impairment and a history of wandering entered another resident's room. The resident whose room was entered became upset, waved his fists, and contact occurred that caused the wandering resident to fall and sustain a bruise and abrasion. Both residents involved had cognitive impairments, and the incident was substantiated as physical abuse by the facility. Prior to the incident, the care plan for the wandering resident noted the risk of physical aggression and included interventions such as encouraging direct line-of-sight supervision to prevent wandering into other residents' rooms. In the second incident, another resident with severe cognitive impairment and agitation was verbally abused by the same resident who had previously engaged in physical aggression. As the resident in a wheelchair approached the aggressor's room and touched a stop sign on the door, the aggressor became visibly angry and yelled loudly, causing the other resident to appear scared and confused, with observable physical signs of distress. Staff immediately intervened to separate and redirect the residents. The care plan for the verbally abused resident included interventions for wandering and agitation, but the incident still occurred. Staff interviews revealed that the resident who committed the abuse was known to display verbal aggression, particularly in the afternoon, and that staff were aware of his behavioral triggers. On the day of the verbal abuse, staff were occupied with other residents and unable to prevent the incident. The social services director was not aware of the verbal abuse incident until informed during the survey, indicating a lack of immediate awareness and response to the event. The facility's failure to prevent these incidents resulted in residents not being kept free from abuse as required by policy.
Failure to Administer Prescribed Antibiotic Due to Unavailability
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering a prescribed antibiotic, Fidaxomicin, as ordered by the physician. The resident, an 83-year-old with diagnoses including diverticulitis with perforation and abscess, lower abdominal pain, bipolar disorder, and a history of C. difficile infection, was admitted with a physician's order for Fidaxomicin 200 mg twice daily for 10 days. Review of the medication administration record and progress notes confirmed that the antibiotic was not administered from admission through the review period, with documentation indicating the medication was not available. Nursing staff and the DON reported that the medication was not in stock, was expensive, and not included in the emergency kit, and that attempts were made to contact the infectious disease doctor for alternatives, but no alternative was provided or documented. The resident and her representative both confirmed that the prescribed antibiotic was not given since admission. The DON stated that the pharmacy indicated a delay in obtaining the medication and that she attempted to contact the infectious disease doctor and the hospital for clarification, but did not document all communication attempts. The physician assistant confirmed that there was no approved alternative for the resident's condition and was not aware the medication was never administered. There was no documentation in the medical record regarding the reason for holding the antibiotic or the anticipated delivery date, and no evidence of discontinuation or substitution by the medical team.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. The incident involved a resident with severe cognitive impairments who was kissed on the mouth without consent by another resident with a history of making unwanted sexual advances. The facility's investigation determined that no abuse occurred due to both residents having cognitive impairments and no apparent adverse effects, but the report identifies the incident as sexual abuse. The resident who committed the act had a history of behavioral issues related to dementia, including making unwanted sexual advances when agitated. Despite this history, the resident's care plan did not include new person-centered interventions to prevent reoccurrence after the incident. The resident was known to become agitated with changes in routine and staff, which was the case on the day of the incident. The staff, including a registered nurse, responded by separating the residents and monitoring them for behavioral changes. However, the report highlights that the facility did not have specific interventions in place to manage changes in routine and staff, which contributed to the resident's agitation and subsequent behavior. The facility's failure to implement adequate preventive measures and interventions led to the deficiency.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, two residents, who were dependent on staff for bathing, did not receive their scheduled showers. The facility's policy required that shower schedules be determined based on resident preference and documented accordingly, but this was not adhered to. Resident #3, who had moderate cognitive impairments and required assistance with daily activities, reported receiving only two showers and one bed bath since admission. The resident's care plan indicated a need for moderate assistance with showering, and the shower schedule showed she was to receive showers twice a week. However, records revealed she received only 10 out of 18 scheduled showers, with no documentation explaining the missed showers or interventions attempted. Staff interviews confirmed that the elimination of a bath aide and insufficient staffing contributed to the failure to provide scheduled showers. Resident #8, who was cognitively intact but had functional limitations, also did not receive the scheduled showers. Despite expressing a preference for showers over bed baths, the resident's care plan inaccurately reflected a preference for bed baths. The resident received or refused a bath only five out of eight opportunities in August and three out of seven in September. Staff interviews highlighted a lack of documentation for refusals and interventions, and the assistant director of nursing acknowledged the need for accurate charting and adherence to resident preferences.
Failure to Provide Residents with Choice of Attending Physician
Penalty
Summary
The facility failed to honor residents' rights to choose their attending physician, as evidenced by the switch to a new provider group without notifying all residents or providing them with options. The Director of Nursing (DON) was unable to provide the facility's policy on resident choice of attending physician when requested. Interviews with residents revealed that they were not informed about the change in providers and were not given a choice. One resident expressed dissatisfaction with the new provider, citing issues with medication management and lack of communication. Record reviews showed no documentation of resident notification or choice regarding the change in providers. The DON confirmed that the provider group switch affected almost all residents and acknowledged the lack of written notice to residents. The Regional Director of Quality Assurance also confirmed that it was the facility's responsibility to inform residents and provide them with a choice, but no documentation of such notification was available.
Inconsistent Food Quality and Temperature in Meal Service
Penalty
Summary
The facility failed to consistently serve food that was palatable, attractive, and at a safe and appetizing temperature. Residents reported various issues with the food, including taste, temperature, and quality. Interviews with multiple residents revealed complaints about cold, overcooked, and unappetizing food. Residents expressed dissatisfaction with the menu choices, taste, and temperature of the meals served. Observations during a test tray evaluation showed that the food temperatures were not within acceptable palatable ranges, with items like the tilapia fillet and peas being below the required temperature. The facility's policy on Meal Preparation for Nutritive Value and Palatability emphasized the importance of conserving nutritive value, flavor, and appearance of food. However, residents consistently reported receiving food that did not meet these standards. Despite the opportunity for residents to provide feedback and request substitutes, issues with food quality persisted. The dietary manager mentioned conducting test trays to ensure food quality, but the observations during the evaluation revealed discrepancies in temperature and taste, indicating a lack of consistency in food preparation and service.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner in various areas, including the main kitchen, main dining room, nourishment rooms, and resident units. Observations revealed multiple instances where staff did not perform proper hand hygiene, handle glassware appropriately, wash hands, change gloves, label and date food items, and cover food during transport. Staff members were observed not washing hands or changing gloves between tasks, handling glassware improperly, and failing to label and date food items in nourishment rooms. Additionally, food items on meal trays were not adequately covered during transport in the hallway to resident rooms, potentially exposing the food to contamination. During observations in the main dining room, staff members were seen handling glassware and serving residents without proper hand hygiene, potentially leading to contamination of food-contact surfaces. In the main kitchen, staff did not wash hands or change gloves appropriately while plating and serving resident meals, increasing the risk of cross-contamination. Furthermore, in one of the nourishment rooms, food items were not labeled, dated, or disposed of timely, potentially compromising food safety and quality. The deficiency in food handling practices was also evident during meal delivery to resident rooms, where food items on meal trays were not adequately covered, risking contamination during transport. Staff interviews revealed that while some staff members were aware of proper food handling practices, there were instances where staff lacked understanding or compliance with established protocols. The facility's policies and procedures regarding hand hygiene, glove usage, labeling and dating of food items, and food transport were not consistently followed by staff members, leading to the identified deficiency in food safety practices. The lack of adherence to established guidelines and protocols in various areas of food handling and service contributed to the deficiency reported by surveyors, highlighting the need for improved staff training and oversight in ensuring compliance with food safety standards.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide assistance with activities of daily living (ADL) for three residents, specifically failing to ensure they received showers as scheduled. Resident #15, who had a history of respiratory failure, kidney disease, diabetes, and anemia, was cognitively intact and required moderate assistance for oral hygiene and was dependent for tub and shower transferring, showering, and dressing. Despite her preference for a bath over a shower due to a traumatic experience at a previous facility, she did not receive any showers or sponge baths between February and March 2024. The facility's documentation did not reflect her preferences or any interventions attempted when she missed her scheduled showers. Resident #37, diagnosed with kidney disease, low blood pressure, diabetes, and epilepsy, was also cognitively intact and required substantial assistance with showering. He was observed with disheveled and greasy hair, indicating a lack of proper hygiene. The records showed that out of 16 scheduled opportunities for showers from February to March 2024, he only received two showers. Staff interviews revealed a lack of awareness about his shower schedule and indicated that the night shift staff were not providing showers for many residents. Resident #60, who had severe cognitive impairment and was dependent on staff for showers, was supposed to receive bed baths three times a week. However, the records indicated that out of six opportunities for bathing from January to February 2024, the resident only received one bath. The documentation did not show any refusals or progress notes explaining the missed baths. The DON confirmed that the resident should have received six baths during the reviewed period but did not, and there were no notes indicating any refusals.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to promote and maintain the residents' dignity for two residents. Resident #45, who has multiple diagnoses including multiple sclerosis and COPD, did not receive his breakfast and lunch meals in a timely manner. On one occasion, he had to go to the kitchen himself to order his meal, and on another occasion, he was only provided with peanut butter and jelly sandwiches after his call light was activated. Interviews with staff revealed that there was no verification process to ensure meal orders were taken and delivered, and food was discarded after meal service, leaving residents without proper meals if they missed the initial service time. Resident #57, who has diagnoses including sepsis and neuropathy, reported that staff frequently entered her room without knocking or identifying themselves. This was observed during the survey when a physical therapist entered her room without knocking and without wearing a name badge. Interviews with staff confirmed that they were aware of the policy requiring them to knock and identify themselves before entering a resident's room, but this practice was not consistently followed. The deficiencies highlight a lack of adherence to policies designed to ensure residents' dignity and respect. The facility's failure to provide timely meals and to ensure staff knock and identify themselves before entering rooms directly impacted the residents' quality of life and sense of dignity.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure that Resident #1 received all prescribed medications per the physician's orders, resulting in significant medication errors. Specifically, the resident did not receive doses of Bisacodyl, Baclofen, Linaclotide, and Zonisamide on various dates in March 2024. The medication administration records (MAR) and progress notes indicated that these medications were unavailable, and there was no documentation that a provider was notified about the unavailability of these medications. Resident #1, who has diagnoses including paraplegia, sciatica, low blood pressure, epilepsy, major depressive disorder, anxiety disorder, and morbid obesity, reported that the facility had run out of his seizure medication for two days. Despite the facility's policy requiring that medications be administered accurately and timely, and that providers be notified if medications are unavailable, this protocol was not followed. The resident's computerized physician orders (CPO) and MAR revealed multiple instances where medications were not administered as prescribed, and there was a lack of documentation indicating that the provider was informed. Interviews with facility staff, including an LPN, a CNA, and the DON, confirmed that there were issues with medication reordering and communication with the pharmacy. The staff acknowledged delays in receiving medications and the need to notify providers when medications were unavailable. Despite in-service education provided to the staff on medication availability and the need to notify providers, the deficiency persisted, as evidenced by the continued failure to administer Resident #1's medications and the lack of proper documentation and provider notification.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to provide routine dental care to Resident #13, who was one of three residents reviewed for ancillary services. Despite a physician order for dentist appointments as needed, there was no documentation in the resident's electronic medical record (EMR) indicating that the resident had been offered or provided access to dental care. The resident, who was cognitively intact and required assistance with various activities of daily living, reported not having been to a dental appointment in two years and stated that facility staff did not ask residents about appointments but only informed them if an appointment was set up. Interviews with facility staff revealed further deficiencies. Certified nurse aide (CNA) #4 stated that Resident #13 did not request to see a dentist, while the social services director (SSD) confirmed that there was no documentation of the resident refusing dental services. The SSD also noted that Resident #13 had not signed a consent form for dental services and had not been seen by a dentist. The facility did not document resident refusals of dental services, contributing to the failure to provide necessary dental care to Resident #13.
Environmental Deficiencies in Laundry Area
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, specifically in the laundry area. Observations revealed multiple environmental concerns, including a non-functional exhaust fan with exposed wires in the soiled linen room, unfinished sheet rock and a hole in the ceiling in the sorting room, chipped paint on the ceiling above a dryer, and a fluorescent light cover hanging down with lint inside. Additionally, there were five holes in the ceiling, two holes in the walls, and lint accumulation behind dryers and on the walls in the laundry room. The Environmental Services Director (ESD) was unaware of these issues and stated she would notify the Maintenance Supervisor (MS). The MS confirmed there were no open work orders for the laundry area and acknowledged the need for repairs, noting that the lint and holes posed a fire safety hazard. The facility's policy on submitting maintenance requests was provided, but no specific protocol for addressing environmental issues was available by the end of the survey. The MS admitted he had never been in the soiled linen area before and had not noticed the wall and ceiling issues in the laundry room. He confirmed that the exhaust fan needed replacement and that all observed environmental concerns required repair. The lack of awareness and action from both the ESD and MS contributed to the failure in maintaining a safe and sanitary environment in the laundry area.
Latest citations in Colorado
A resident with severe dementia, hallucinations, delusions, and chronic pain, who was independent with mobility and at risk for wandering, was struck in the face by another cognitively impaired resident known to exhibit verbal and physical aggression and to be highly protective of her room. An RN heard a commotion, saw the victim outside the aggressor’s room, and attempted to intervene but witnessed the aggressor hit the victim before reaching them, resulting in a lip laceration and bruise. The aggressor’s care plan noted use of a doorway stop sign or closed door and the need to redirect others away from her room, but she often refused these measures. At the time of the incident, only one CNA and one nurse were on the memory care unit due to an unfilled CNA call-in, and staff reported it was difficult to manage when two CNAs were not present. The facility investigation substantiated the event as abuse and identified that both residents may have had increased pain contributing to agitation before the altercation.
A resident with severe cognitive impairment and multiple chronic conditions intentionally slid from a wheelchair to sit on the floor and refused assistance to return to the chair. An LPN directed two CNAs to place a blanket under the resident and drag the resident across the floor, onto an elevator, and to another floor, rather than allowing the resident to remain seated on the floor as requested. The resident later reported trying to resist and stated dislike of the experience. Documentation by the LPN omitted how the resident was actually moved between floors, despite care plan goals for dignity and autonomy and a facility policy requiring residents be treated with dignity and respect and that their choices and preferences be honored.
Surveyors found that staff repeatedly failed to follow hand hygiene and Enhanced Barrier Precautions (EBP) requirements. CNAs and an LPN provided direct care, including incontinence care, use of a mechanical lift sling, and gastric tube feeding, without performing hand hygiene before or after care and without using required gowns for residents on EBP. One CNA handled a soiled lift sling, touched his hair and face, used a touchscreen to document care, and then assisted another resident without cleaning his hands. Another CNA entered an EBP room wearing only gloves, not a gown, and did not perform hand hygiene after removing gloves. An LPN handled a feeding tube and provided care to residents on EBP without hand hygiene or gown use. A resident’s representative reported seeing staff work with a feeding tube without gloves or a gown, while staff interviews and facility policy described correct practices that were not followed in practice.
A resident with severe cognitive impairment and multiple serious diagnoses had a physician-appointed health care proxy who reported that the facility did not inform her when the resident’s condition changed or when an antibiotic was started, and that her calls were not returned for days. Another representative for the same resident stated that calls went to a general voicemail and were rarely or very slowly returned. Grievance records documented repeated concerns about delayed communication, lack of notification about new medications, and difficulty reaching staff. Other residents’ representatives similarly reported that calls to check on residents or report suspected verbal abuse went to voicemail and were returned late or not at all, while staff acknowledged that calls often went to voicemail and that several calls from representatives were missed or delayed.
The facility failed to investigate an allegation of verbal abuse and threats between two cognitively impaired roommates after a family member, who was on the phone with one resident, reported hearing the other resident yelling loudly and making threats. The resident’s representative could not reach staff by phone and contacted EMS, which responded to the facility, yet no investigation or documentation of the altercation, alleged threats, or EMS involvement was found in either resident’s record. Staff acknowledged loud yelling and arguing and initiated a room change, but the RN did not fully inform the DON, the SSD—who was not present—dismissed the event as a simple argument, and the NHA did not treat or report it as abuse, contrary to facility policies requiring identification, investigation, and reporting of possible verbal or mental abuse by other residents.
Unsafe food handling and kitchen sanitation practices were observed in the dining room and main kitchen. Staff handled ready-to-eat foods with bare hands, failed to wash hands between tasks and after bathroom use, and touched food, dishes, and meal tickets while plating and serving meals. The facility also kept moldy croissants in dry storage, used a pencil to prop up a hood drip pan, and allowed a dietary aide with artificial nails and multiple bracelets to serve residents.
The facility failed to maintain and document safe food temperatures during meal service, resulting in cold foods being held and served within the temperature danger zone and incomplete temperature logs on multiple days. During a lunch service observation, various forms of chicken salad were held at 45–55°F, yet plates were assembled and sent out, and a resident reported that meals delivered to the room were always cold and often not eaten. Staff interviews showed inconsistent understanding of required hot and cold holding temperatures and confirmed that temperature logs were sometimes not completed as required.
Failure to Honor Residents’ Choice of Attending Physician: Three cognitively intact residents said they were not allowed to choose their own attending physician and were required to see the facility MD instead. EMR and admission agreement review showed no documentation that they were offered a choice of physician, despite one resident wanting to continue with a community PCP. The NHA stated residents could choose their attending physician, but also said the facility had only one physician available for residents to choose from.
Psychotropic Medication Documentation and PRN Behavior Monitoring Deficiencies Survey review found that several residents had psychotropic medications ordered without documented physician rationale, resident-specific target behaviors, or individualized non-pharmacological interventions. Generic behavior-monitoring orders were used instead of approaches tied to each resident’s history, interests, and identified behaviors, and one resident’s PRN antipsychotic was administered multiple times without documentation of attempted non-pharmacological interventions before use. The EMR also showed notes of stability or no unwanted behaviors for some residents, yet the records still lacked rationale supporting continued psychotropic treatment.
Failure to Address Suicidal Ideation and Individualized Psychosocial Needs: The facility did not adequately address suicidal statements, trauma-related needs, or individualized behavioral interventions for multiple residents. One resident with dementia, anxiety, and PTSD made a suicidal threat, but the record did not show ongoing safety monitoring or documented follow-up. Another resident with PTSD, depression, and a history of trauma and suicide attempts had ongoing depressive symptoms, but the care plan and orders did not reflect the PASRR-identified need for therapeutic support, psychiatric oversight, coping skills, or a safety plan. A third resident with autism and mood disturbance had inappropriate sexual behavior toward the DON, but the care plan was not updated with person-centered interventions specific to that behavior.
Failure to Prevent Resident-to-Resident Physical Abuse on Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. On the date of the incident, an RN heard a commotion in the hallway outside the alleged assailant’s room and observed that resident strike another resident, causing the victim’s lip to bleed. The RN had seen both residents near the medication cart a few minutes earlier without concern and attempted to intervene when she saw the victim standing outside the assailant’s room, but was unable to reach them before the strike occurred. The two residents were then separated, and frequent checks were initiated. The victim was a younger-than-65 resident with vascular dementia (severe, with agitation), Alzheimer’s disease, Lewy body disease, bipolar disorder, and chronic pain. Her MDS showed short- and long-term memory problems, hallucinations, delusions, and physical and verbal behaviors toward others, with moderately impaired cognition and impaired decision-making. She was independent with mobility and had a care plan for wandering and dementia that identified her as pleasantly confused and easily redirected, with interventions to identify wandering patterns, offer diversions, and assess for pain or toileting needs when agitated. Documentation on the day of the incident noted her involvement in a resident-to-resident altercation, a small laceration to the middle of her upper lip, and a small bruise below her lower lip. The assailant was an older resident with severe vascular dementia with agitation, memory deficit after intracranial hemorrhage, and recurrent depressive disorder. Her MDS documented short- and long-term memory problems, fluctuating disorganized thinking, and verbal behaviors directed toward others that could significantly intrude on others’ privacy or disrupt the environment. Her behavior/dementia care plan identified verbal aggression (yelling/screaming), physical aggression (hitting), refusal of care, withdrawal, tearfulness, and negative statements, and noted that she was protective of her room and became upset if others entered or tried to enter. The care plan included use of a velcro stop sign across her doorway or keeping her door closed, but also documented that she often declined having the door closed, requiring staff to redirect other residents away from her room. Staff statements indicated that at the time of the incident there was one CNA and one nurse on the memory care unit, that one CNA had called in and was not replaced, and that it was hard when there were not two CNAs on the unit. The facility’s investigation substantiated the incident as abuse and identified that both residents may have been experiencing increased pain leading up to the altercation, with pain, constipation, and urinary retention noted as contributing factors for the victim and hand contracture pain and refusal of interventions noted for the assailant.
Resident Dragged on Blanket Instead of Honoring Request to Sit on Floor
Penalty
Summary
The deficiency involves a failure to honor a resident’s right to dignity and self-determination when staff did not allow the resident to remain seated on the floor per his wishes and instead dragged him on a blanket between floors. Late at night, the resident, who lived on the second floor, was in his wheelchair on the first floor and intentionally slid out of his wheelchair to sit on the ground according to his own wishes. When staff offered assistance to help him back into his wheelchair, he refused. Despite this refusal, an LPN directed two CNAs to move the resident from the first floor back to the second floor. Following the resident’s refusal to get back into his wheelchair, the LPN instructed the CNAs to place a blanket underneath the resident so he could be dragged while lying on it. The CNAs and the LPN maneuvered the blanket under the resident by moving him from side to side. One CNA positioned herself behind the resident and placed her arms under his armpits, while the other CNA held the resident’s pants at his ankles. The LPN then pulled on the blanket with the resident on it. Together, the three staff members dragged the resident on the blanket across the floor and onto the elevator, transported him to the second floor, and then dragged him off the elevator onto the second floor hallway. Once on the second floor, the resident agreed to have two staff members assist him back into his wheelchair, and a two-person transfer was performed to lift him from the floor into the chair. The resident later reported that he remembered being pulled on the blanket, stated that he "tried to fight them like crazy," and said he did not like what had been done. The nursing progress note written by the LPN the following morning documented that the resident had remained on the first floor until late at night, refused to talk with staff, refused care, and declined snacks, fluids, and redirection, but the note did not document how he was actually relocated to the second floor. The resident’s records showed he had severe cognitive impairment with a BIMS score of 3/15, diagnoses including Parkinson’s disease, depression, unspecified intellectual disabilities, traumatic brain injury, seizures, and chronic kidney disease stage 3, and care plan goals that included being treated with dignity and autonomy. The facility’s dignity policy stated that residents are to be treated with dignity and respect at all times, that their choices and preferences are to be honored, and that demeaning practices are prohibited, which was not followed in this incident.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to hand hygiene and adherence to Enhanced Barrier Precautions (EBP) on all four units. The facility’s own policies require hand hygiene before and after direct patient care and the use of gowns and gloves during high-contact care activities for residents on EBP. CDC guidance cited in the report emphasizes that hand hygiene protects both healthcare personnel and patients, and that EBP requires targeted gown and glove use during high-contact resident care activities, particularly for residents with wounds, indwelling devices, or MDRO colonization or infection. Surveyors observed multiple instances where staff did not follow these requirements. An unidentified CNA exited a room of a resident on EBP without wearing a gown while providing care. On another occasion, a CNA exited a resident’s room carrying a soiled mechanical lift sling without gloves, failed to perform hand hygiene, touched his hair and face, used a touchscreen to document care, and then entered another resident’s room to answer a call light and assist with a request without performing hand hygiene before or after assisting that resident. Another CNA entered the room of a resident on EBP, donned only gloves without a gown, provided incontinence care, then left the room with soiled linens and trash properly disposed of, removed gloves, but did not perform hand hygiene before caring for another resident. Additional observations showed an LPN entering the room of a resident on EBP for gastric tube feeding, setting up and handling the feeding tube without performing hand hygiene beforehand and without wearing a gown. The same LPN later entered another EBP room, provided care, and left without performing hand hygiene. A resident’s representative reported seeing staff work with the resident’s feeding tube without gloves or a gown. In interviews, CNAs and nursing staff described correct hand hygiene and EBP practices, including washing hands for about 20 seconds and using gowns and gloves for residents on EBP, and the DON stated she expected staff to perform hand hygiene when entering and exiting rooms and to follow EBP procedures requiring gown and glove use. These stated practices conflicted with the observed failures in hand hygiene and EBP adherence documented by surveyors.
Failure to Notify Health Care Proxy and Return Calls Regarding Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to inform a resident’s physician-appointed health care proxy of changes in the resident’s condition and new treatments, and to return the proxy’s calls in a timely manner. Facility policy on Notification of Changes required informing the resident, consulting with the physician, and notifying the family member or legal representative when there was a change requiring such notification, and specified that when residents were incapable of making their own decisions, the representative would make necessary decisions. Resident #1 was under 65, admitted with diagnoses including paralysis and weakness following a stroke, respiratory failure, cognitive communication deficit, and encephalopathy, and was documented as severely cognitively impaired with a BIMS score of 0/15, indicating reliance on the health care proxy for decision-making. The health care proxy reported that the facility made it very difficult to contact the resident, stating that staff did not return calls for days and that she was not informed when the resident developed an infection and was started on an antibiotic until after the medication had already been initiated. She stated she had several questions about the medication and was not consulted on the medical decision prior to its start. Another representative reported that calls to the facility went to a general voicemail and that her messages were either not returned or took several days for a response. Grievance records showed repeated concerns from the resident’s representatives about delays in speaking with the resident, delays in return calls, and lack of notification about new medications and changes in condition. Additional interviews with other residents’ representatives supported a broader pattern of delayed or absent communication. One representative of another resident reported that his call to check on a newly admitted resident went to voicemail and was not returned for two days. Another resident’s representative and a secondary witness reported that when they attempted to report suspected verbal abuse, their calls to the facility and to the SSD went to voicemail and were never returned. Staff interviews confirmed that calls first went to the front desk and then to the nurses’ stations, that calls often went to voicemail when nurses were unable to answer, and that voicemail messages were expected to be returned within 24 hours. The NHA acknowledged that several calls from the resident’s representatives went to voicemail and that calls were often made during shift change when it was harder to reach the nurse on duty, but there was no documentation to support the claimed regular communication with the health care proxy.
Failure to Investigate Alleged Verbal Abuse Between Cognitively Impaired Roommates
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of verbal abuse and threats between two cognitively impaired residents after a family member reported overhearing the incident. Facility policy on abuse, neglect, exploitation, and misappropriation requires that all possible incidents of abuse, including verbal and mental abuse by other residents, be identified, investigated, and reported within required timeframes, with residents protected from further harm during investigations. The policy on identifying types of abuse specifies that yelling or hovering over a resident with intent to intimidate is an example of mental and verbal abuse. Despite these policies, the facility did not initiate or document an investigation into a reported verbal altercation that included alleged threats. One resident, under age 65, with dysphagia, left-sided hemiplegia, attention and concentration deficit, delusional disorder, and major depressive disorder, had moderate cognitive impairment and was dependent on staff for most ADLs. He reported that he and his roommate yelled back and forth at each other after the roommate told him to “shut the [expletive],” but he did not recall the specific words used and denied any physical contact. His guardian stated that he later reported being fearful of his roommate after the incident. Another representative, who was on the phone with him during the event, reported hearing the roommate yelling loudly and making threats toward him, then hearing a nurse enter to calm the situation. This representative attempted to call the facility to report the yelling and threatening behavior, was sent to voicemail without a return call, and subsequently contacted emergency services. The roommate, an older resident with dementia, cognitive communication deficit, depression, and insomnia, also had moderate cognitive impairment and required staff assistance for most ADLs. He did not recall the incident, and his representative only learned of it the following day and was told it involved yelling about loud phone use. A review of both residents’ medical records revealed no documentation of the verbal altercation, the alleged threats, or related concerns, and no investigation documents were produced when requested. Staff interviews confirmed there had been loud yelling and arguing, that EMS responded to the facility, and that a room change was initiated due to the incident, but the RN who responded did not report the EMS involvement to the DON. The SSD, who was not present during the incident, characterized it as just an argument and stated there were no threats, and the NHA stated the event was not reported as abuse because they believed no threats were made. No contemporaneous interviews with the residents were documented, and no inquiry was made by facility staff into why EMS had been called in relation to the altercation, resulting in a failure to investigate the allegation of verbal abuse as required by facility policy.
Unsafe Food Handling and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the main kitchen and dining areas. During meal service observations, staff repeatedly handled ready-to-eat foods with bare hands and did not perform hand hygiene when changing tasks, after touching dirty dishes, after using the bathroom, or before serving food. An LPN cut a resident’s patty melt and handed pieces to the resident with her bare hand without sanitizing her hands. A DA passed drinks by touching the rims of cups, and another DA tore a resident’s patty melt into smaller pieces with bare hands and handed food to the resident. During a later observation, kitchen staff continued to work without washing hands between tasks and while handling food, dishes, and meal tickets. A DA entered the kitchen from the dishroom and did not wash his hands before putting away snacks. A cook did not wash her hands after working at the sink, after touching dirty dishes, after exiting the bathroom in the kitchen, or before serving room trays. She was observed touching shrimp, corn bread, rice, squash, cheese, and frozen fries with bare hands while plating and preparing meals, and she also handled fryer baskets and food items without washing her hands. Another cook wiped her hands on her clothing, handled meal tickets, and touched ready-to-eat foods with bare hands while assembling plates and serving meals. The facility also failed to discard expired or spoiled food, maintain equipment in good repair, and prevent staff from wearing prohibited items while preparing or serving food. A plastic bag of croissants in dry storage contained bread-like food covered in dark green and black fuzz and remained on the bread rack on two separate observations. In the kitchen hood system above the grill, a half wooden pencil was being used to hold up the grease drip pan on two observations. In addition, a dietary aide taking meal orders, passing drinks, and serving meals had artificial nails approximately half an inch long and multiple fabric bracelets on her wrists while working with residents.
Failure to Maintain and Document Safe Food Temperatures During Meal Service
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner by not maintaining appropriate food temperatures during meal service and by not consistently documenting food temperatures as required. During a continuous observation of lunch meal service, chicken salad, including soft and bite-sized and pureed versions, was found on the steam table at temperatures of 55°F and 45°F, which were within the documented temperature danger zone and below the required cold-holding standard. Despite these temperatures, plates with wedge chicken salad and a Hawaiian roll were assembled and placed on the meal cart for service. A resident reported that meals delivered to his room were always cold, leading him not to eat them and to attempt to obtain food from outside the facility. Review of the facility’s April 2026 food temperature logs showed multiple instances where temperatures were not documented for breakfast, lunch, and dinner services on numerous dates. Staff interviews revealed inconsistent understanding and application of proper holding temperatures, with the cook and dietary manager providing varying temperature thresholds that did not align with the facility policy or the Colorado Retail Food Establishment Rules and Regulations. The cook acknowledged that the wedge chicken salad should not have been served at 55°F and attributed difficulty maintaining proper temperatures to a hot room with inadequate ventilation, while the dietary manager stated that cooks sometimes forgot to complete the temperature logs.
Failure to Honor Residents’ Choice of Attending Physician
Penalty
Summary
The facility failed to ensure three cognitively intact residents were allowed to choose their own attending physician. Resident #15, Resident #28, and Resident #30 each stated during a group interview that they did not have a choice in who their physician could be while in the facility and that they had to see the facility’s MD. Resident #15 said she had a primary care physician in town that she wanted to continue seeing, but she was told she could not see that physician. Resident #28 and Resident #30 each said they were required to see the facility’s MD instead of choosing their own physician. Record review for each of the three residents, including the admission agreement and EMR, showed no documentation that they were provided a choice of attending physician. Resident #15 had diagnoses including COPD, cirrhosis of the liver, and osteoarthritis, and her MDS showed she was cognitively intact with a BIMS score of 15. Resident #28 had diagnoses including type 2 diabetes mellitus, asthma, osteoarthritis, and TIA/cerebral infarction, and was also cognitively intact with a BIMS score of 15. Resident #30 had diagnoses including type 2 diabetes mellitus, wedge compression fracture of T11-T12 and L3, and hypertension, and his MDS likewise showed a BIMS score of 15. The NHA stated residents were able to choose their attending physician when admitted, but also said the facility had one physician residents could choose from and was not aware that these residents wanted different physicians.
Psychotropic Medication Documentation and PRN Behavior Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure four residents were free from unnecessary psychotropic medication use and chemical restraint concerns. Survey review found that the facility did not document a physician’s rationale for the continued use of psychotropic medications for three residents, did not document resident-specific care approaches with medication-specific target behaviors and person-centered interventions for those residents, and did not ensure one resident’s PRN antipsychotic use had corresponding documentation of identified behaviors and non-pharmacological interventions. For one resident with PTSD, anxiety, and depression, the record showed buspirone, Valium, duloxetine, and Lexapro orders with behavior-monitoring language, but the orders did not identify resident-specific non-pharmacological interventions for specific behaviors. The resident’s PASRR described a history of self-harm, suicidal thoughts, mood swings, loss of interest, and low energy, and recommended therapeutic interventions, coping skills, psychiatric oversight, increased socialization, and activities such as puzzles, games, and painting. The EMR review did not show documented behaviors during the review period, and it did not show a physician rationale to justify continued psychotropic use. For another resident with schizoaffective disorder, dementia, anxiety, and depression, the care plan and orders listed generic interventions and behavior targets such as screaming, hallucinations, kicking, and yelling, but the resident-specific behaviors and interests identified in the PASRR, including hearing the devil inside her head and being soothed by prayer and rosary use, were not incorporated into the behavior-monitoring orders or care plan. The record also lacked documentation of non-pharmacological interventions used for the resident’s behaviors and lacked a physician rationale for continued psychotropic use despite notes stating the resident was stable and not experiencing unwanted behaviors. A third resident with vascular dementia, anxiety, and PTSD had orders for Abilify, mirtazapine, sertraline, clonazepam, and behavior monitoring tied to verbal aggression, exit seeking, tearfulness, and hitting staff, but the orders remained generic and did not reflect the resident’s individualized approaches such as listening to 80’s rock music or watching a favorite program when crying or confused. The EMR again did not show a physician rationale for continued psychotropic use despite notes indicating pleasant mood and no unwanted behaviors. For the resident who died during the stay and had dementia and depression, the record showed Lexapro, Seroquel, and PRN injectable haloperidol ordered for behaviors such as swinging at staff and agitation. The PRN haloperidol order did not list a diagnosed specific condition, only behaviors, and the order for non-pharmacological interventions was not initiated until after the resident had already been receiving psychotropic medications. MAR and order administration notes showed multiple PRN haloperidol administrations, but several entries lacked documentation of attempted non-pharmacological interventions before the medication was given, and one note only documented encouragement to sit down without identifying the other ordered interventions or their effectiveness.
Failure to Address Suicidal Ideation and Individualized Psychosocial Needs
Penalty
Summary
The facility failed to ensure that residents with mental disorders, psychosocial adjustment difficulties, and trauma histories received appropriate treatment and services to support their mental and psychosocial well-being. For one resident with vascular dementia, anxiety, and PTSD, the record showed repeated depression screens indicating little interest, depressed mood, poor appetite, sleep problems, low energy, and feelings of worthlessness, along with notes describing chronic behaviors potentially causing harm, tearfulness, withdrawal, and anxiety. A behavior note documented that the resident stated she was going to kill herself, but the record did not show documented interventions to keep her safe afterward or ongoing monitoring for suicidal ideation. A second resident with PTSD, anxiety, depression, and a documented history of trauma, self-harm, suicidal thoughts, and numerous suicide attempts had a PASRR evaluation identifying the need for therapeutic interventions, psychiatric oversight, coping skills development, and a safety plan. The resident told staff she had previously seen a therapist at the facility, but that therapy had stopped and no new arrangements had been made. She also reported that staff had not asked about her PTSD triggers or what interventions would help her. The record showed depression screens with ongoing depressive symptoms, but no follow-up documentation after those screenings, and the care plan and physician orders did not reflect the resident’s suicidal history or the specialized services identified in the PASRR. The facility also failed to provide individualized care approaches for a resident with autistic disorder, dementia with mood disturbance, anxiety disorder, major depressive disorder, and cognitive communication deficit. The resident had a history of inappropriate sexual behaviors and was documented as having sexually inappropriate contact with the DON when he squeezed her breast during a dining activity. Although the resident was placed on 15-minute behavior monitoring for 24 hours, the care plan was not revised to reflect a person-centered intervention specific to that sexual behavior. Staff interviews showed that interventions were inconsistently understood and that the nursing staff did not know what person-centered interventions were in place for the resident’s behaviors.
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