Durango Health And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Durango, Colorado.
- Location
- 2911 Junction St, Durango, Colorado 81301
- CMS Provider Number
- 065243
- Inspections on file
- 22
- Latest survey
- March 31, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Durango Health And Rehabilitation during CMS and state inspections, most recent first.
Two severely cognitively impaired residents in a memory care unit, both with dementia and significant behavioral risk factors, became agitated with each other and engaged in a physical altercation that resulted in a facial scratch to one resident. Facility policy required immediate intervention, separation, and monitoring to prevent abuse, and both residents’ care plans identified risks for aggression, anxiety, and resident-to-resident altercations. Staff reported that only one staff member was assigned to seven residents, that residents often invaded each other’s space, and that fights did occur, including a fist fight between these two residents during the incident in question. The facility’s investigation substantiated the event as physical abuse, demonstrating a failure to protect residents from abuse and to implement effective monitoring and behavioral interventions.
A resident with Alzheimer's disease and severe dementia, identified as high risk for elopement and requiring structured activities, was able to leave the facility unsupervised and remained missing for 49 hours before being found with minor injuries and dehydration. The resident's care plan included interventions for wandering, but the facility's outdated wander guard system and lack of effective supervision allowed the elopement to occur.
A facility failed to inform a resident's MDPOA about the discontinuation of Carbidopa-Levodopa, a Parkinson's medication, for 27 days. The resident, with severe cognitive impairments and diagnosed with Parkinson's disease, experienced a rapid decline after the medication was stopped. Staff interviews revealed a misunderstanding of the notification policy, as the DON believed only changes involving psychotropic medications required notification. This led to a significant lapse in communication and adherence to the facility's policy.
The facility failed to follow the posted menus, serving meals that did not match the planned items, such as substituting broccoli with green beans and altering recipes without informing residents. Residents were not consulted about these changes, leading to dissatisfaction. The dietary manager admitted to recipe alterations and communication issues regarding ingredient availability.
The facility failed to maintain a safe environment, as evidenced by an unwitnessed fall of a resident with an improperly functioning call light, incomplete neurological checks, and lack of care plan updates. Additionally, residents were found with medications and heating devices in their rooms without proper assessments or physician orders, highlighting deficiencies in safety protocols and care management.
The facility failed to inform residents about the duration of their COVID-19 isolation. A resident with severe cognitive impairment was not notified about his isolation period, and there was no documentation in his EMR. Another resident with moderate cognitive impairment was unsure of his isolation end date despite being told verbally. A resident with no cognitive impairment was also not informed, and another resident with moderate cognitive impairment was unaware of the reason for his isolation. Staff interviews indicated a lack of documentation and memory aids for residents.
The facility failed to provide timely and complete Notice of Medicare Non-Coverage (NOMNC) to three residents, resulting in a deficiency. A resident received an incomplete NOMNC lacking the last covered day and appeal information, while two other residents did not receive NOMNC letters upon changes to their Medicare coverage. The oversight was attributed to the previous social services department's failure to issue the notices appropriately.
A long-term care facility was found to have a medication error rate of 10.34%, exceeding the acceptable limit of 5%. Errors included administering the wrong insulin type to a resident, failing to provide Lactaid to a lactose-intolerant resident before giving them dairy, and administering levothyroxine after breakfast instead of on an empty stomach. These incidents were confirmed by the DON and consulting pharmacist.
The facility failed to serve food at palatable temperatures, as reported by several residents who consistently received cold meals. An observation confirmed that food temperatures were below the required 135 degrees F, with the dietary manager acknowledging the ineffectiveness of the current food warming methods.
The facility failed to maintain an effective infection control program, with housekeeping staff not following proper sanitation procedures, residents not offered hand hygiene before meals, and improper disposal of contaminated medication cups. Additionally, the water management plan was outdated and not effectively implemented, lacking documentation of Legionella testing.
The facility failed to ensure CNAs received the required 12 hours of training per year due to the absence of a tracking system. A review showed that two CNAs received only seven and eight hours of training, respectively, in the previous year. The staff development coordinator confirmed the lack of a monitoring system and the shortfall in training hours.
The facility failed to manage the personal funds accounts for two Medicaid-funded residents, resulting in their accounts exceeding the Medicaid eligibility limit. There was no documentation of notifications to the residents or their legal representatives when their accounts approached the limit. Interviews revealed a lack of record-keeping and insufficient assistance in spending down funds.
In a memory care unit, a resident with dementia pushed another, causing a fall, while another resident's medication reduction led to increased aggression, resulting in two altercations. Staff witnessed these events, and investigations confirmed physical abuse. The facility's failure to protect residents from abuse by others was evident.
The facility failed to follow professional standards during medication administration for three residents. An ADON left insulin supplies at a resident's bedside, an RN stored medication in her pocket, and another ADON returned tablets to a stock bottle, risking contamination. These actions violated the facility's medication administration policy.
A resident with multiple medical conditions and specific activity preferences was not provided with meaningful activities or one-to-one visits as per her care plan. Observations showed she was often left without engagement, and interviews revealed her feelings of boredom. The activity director confirmed a lack of documentation for the required visits.
Two residents with diabetes did not receive care according to physician orders and facility protocols. One resident had multiple high blood sugar readings without physician notification, while another experienced delays in rechecking high blood sugar levels, contrary to the hyperglycemia protocol. Interviews revealed staff uncertainty and lack of documentation, indicating a failure in diabetic management.
A resident with severe cognitive impairment and multiple health conditions developed a Stage 2 pressure ulcer due to the facility's failure to implement timely interventions. Observations showed the resident was often without pressure-reducing boots and not repositioned as required. Delays in applying physician-ordered interventions, such as nutritional supplements and pressure-reducing devices, contributed to the deficiency.
A resident with limited range of motion did not receive the recommended restorative nursing services following physical therapy discharge. Despite recommendations for services four to five times per week, the resident only received them six times over several weeks, leading to increased stiffness and a fall. Staff interviews revealed awareness of the resident's decline and acknowledged staffing shortages as a contributing factor.
The facility failed to provide necessary respiratory care for two residents. One resident with severe cognitive impairment and multiple diagnoses, including COPD, was not consistently provided with supplemental oxygen as per physician's orders, resulting in low oxygen saturation levels. Another resident, with moderate cognitive impairments, was performing her own tracheostomy care without proper assessment or observation from staff. Interviews revealed a lack of awareness and assessment regarding the residents' needs for respiratory care.
The facility failed to manage pain for three residents by not establishing parameters for PRN pain medications, leading to inconsistencies in administration. One resident with severe cognitive impairment had inconsistent administration of acetaminophen and hydrocodone-acetaminophen for varying pain levels. Another resident with chronic pain syndrome reported having to request all pain medications, and a third resident with a fracture had PRN medications without established parameters. Staff interviews confirmed the lack of necessary pain parameters.
A resident in an LTC facility was administered the incorrect type of insulin due to a medication error. The ADON gave Humulin R instead of the prescribed insulin lispro, following a high blood sugar reading. The error was linked to insurance issues preventing the use of insulin pens, and the facility's diabetic management policy was not followed.
The facility failed to properly store and label medications, with expired and undated items found in medication carts and storage rooms. Staff interviews revealed lapses in adherence to medication management protocols, highlighting a deficiency in maintaining medication safety and compliance.
A resident with Parkinson's disease was not provided the correct dysphagia advanced diet as prescribed, receiving pureed meals instead. Despite being cognitively intact and having no history of choking, the resident's meal tickets did not match the physician's orders. Staff interviews revealed a breakdown in communication and adherence to dietary procedures, leading to the deficiency.
A facility failed to maintain accurate medical records by destroying a resident's Medical Orders for Scope of Treatment (MOST) forms after the resident's death. The resident, who had a history of heart disease and COPD, changed his code status from full code to DNR during his decline, but the facility did not retain the MOST forms in the electronic medical record. Staff interviews revealed a misunderstanding about the status of MOST forms as part of the medical record, leading to their improper destruction.
Failure to Prevent Resident-to-Resident Physical Abuse in Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, specifically resident-to-resident physical abuse between two cognitively impaired residents in the memory care unit. Facility policy required that residents be free from all forms of abuse and that staff immediately intervene, ensure resident safety, and keep residents separated and monitored when an assailant is identified. Despite this policy, the facility’s own investigation of an incident on 11/26/25 documented that two residents in the memory care unit became frustrated and agitated with each other, with elevated voices and defensive body language, and moved their arms as if they were going to hit each other. One resident sustained a superficial scratch above his left eyebrow, and the investigation concluded that the other resident likely made contact, resulting in the injury, and the incident was substantiated as physical abuse. One resident involved had Alzheimer’s disease and schizophrenia, was severely cognitively impaired with a BIMS score of 1, and required maximum assistance with ADLs. His care plan identified him as being at risk for resident-to-resident altercations related to individuals invading his space and at risk for re‑traumatization, with anxiety triggered by male caregivers or those perceived to be male. Interventions in his care plan included providing opportunities for positive interaction and attention, such as stopping and talking with him while passing by. On the date of the incident, a skin assessment documented a scratch above his left eyebrow, consistent with the facility’s determination that he was the victim of physical abuse by another resident. The other resident involved had Lewy body dementia, hypertension, and depression, was also severely cognitively impaired with a BIMS score of 0, and required maximum assistance with ADLs. His behavior care plan identified a risk for verbally abusive behaviors and potential psychosocial issues due to a prior incident in which he had received unprovoked agitation with physical abuse from another resident, with interventions including monitoring for signs of aggression, fear, or psychosocial trauma and documenting behaviors and interventions. An antipsychotic medication care plan further identified him as being at risk for aggressive behaviors, including non‑redirectable agitation, with instructions to intervene immediately if agitation was observed. Staff interviews indicated that only one staff member was assigned to seven residents on the unit, that residents sometimes got into each other’s space and fights occurred, and that the two residents had been seen in a fist fight on the date of the incident, demonstrating that the facility did not effectively prevent or intervene to stop resident‑to‑resident physical abuse in accordance with its abuse prevention policy and the residents’ care plans.
Failure to Prevent Elopement of High-Risk Resident
Penalty
Summary
The facility failed to ensure an environment free from accident hazards and did not provide adequate supervision to prevent accidents for one of three residents reviewed for accidents or hazards. Specifically, a resident with Alzheimer's disease and severe dementia, who was identified as being at risk for elopement and required structured activities and distractions from wandering, was able to leave the facility unsupervised. On the day of the incident, the resident was last seen at the nurses' station around 12:45 p.m. and was discovered missing shortly after lunch was delivered to his room. Staff initiated a search of the building and surrounding areas, and the police were notified when the resident could not be found. The resident remained missing for approximately 49 hours before being located within a mile of the facility. Upon being found, the resident had abrasions and required intravenous fluids at the hospital. The resident's care plan had previously identified him as being at risk for elopement and wandering, with interventions such as documenting wandering behavior, providing structured activities, and using reorientation strategies. Despite these interventions, the resident was able to exit the facility without staff knowledge or accompaniment. Interviews with facility staff revealed that the resident was not a typical dementia patient and had a history of wandering and repetitive questioning. The facility had attempted to place the resident in a secured unit prior to the incident, but this led to behavioral issues. At the time of the incident, the facility's wander guard system had not yet been updated as previously agreed upon by the former managing company, which contributed to the resident's ability to elope.
Failure to Notify MDPOA of Medication Change
Penalty
Summary
The facility failed to inform a resident's medical durable power of attorney (MDPOA) about a significant change in the resident's treatment plan, specifically the discontinuation of Carbidopa-Levodopa, a medication used to manage Parkinson's disease. The resident, who had severe cognitive impairments and was diagnosed with Parkinson's disease and neurocognitive disorder with Lewy Bodies, was admitted to the facility with these conditions. The medication was discontinued on December 2, 2024, based on the physician's recommendation, as it was not at a therapeutic level. However, the MDPOA was not informed of this change until December 29, 2024, during a care conference, which was 27 days after the medication was stopped. Interviews with facility staff revealed a lack of communication and understanding of the notification policy. The nurse practitioner stated that the decision to discontinue the medication was made after consulting with the facility's medical director, and the director of nursing (DON) admitted that the nursing staff only notified residents or their MDPOAs of changes involving psychotropic medications. The DON was unaware that the MDPOA needed to be informed of changes in the resident's care, leading to a significant lapse in communication and failure to adhere to the facility's policy on notifying responsible parties of treatment changes.
Failure to Follow Menus and Communicate Substitutions
Penalty
Summary
The facility failed to ensure that the menus were followed to meet the residents' nutritional needs, as observed during meal services. The facility's policy required that menus be planned in advance and served as written unless a substitution was necessary. However, during observations, it was noted that the food items served did not match the posted daily menus. For instance, during a dinner service, the menu listed shrimp scampi with specific sides, but the meal served included plain spaghetti noodles with a thick white sauce and snow peas, deviating from the planned menu. Similarly, during a lunch service, broccoli florets were replaced with green beans without informing the residents or obtaining their consent. Interviews with residents revealed dissatisfaction with the menu substitutions, as they were not informed or consulted about the changes. One resident expressed that they received a meal they had specifically requested not to have, indicating a lack of communication and consideration for resident preferences. The dietary manager admitted to altering the shrimp scampi recipe by adding cream, which was not part of the original recipe, and acknowledged that this change was not communicated to residents or staff. The dietary manager also mentioned that the kitchen's increased production of soups from scratch was affecting the availability of other ingredients, leading to these inconsistencies.
Deficiencies in Resident Safety and Care Plan Management
Penalty
Summary
The facility failed to ensure an environment free from accident hazards for several residents, leading to multiple deficiencies. Resident #7 experienced an unwitnessed fall in the bathroom, where the call light cord was improperly wrapped around a grab bar, rendering it non-functional. Despite the resident's fall, neurological checks were not completed according to the facility's protocol, as the resident was allowed to leave the facility during the 72-hour post-fall assessment period. Additionally, the resident's fall care plan was not updated with new interventions following the incident. Resident #27 was found to have a jar of wart removal medication and eye drops at her bedside without a physician's order or an assessment to determine her ability to self-administer these medications. Furthermore, there was no safety assessment conducted to evaluate her ability to safely use a hot tea kettle with a heating element in her room. Similarly, Resident #11 had a space heater in his room, and Resident #22 had a coffee maker with a heating element, both without documented safety assessments to determine their ability to use these devices safely. Interviews with staff, including registered nurses and the director of nursing, revealed a lack of adherence to protocols and procedures regarding neurological assessments, medication self-administration, and safety assessments for devices with heating elements. The facility's failure to conduct necessary assessments and update care plans contributed to an environment with potential accident hazards, compromising resident safety.
Failure to Inform Residents About COVID-19 Isolation Duration
Penalty
Summary
The facility failed to ensure that residents were fully informed and understood their health status, care, and treatments, specifically regarding the duration of isolation due to COVID-19. Four residents were affected by this deficiency. Resident #4, who had severe cognitive impairment, was not informed about the length of his isolation or when he could leave his room. There was no documentation in his electronic medical record (EMR) indicating that he or his legal representative was notified about the room change or the isolation period. Resident #53, with moderate cognitive impairment, was also not adequately informed about his isolation period. Although he was told verbally that isolation would last for 10 days, he was unsure of the exact date when it would end. A sign indicating the end date of isolation was placed in his room but was not easily visible to him. Despite repeated inquiries, there was no documentation in his EMR confirming that he or his legal representative was informed about the isolation duration. Resident #70, who had no cognitive impairment, expressed concerns about not knowing when his isolation would end. There was no documentation in his EMR indicating that he was informed about the isolation period. Similarly, Resident #41, with moderate cognitive impairment, was not informed about the reason for his isolation or when he could leave his room. Staff interviews revealed that there was a lack of documentation regarding resident education about COVID-19 infections, and memory aids were not provided to assist residents with cognitive impairments in understanding their isolation status.
Failure to Provide Timely and Complete NOMNC
Penalty
Summary
The facility failed to provide timely and complete Notice of Medicare Non-Coverage (NOMNC) to three residents, resulting in a deficiency. Resident #23, who was cognitively intact and required assistance with daily activities due to hemiplegia and hemiparesis, received an incomplete NOMNC. The notice lacked the last covered day and appeal information, which are essential for the resident to understand their coverage and appeal rights. This omission was confirmed by the Social Services Director (SSD), who acknowledged that the resident would not have been able to appeal without the necessary information. Additionally, the facility did not issue NOMNC letters to Resident #81 and Resident #82 upon changes to their Medicare coverage. Resident #81, who was cognitively intact and independent in activities of daily living, was discharged home with home health services but did not receive a NOMNC letter indicating the last covered day of Medicare A services or appeal information. Similarly, Resident #82, who required supervision and assistance with mobility, was discharged without receiving a NOMNC letter. The SSD and Nursing Home Administrator (NHA) confirmed the absence of these notices, attributing the oversight to the previous social services department's failure to issue them appropriately.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 10.34%. This was due to three specific incidents involving medication administration errors. The first incident involved the assistant director of nursing (ADON) #2 administering the wrong type of insulin to a resident. The resident's physician had ordered insulin lispro (Humalog) to be administered according to a sliding scale, but ADON #2 administered Humulin R instead, which was not labeled and not in accordance with the physician's order. The second incident involved a registered nurse (RN) #1 who failed to administer Lactaid to a lactose-intolerant resident before giving them yogurt, which contained dairy. The RN was unable to find the correct dose of Lactaid and proceeded to administer other medications mixed in yogurt, contrary to the physician's order and manufacturer's guidelines. This resulted in the resident not receiving the medication timely or as prescribed. The third incident involved ADON #1 administering levothyroxine to a resident 90 minutes after the scheduled time and after the resident had eaten breakfast. The medication was supposed to be administered on an empty stomach, as per the physician's order and manufacturer's guidelines. These errors were confirmed through interviews with the director of nursing (DON) and the consulting pharmacist, who highlighted the discrepancies in medication administration.
Failure to Serve Food at Palatable Temperatures
Penalty
Summary
The facility failed to consistently serve food that was palatable, attractive, and at a safe and appetizing temperature, as required by their policy. The policy, revised in February 2023, mandates that food should be prepared to maintain nutritive value, flavor, and appearance, and served at a palatable temperature to ensure resident satisfaction and minimize risks. However, during a group interview with six alert and oriented residents, it was reported that the food was consistently cold, whether served in the dining room or as a room tray. An observation conducted on April 25, 2024, revealed that a test tray for a regular diet, which was served immediately after the last resident received their room tray, had food temperatures below the palatable threshold of 135 degrees Fahrenheit. The test tray, consisting of shrimp scampi, spaghetti noodles, and snow peas, was plated at 6:10 p.m. and delivered at 7:20 p.m., with temperatures recorded at 123 degrees F for spaghetti noodles, 109 degrees F for snow peas, and 112 degrees F for shrimp scampi. The dietary manager confirmed that the food carts used for passing room trays were not heated, and the plate warmer in the kitchen was ineffective in maintaining the desired food temperature.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Housekeeping staff did not consistently change gloves or perform hand hygiene when appropriate, leading to improper sanitation of resident rooms. Observations revealed that high-touch surfaces, such as call light cords, were not cleaned, and the cleaning process did not follow the recommended procedure of moving from clean to dirty areas. Interviews with housekeeping staff indicated a lack of adequate training and education, with staff reporting minimal orientation and no recent training. Additionally, the facility did not offer hand hygiene to residents before meals, contrary to its own policy. Observations in the main dining room showed multiple residents were not offered hand hygiene before or after eating, despite using their hands to consume food. Interviews with residents and staff confirmed that hand hygiene was not routinely offered, highlighting a significant gap in infection prevention practices. The facility also failed to dispose of contaminated medication pass water cups properly. An RN was observed placing medication cups that had fallen on the floor back onto the medication cart without sanitizing the area. Furthermore, the facility's water management plan was outdated and not effectively implemented. The plan had not been updated since 2021, and there was no documentation of Legionella testing as required by the plan. The NHA admitted to initiating a new water management plan during the survey but lacked evidence of ongoing testing for Legionella.
Deficiency in CNA Training Hours
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNAs) received the required 12 hours of training per year, as mandated. Specifically, the facility did not have a system in place to track CNA training hours to ensure compliance with the annual requirement. A review of training records revealed that CNA #9 received only seven hours of training, while CNA #10 received eight hours in the previous calendar year, both falling short of the required 12 hours. During an interview, the staff development coordinator acknowledged the absence of a monitoring system and confirmed the shortfall in training hours for the CNAs.
Failure to Manage Resident Personal Funds Accounts
Penalty
Summary
The facility failed to adequately manage the personal funds accounts for two Medicaid-funded residents, resulting in their accounts exceeding the Medicaid eligibility limit. Resident #2 had $2,354.81 in her account, which was $354.81 over the $2,000 limit, while Resident #30 had $3,683.41, exceeding the limit by $1,683.41. There was no documentation to indicate that the facility had notified either resident or their legal representatives when their accounts reached $200 less than the eligibility resource limit, as required. Interviews with the business office manager (BOM) and the social services director (SSD) revealed that the facility did not maintain records of notifications sent to residents about their account balances. The BOM acknowledged the responsibility to assist residents in spending down their funds and mentioned using a facility Amazon account for this purpose. Despite efforts to help Resident #2 spend her money, her account remained over the limit. The SSD confirmed that the facility could have done more to assist both residents in managing their funds to avoid exceeding the Medicaid eligibility limit.
Failure to Protect Residents from Abuse in Memory Care Unit
Penalty
Summary
The facility failed to protect three residents from physical abuse by other residents, as evidenced by multiple incidents in the memory care unit. Resident #42 was pushed by Resident #25, resulting in a fall, while Resident #52 was pushed by Resident #24, causing her to fall back into her wheelchair. Additionally, Resident #24 and Resident #68 were involved in a physical altercation where Resident #24 slapped Resident #68's hand, and Resident #68 retaliated by slapping Resident #24's chest. These incidents were witnessed by staff members who reported them to the appropriate personnel. Resident #25, who has dementia with behavioral disturbances, displayed daily behavioral symptoms directed at others, including hitting and pushing. A gradual dose reduction (GDR) of her anti-anxiety medication was in progress, which was later reversed due to increased aggression. Resident #24, also diagnosed with dementia with behavioral disturbances, was undergoing a GDR of her antipsychotic medication, which was identified as a contributing factor to her increased agitation and aggressive behaviors. Resident #52, who was legally blind and had moderate cognitive impairment, was identified as a moderate fall risk. The facility's investigations into these incidents concluded that physical abuse was substantiated in each case. The investigations revealed that the GDRs for Residents #24 and #25 were contributing factors to the altercations. Despite the facility's policy to prevent resident abuse and provide a safe environment, the incidents occurred, indicating a failure to adequately protect residents from abuse by other residents.
Medication Administration Deficiencies in LTC Facility
Penalty
Summary
The facility failed to adhere to professional standards of practice during medication administration for three residents. For Resident #67, the assistant director of nursing (ADON) left an insulin supply box containing insulin and sharps at the bedside after checking the resident's blood sugar. This action was contrary to the facility's policy, which mandates that medications should not be left with the resident. Resident #67 was cognitively intact and had multiple diagnoses, including type 1 diabetes mellitus and functional quadriplegia. For Resident #26, a registered nurse (RN) placed half of an olanzapine tablet in a medication cup and stored it in her pocket, intending to dispose of it later. This practice violated the facility's policy on medication storage. Resident #26 had moderate cognitive impairment and several medical conditions, including type 2 diabetes mellitus and acute respiratory failure. In the case of Resident #29, an ADON returned two 10 mg famotidine tablets to a stock medication bottle after realizing a dosage error, which could lead to contamination. Resident #29 also had moderate cognitive impairment and was diagnosed with chronic respiratory failure and type 2 diabetes mellitus.
Failure to Provide Resident with Individualized Activities
Penalty
Summary
The facility failed to provide a resident with an ongoing program of activities tailored to meet her needs and interests, as outlined in her individualized care plan. The resident, who is under 65 years old, has multiple medical conditions including non-ischemic myocardial injury, heart failure, hemiplegia, hemiparesis following a stroke, and type 2 diabetes with chronic kidney disease. Her assessment indicated preferences for activities such as interacting with animals, going outside, reading, listening to music, and keeping up with the news. Despite these preferences, observations revealed that the resident was often left in her room without engagement in any activities, such as watching television or listening to music, and no staff were observed providing her with activities during the survey period. Interviews and record reviews further highlighted the deficiency. The resident expressed feelings of boredom and a lack of activities, stating she had not been reading due to illness. The activities care plan, initiated in early May, aimed for weekly one-to-one visits from activities staff, but there was no documentation of these visits or any refusals in the resident's progress notes for May and June. The activity director confirmed the lack of documentation and noted that the resident had been refusing visits since her health declined. The director also acknowledged the need for improved documentation and had begun training staff on documentation expectations.
Failure to Follow Diabetic Management Protocols
Penalty
Summary
The facility failed to provide appropriate treatment and care according to physician orders and the comprehensive person-centered care plan for two residents with diabetes. Resident #58, who was cognitively intact and diagnosed with type 2 diabetes mellitus, had several instances of high blood sugar readings that exceeded the physician-ordered parameters. Despite the facility's policy requiring physician notification for blood sugar levels above 400 mg/dl, there was no documentation of such notifications for multiple high readings in January, February, and May 2024. Resident #67, also cognitively intact and diagnosed with type 1 diabetes mellitus, experienced numerous high blood sugar readings over 400 mg/dl in June 2024. The facility's hyperglycemia protocol required rechecking blood sugar every hour and notifying the physician for readings above 400 mg/dl. However, the records showed significant delays in rechecking blood sugar levels, sometimes spanning several hours, and no documentation indicated that the hyperglycemia protocol was followed during this period. Interviews with the facility's nursing staff revealed a lack of adherence to the hyperglycemia protocol. The Assistant Director of Nursing was unsure about the required time frame for rechecking blood sugar levels, while the Director of Nursing acknowledged that the protocol was not followed as per the physician's orders. The DON admitted that there was no documentation of follow-up actions for high blood sugar readings, indicating a systemic issue in monitoring and managing diabetic care for these residents.
Failure to Prevent Pressure Ulcer Development
Penalty
Summary
The facility failed to provide timely and appropriate pressure ulcer care for a resident, leading to the development of a Stage 2 pressure injury on the resident's right lateral ankle. The resident, who was under 65 years old and had severe cognitive impairment, was admitted with multiple health conditions including non-ischemic myocardial injury, heart failure, hemiplegia, and diabetes with chronic kidney disease. Despite these conditions, the resident was not initially identified as being at risk for pressure ulcers, and the facility did not implement necessary interventions to prevent pressure injuries. Observations revealed that the resident was often left without pressure-reducing boots, which were part of the prescribed care to offload pressure from the feet and ankles. The resident was observed lying on her right side for extended periods without repositioning or the use of pressure-reducing devices, contrary to the facility's policy and physician's orders. The facility's failure to apply pressure-reducing boots and ensure proper positioning contributed to the development of the pressure injury. The facility's records and staff interviews indicated delays in implementing physician-ordered interventions, such as nutritional supplements and pressure-reducing boots, which were not put in place until several days after the pressure injury was identified. Additionally, the facility's care plan lacked nutritional interventions for pressure injury prevention or healing, and there was a lack of documentation and follow-up on the resident's nutritional needs. These oversights and delays in care contributed to the resident's pressure injury and highlighted deficiencies in the facility's pressure ulcer prevention and care practices.
Failure to Provide Recommended Restorative Nursing Services
Penalty
Summary
The facility failed to provide appropriate restorative nursing services to a resident with limited range of motion, as recommended by physical therapy. The resident, who was over 65 years old and diagnosed with dementia, Parkinson's disease, and anemia, had completed physical therapy goals by May 2024. The discharge summary from physical therapy recommended a restorative nursing program to maintain the resident's current level of function, including restorative ambulation and range of motion exercises. However, the facility did not implement these services in a timely manner, with a delay of 20 days before the resident began receiving restorative nursing services. The resident expressed concerns about increased stiffness and difficulty in movement, attributing a recent fall to a decline in physical strength due to the lack of restorative services. Despite the physical therapy recommendation for services four to five times per week, the resident only received these services six times between late May and mid-June 2024. The facility's failure to offer the recommended frequency of restorative nursing services was compounded by the resident's COVID-19 diagnosis, during which time services were put on hold without being offered in the resident's room. Interviews with staff, including a registered nurse, a CNA, the MDS coordinator, and the DON, revealed awareness of the resident's increased need for assistance and the importance of following physical therapy recommendations. The MDS coordinator acknowledged that the reduction in restorative services was due to staffing shortages, which may have contributed to the resident's decline in physical function. The DON confirmed that restorative services should have been provided even during the resident's COVID-19 infection, indicating a lapse in adherence to recommended care protocols.
Deficiencies in Respiratory Care and Assessment
Penalty
Summary
The facility failed to provide necessary respiratory care consistent with professional standards for two residents. Resident #4, who had severe cognitive impairment and multiple diagnoses including COPD and chronic respiratory failure, was not consistently provided with supplemental oxygen as per physician's orders. Observations revealed that Resident #4 was often without an oxygen cannula, despite having low oxygen saturation levels, sometimes as low as 69%. Staff failed to ensure the resident received oxygen therapy consistently, and there was a lack of documentation and communication with the physician regarding the resident's low oxygen saturation levels. Additionally, the facility did not adequately assess Resident #3's ability to perform tracheostomy care independently. Despite having moderate cognitive impairments, Resident #3 was performing her own tracheostomy care without any assistance or observation from the nursing staff. The facility failed to conduct a proper assessment to ensure that Resident #3 could safely perform this care, as there was no direct observation or return demonstration documented. Interviews with staff revealed a lack of awareness and assessment regarding the residents' needs for respiratory care. CNA #1 and RN #2 acknowledged that Resident #4 often removed his oxygen, but there was no consistent effort to ensure he wore it as required. Similarly, RN #3 and RN #1 were unaware of any assessment of Resident #3's ability to perform tracheostomy care safely. The facility's failure to provide appropriate respiratory care and assessments for these residents highlights significant deficiencies in their care practices.
Failure to Establish PRN Pain Medication Parameters
Penalty
Summary
The facility failed to manage pain for three residents in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, the facility did not establish parameters for as-needed (PRN) pain medications for three residents. This deficiency was identified through interviews and record reviews. Resident #57, who had severe cognitive impairment and multiple diagnoses including lumbar radiculopathy and lumbar spondylosis, had physician orders for acetaminophen and hydrocodone-acetaminophen for pain management. However, the orders did not specify when to administer each medication based on the resident's pain level. The medication administration record showed inconsistencies in the administration of these medications for varying pain levels, and the physician's progress note with pain parameters was not reflected in the orders. Resident #58, who was cognitively intact and had chronic pain syndrome, also had multiple PRN pain medications ordered without specific parameters. The resident reported having to request all pain medications and expressed concerns about not receiving medications automatically. Similarly, Resident #11, who had a fracture and other conditions, had PRN pain medications ordered without established parameters. Staff interviews confirmed the lack of pain parameters, which are necessary to ensure the correct medication is administered based on the resident's reported pain level.
Medication Error: Incorrect Insulin Administered
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, specifically in the administration of insulin. The assistant director of nursing (ADON) administered the incorrect type of insulin to a resident. The physician's order specified the use of insulin lispro (Humalog) to be administered according to a sliding scale based on the resident's blood sugar levels. However, the ADON administered Humulin R, a different type of insulin, which was not labeled with a pharmacy label. This error occurred after the ADON obtained a blood sugar reading indicating the resident's blood sugar was over 600 mg/dl and proceeded to administer eight units of Humulin R instead of the prescribed insulin lispro. The error was attributed to the resident's insurance not covering the insulin pens, leading the facility to use Humulin R from a vial. The ADON acknowledged the mistake and noted that the physician should have been notified to change the order. Interviews with the director of nursing (DON) and the consulting pharmacist confirmed the error, highlighting the difference in the action times between the two types of insulin. The facility's diabetic management policy and professional standards emphasize the importance of administering medications as prescribed, which was not adhered to in this instance.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored and labeled according to professional standards. During observations, it was found that two of the six medication carts and one of the two medication storage rooms contained improperly labeled and expired medications. Specifically, an open Tresiba FlexTouch Pen-injector was not labeled with the date it was opened, and an open bottle of isopropyl alcohol had expired. Additionally, several expired medications, including multivitamins, esomeprazole magnesium, vitamin B12, loperamide HCL, spironolactone, omeprazole, and furosemide, were found in the medication storage room and on the medication carts. Interviews with staff revealed a lack of adherence to proper medication management protocols. An LPN acknowledged that insulin pens should be dated when opened and agreed to dispose of the expired isopropyl alcohol. An RN confirmed that expired medications should be disposed of and mentioned using a drug buster for this purpose. The assistant director of nursing also recognized that the expired package of omeprazole should have been removed from the medication cart. These findings indicate a failure in maintaining medication safety and compliance with professional standards, potentially compromising resident care.
Failure to Provide Correct Mechanically-Altered Diet
Penalty
Summary
The facility failed to provide a resident with the correct mechanically-altered diet as prescribed, leading to a deficiency in dietary care. The resident, a 79-year-old with Parkinson's disease, malnutrition, and GERD, was cognitively intact and required assistance with meal setup and cleanup. Despite being prescribed a dysphagia advanced diet, which includes soft and bite-sized foods, the resident was repeatedly served pureed meals, which did not align with her dietary needs or preferences. Observations revealed that the resident was served pureed food items instead of the prescribed dysphagia advanced diet. The resident expressed dissatisfaction with the pureed food, noting it lacked flavor and was not necessary as she had no history of choking. The facility's dietary records and meal tickets did not reflect the correct diet order, indicating a failure in communication and adherence to the prescribed dietary plan. Interviews with staff, including the SLP and DON, highlighted a breakdown in the process of updating and communicating diet orders. The SLP confirmed the resident's need for a dysphagia advanced diet and noted that the kitchen did not follow the IDDSI framework. The DON acknowledged the discrepancy between the meal tickets and physician's orders, indicating a lack of regular comparison and verification of diet orders. The dietary consultant was unaware of how the incorrect diet change appeared in the resident's profile, suggesting procedural lapses in the dietary department.
Failure to Retain MOST Forms in Resident's Medical Record
Penalty
Summary
The facility failed to maintain accurate medical records for a resident, specifically regarding the Medical Orders for Scope of Treatment (MOST) forms. The resident, an 80-year-old with a history of atherosclerotic heart disease and chronic obstructive pulmonary disorder, was admitted and later passed away. During the resident's decline, he expressed a desire to change his code status from full code to Do Not Resuscitate (DNR), which was documented and witnessed by two nurses. However, the facility did not retain the initial or amended MOST forms in the resident's electronic medical record (EMR), as they were destroyed following the resident's death. Interviews with facility staff, including the nursing home administrator (NHA), registered nurse (RN), infection preventionist (IP), nurse practitioner (NP), and regional clinical consultant (RCC), revealed a misunderstanding regarding the status of MOST forms as part of the resident's medical record. The NHA and IP believed the MOST forms were not part of the permanent medical record and were destroyed after discharge or death. However, the NP and RCC confirmed that the MOST forms are considered physician's orders and should be retained as part of the medical record. The facility lacked a policy on the destruction of MOST forms, leading to the improper handling of these critical documents.
Latest citations in Colorado
A resident with severe dementia, hallucinations, delusions, and chronic pain, who was independent with mobility and at risk for wandering, was struck in the face by another cognitively impaired resident known to exhibit verbal and physical aggression and to be highly protective of her room. An RN heard a commotion, saw the victim outside the aggressor’s room, and attempted to intervene but witnessed the aggressor hit the victim before reaching them, resulting in a lip laceration and bruise. The aggressor’s care plan noted use of a doorway stop sign or closed door and the need to redirect others away from her room, but she often refused these measures. At the time of the incident, only one CNA and one nurse were on the memory care unit due to an unfilled CNA call-in, and staff reported it was difficult to manage when two CNAs were not present. The facility investigation substantiated the event as abuse and identified that both residents may have had increased pain contributing to agitation before the altercation.
A resident with severe cognitive impairment and multiple chronic conditions intentionally slid from a wheelchair to sit on the floor and refused assistance to return to the chair. An LPN directed two CNAs to place a blanket under the resident and drag the resident across the floor, onto an elevator, and to another floor, rather than allowing the resident to remain seated on the floor as requested. The resident later reported trying to resist and stated dislike of the experience. Documentation by the LPN omitted how the resident was actually moved between floors, despite care plan goals for dignity and autonomy and a facility policy requiring residents be treated with dignity and respect and that their choices and preferences be honored.
Surveyors found that staff repeatedly failed to follow hand hygiene and Enhanced Barrier Precautions (EBP) requirements. CNAs and an LPN provided direct care, including incontinence care, use of a mechanical lift sling, and gastric tube feeding, without performing hand hygiene before or after care and without using required gowns for residents on EBP. One CNA handled a soiled lift sling, touched his hair and face, used a touchscreen to document care, and then assisted another resident without cleaning his hands. Another CNA entered an EBP room wearing only gloves, not a gown, and did not perform hand hygiene after removing gloves. An LPN handled a feeding tube and provided care to residents on EBP without hand hygiene or gown use. A resident’s representative reported seeing staff work with a feeding tube without gloves or a gown, while staff interviews and facility policy described correct practices that were not followed in practice.
A resident with severe cognitive impairment and multiple serious diagnoses had a physician-appointed health care proxy who reported that the facility did not inform her when the resident’s condition changed or when an antibiotic was started, and that her calls were not returned for days. Another representative for the same resident stated that calls went to a general voicemail and were rarely or very slowly returned. Grievance records documented repeated concerns about delayed communication, lack of notification about new medications, and difficulty reaching staff. Other residents’ representatives similarly reported that calls to check on residents or report suspected verbal abuse went to voicemail and were returned late or not at all, while staff acknowledged that calls often went to voicemail and that several calls from representatives were missed or delayed.
The facility failed to investigate an allegation of verbal abuse and threats between two cognitively impaired roommates after a family member, who was on the phone with one resident, reported hearing the other resident yelling loudly and making threats. The resident’s representative could not reach staff by phone and contacted EMS, which responded to the facility, yet no investigation or documentation of the altercation, alleged threats, or EMS involvement was found in either resident’s record. Staff acknowledged loud yelling and arguing and initiated a room change, but the RN did not fully inform the DON, the SSD—who was not present—dismissed the event as a simple argument, and the NHA did not treat or report it as abuse, contrary to facility policies requiring identification, investigation, and reporting of possible verbal or mental abuse by other residents.
Unsafe food handling and kitchen sanitation practices were observed in the dining room and main kitchen. Staff handled ready-to-eat foods with bare hands, failed to wash hands between tasks and after bathroom use, and touched food, dishes, and meal tickets while plating and serving meals. The facility also kept moldy croissants in dry storage, used a pencil to prop up a hood drip pan, and allowed a dietary aide with artificial nails and multiple bracelets to serve residents.
The facility failed to maintain and document safe food temperatures during meal service, resulting in cold foods being held and served within the temperature danger zone and incomplete temperature logs on multiple days. During a lunch service observation, various forms of chicken salad were held at 45–55°F, yet plates were assembled and sent out, and a resident reported that meals delivered to the room were always cold and often not eaten. Staff interviews showed inconsistent understanding of required hot and cold holding temperatures and confirmed that temperature logs were sometimes not completed as required.
Failure to Honor Residents’ Choice of Attending Physician: Three cognitively intact residents said they were not allowed to choose their own attending physician and were required to see the facility MD instead. EMR and admission agreement review showed no documentation that they were offered a choice of physician, despite one resident wanting to continue with a community PCP. The NHA stated residents could choose their attending physician, but also said the facility had only one physician available for residents to choose from.
Psychotropic Medication Documentation and PRN Behavior Monitoring Deficiencies Survey review found that several residents had psychotropic medications ordered without documented physician rationale, resident-specific target behaviors, or individualized non-pharmacological interventions. Generic behavior-monitoring orders were used instead of approaches tied to each resident’s history, interests, and identified behaviors, and one resident’s PRN antipsychotic was administered multiple times without documentation of attempted non-pharmacological interventions before use. The EMR also showed notes of stability or no unwanted behaviors for some residents, yet the records still lacked rationale supporting continued psychotropic treatment.
Failure to Address Suicidal Ideation and Individualized Psychosocial Needs: The facility did not adequately address suicidal statements, trauma-related needs, or individualized behavioral interventions for multiple residents. One resident with dementia, anxiety, and PTSD made a suicidal threat, but the record did not show ongoing safety monitoring or documented follow-up. Another resident with PTSD, depression, and a history of trauma and suicide attempts had ongoing depressive symptoms, but the care plan and orders did not reflect the PASRR-identified need for therapeutic support, psychiatric oversight, coping skills, or a safety plan. A third resident with autism and mood disturbance had inappropriate sexual behavior toward the DON, but the care plan was not updated with person-centered interventions specific to that behavior.
Failure to Prevent Resident-to-Resident Physical Abuse on Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. On the date of the incident, an RN heard a commotion in the hallway outside the alleged assailant’s room and observed that resident strike another resident, causing the victim’s lip to bleed. The RN had seen both residents near the medication cart a few minutes earlier without concern and attempted to intervene when she saw the victim standing outside the assailant’s room, but was unable to reach them before the strike occurred. The two residents were then separated, and frequent checks were initiated. The victim was a younger-than-65 resident with vascular dementia (severe, with agitation), Alzheimer’s disease, Lewy body disease, bipolar disorder, and chronic pain. Her MDS showed short- and long-term memory problems, hallucinations, delusions, and physical and verbal behaviors toward others, with moderately impaired cognition and impaired decision-making. She was independent with mobility and had a care plan for wandering and dementia that identified her as pleasantly confused and easily redirected, with interventions to identify wandering patterns, offer diversions, and assess for pain or toileting needs when agitated. Documentation on the day of the incident noted her involvement in a resident-to-resident altercation, a small laceration to the middle of her upper lip, and a small bruise below her lower lip. The assailant was an older resident with severe vascular dementia with agitation, memory deficit after intracranial hemorrhage, and recurrent depressive disorder. Her MDS documented short- and long-term memory problems, fluctuating disorganized thinking, and verbal behaviors directed toward others that could significantly intrude on others’ privacy or disrupt the environment. Her behavior/dementia care plan identified verbal aggression (yelling/screaming), physical aggression (hitting), refusal of care, withdrawal, tearfulness, and negative statements, and noted that she was protective of her room and became upset if others entered or tried to enter. The care plan included use of a velcro stop sign across her doorway or keeping her door closed, but also documented that she often declined having the door closed, requiring staff to redirect other residents away from her room. Staff statements indicated that at the time of the incident there was one CNA and one nurse on the memory care unit, that one CNA had called in and was not replaced, and that it was hard when there were not two CNAs on the unit. The facility’s investigation substantiated the incident as abuse and identified that both residents may have been experiencing increased pain leading up to the altercation, with pain, constipation, and urinary retention noted as contributing factors for the victim and hand contracture pain and refusal of interventions noted for the assailant.
Resident Dragged on Blanket Instead of Honoring Request to Sit on Floor
Penalty
Summary
The deficiency involves a failure to honor a resident’s right to dignity and self-determination when staff did not allow the resident to remain seated on the floor per his wishes and instead dragged him on a blanket between floors. Late at night, the resident, who lived on the second floor, was in his wheelchair on the first floor and intentionally slid out of his wheelchair to sit on the ground according to his own wishes. When staff offered assistance to help him back into his wheelchair, he refused. Despite this refusal, an LPN directed two CNAs to move the resident from the first floor back to the second floor. Following the resident’s refusal to get back into his wheelchair, the LPN instructed the CNAs to place a blanket underneath the resident so he could be dragged while lying on it. The CNAs and the LPN maneuvered the blanket under the resident by moving him from side to side. One CNA positioned herself behind the resident and placed her arms under his armpits, while the other CNA held the resident’s pants at his ankles. The LPN then pulled on the blanket with the resident on it. Together, the three staff members dragged the resident on the blanket across the floor and onto the elevator, transported him to the second floor, and then dragged him off the elevator onto the second floor hallway. Once on the second floor, the resident agreed to have two staff members assist him back into his wheelchair, and a two-person transfer was performed to lift him from the floor into the chair. The resident later reported that he remembered being pulled on the blanket, stated that he "tried to fight them like crazy," and said he did not like what had been done. The nursing progress note written by the LPN the following morning documented that the resident had remained on the first floor until late at night, refused to talk with staff, refused care, and declined snacks, fluids, and redirection, but the note did not document how he was actually relocated to the second floor. The resident’s records showed he had severe cognitive impairment with a BIMS score of 3/15, diagnoses including Parkinson’s disease, depression, unspecified intellectual disabilities, traumatic brain injury, seizures, and chronic kidney disease stage 3, and care plan goals that included being treated with dignity and autonomy. The facility’s dignity policy stated that residents are to be treated with dignity and respect at all times, that their choices and preferences are to be honored, and that demeaning practices are prohibited, which was not followed in this incident.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to hand hygiene and adherence to Enhanced Barrier Precautions (EBP) on all four units. The facility’s own policies require hand hygiene before and after direct patient care and the use of gowns and gloves during high-contact care activities for residents on EBP. CDC guidance cited in the report emphasizes that hand hygiene protects both healthcare personnel and patients, and that EBP requires targeted gown and glove use during high-contact resident care activities, particularly for residents with wounds, indwelling devices, or MDRO colonization or infection. Surveyors observed multiple instances where staff did not follow these requirements. An unidentified CNA exited a room of a resident on EBP without wearing a gown while providing care. On another occasion, a CNA exited a resident’s room carrying a soiled mechanical lift sling without gloves, failed to perform hand hygiene, touched his hair and face, used a touchscreen to document care, and then entered another resident’s room to answer a call light and assist with a request without performing hand hygiene before or after assisting that resident. Another CNA entered the room of a resident on EBP, donned only gloves without a gown, provided incontinence care, then left the room with soiled linens and trash properly disposed of, removed gloves, but did not perform hand hygiene before caring for another resident. Additional observations showed an LPN entering the room of a resident on EBP for gastric tube feeding, setting up and handling the feeding tube without performing hand hygiene beforehand and without wearing a gown. The same LPN later entered another EBP room, provided care, and left without performing hand hygiene. A resident’s representative reported seeing staff work with the resident’s feeding tube without gloves or a gown. In interviews, CNAs and nursing staff described correct hand hygiene and EBP practices, including washing hands for about 20 seconds and using gowns and gloves for residents on EBP, and the DON stated she expected staff to perform hand hygiene when entering and exiting rooms and to follow EBP procedures requiring gown and glove use. These stated practices conflicted with the observed failures in hand hygiene and EBP adherence documented by surveyors.
Failure to Notify Health Care Proxy and Return Calls Regarding Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to inform a resident’s physician-appointed health care proxy of changes in the resident’s condition and new treatments, and to return the proxy’s calls in a timely manner. Facility policy on Notification of Changes required informing the resident, consulting with the physician, and notifying the family member or legal representative when there was a change requiring such notification, and specified that when residents were incapable of making their own decisions, the representative would make necessary decisions. Resident #1 was under 65, admitted with diagnoses including paralysis and weakness following a stroke, respiratory failure, cognitive communication deficit, and encephalopathy, and was documented as severely cognitively impaired with a BIMS score of 0/15, indicating reliance on the health care proxy for decision-making. The health care proxy reported that the facility made it very difficult to contact the resident, stating that staff did not return calls for days and that she was not informed when the resident developed an infection and was started on an antibiotic until after the medication had already been initiated. She stated she had several questions about the medication and was not consulted on the medical decision prior to its start. Another representative reported that calls to the facility went to a general voicemail and that her messages were either not returned or took several days for a response. Grievance records showed repeated concerns from the resident’s representatives about delays in speaking with the resident, delays in return calls, and lack of notification about new medications and changes in condition. Additional interviews with other residents’ representatives supported a broader pattern of delayed or absent communication. One representative of another resident reported that his call to check on a newly admitted resident went to voicemail and was not returned for two days. Another resident’s representative and a secondary witness reported that when they attempted to report suspected verbal abuse, their calls to the facility and to the SSD went to voicemail and were never returned. Staff interviews confirmed that calls first went to the front desk and then to the nurses’ stations, that calls often went to voicemail when nurses were unable to answer, and that voicemail messages were expected to be returned within 24 hours. The NHA acknowledged that several calls from the resident’s representatives went to voicemail and that calls were often made during shift change when it was harder to reach the nurse on duty, but there was no documentation to support the claimed regular communication with the health care proxy.
Failure to Investigate Alleged Verbal Abuse Between Cognitively Impaired Roommates
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of verbal abuse and threats between two cognitively impaired residents after a family member reported overhearing the incident. Facility policy on abuse, neglect, exploitation, and misappropriation requires that all possible incidents of abuse, including verbal and mental abuse by other residents, be identified, investigated, and reported within required timeframes, with residents protected from further harm during investigations. The policy on identifying types of abuse specifies that yelling or hovering over a resident with intent to intimidate is an example of mental and verbal abuse. Despite these policies, the facility did not initiate or document an investigation into a reported verbal altercation that included alleged threats. One resident, under age 65, with dysphagia, left-sided hemiplegia, attention and concentration deficit, delusional disorder, and major depressive disorder, had moderate cognitive impairment and was dependent on staff for most ADLs. He reported that he and his roommate yelled back and forth at each other after the roommate told him to “shut the [expletive],” but he did not recall the specific words used and denied any physical contact. His guardian stated that he later reported being fearful of his roommate after the incident. Another representative, who was on the phone with him during the event, reported hearing the roommate yelling loudly and making threats toward him, then hearing a nurse enter to calm the situation. This representative attempted to call the facility to report the yelling and threatening behavior, was sent to voicemail without a return call, and subsequently contacted emergency services. The roommate, an older resident with dementia, cognitive communication deficit, depression, and insomnia, also had moderate cognitive impairment and required staff assistance for most ADLs. He did not recall the incident, and his representative only learned of it the following day and was told it involved yelling about loud phone use. A review of both residents’ medical records revealed no documentation of the verbal altercation, the alleged threats, or related concerns, and no investigation documents were produced when requested. Staff interviews confirmed there had been loud yelling and arguing, that EMS responded to the facility, and that a room change was initiated due to the incident, but the RN who responded did not report the EMS involvement to the DON. The SSD, who was not present during the incident, characterized it as just an argument and stated there were no threats, and the NHA stated the event was not reported as abuse because they believed no threats were made. No contemporaneous interviews with the residents were documented, and no inquiry was made by facility staff into why EMS had been called in relation to the altercation, resulting in a failure to investigate the allegation of verbal abuse as required by facility policy.
Unsafe Food Handling and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the main kitchen and dining areas. During meal service observations, staff repeatedly handled ready-to-eat foods with bare hands and did not perform hand hygiene when changing tasks, after touching dirty dishes, after using the bathroom, or before serving food. An LPN cut a resident’s patty melt and handed pieces to the resident with her bare hand without sanitizing her hands. A DA passed drinks by touching the rims of cups, and another DA tore a resident’s patty melt into smaller pieces with bare hands and handed food to the resident. During a later observation, kitchen staff continued to work without washing hands between tasks and while handling food, dishes, and meal tickets. A DA entered the kitchen from the dishroom and did not wash his hands before putting away snacks. A cook did not wash her hands after working at the sink, after touching dirty dishes, after exiting the bathroom in the kitchen, or before serving room trays. She was observed touching shrimp, corn bread, rice, squash, cheese, and frozen fries with bare hands while plating and preparing meals, and she also handled fryer baskets and food items without washing her hands. Another cook wiped her hands on her clothing, handled meal tickets, and touched ready-to-eat foods with bare hands while assembling plates and serving meals. The facility also failed to discard expired or spoiled food, maintain equipment in good repair, and prevent staff from wearing prohibited items while preparing or serving food. A plastic bag of croissants in dry storage contained bread-like food covered in dark green and black fuzz and remained on the bread rack on two separate observations. In the kitchen hood system above the grill, a half wooden pencil was being used to hold up the grease drip pan on two observations. In addition, a dietary aide taking meal orders, passing drinks, and serving meals had artificial nails approximately half an inch long and multiple fabric bracelets on her wrists while working with residents.
Failure to Maintain and Document Safe Food Temperatures During Meal Service
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner by not maintaining appropriate food temperatures during meal service and by not consistently documenting food temperatures as required. During a continuous observation of lunch meal service, chicken salad, including soft and bite-sized and pureed versions, was found on the steam table at temperatures of 55°F and 45°F, which were within the documented temperature danger zone and below the required cold-holding standard. Despite these temperatures, plates with wedge chicken salad and a Hawaiian roll were assembled and placed on the meal cart for service. A resident reported that meals delivered to his room were always cold, leading him not to eat them and to attempt to obtain food from outside the facility. Review of the facility’s April 2026 food temperature logs showed multiple instances where temperatures were not documented for breakfast, lunch, and dinner services on numerous dates. Staff interviews revealed inconsistent understanding and application of proper holding temperatures, with the cook and dietary manager providing varying temperature thresholds that did not align with the facility policy or the Colorado Retail Food Establishment Rules and Regulations. The cook acknowledged that the wedge chicken salad should not have been served at 55°F and attributed difficulty maintaining proper temperatures to a hot room with inadequate ventilation, while the dietary manager stated that cooks sometimes forgot to complete the temperature logs.
Failure to Honor Residents’ Choice of Attending Physician
Penalty
Summary
The facility failed to ensure three cognitively intact residents were allowed to choose their own attending physician. Resident #15, Resident #28, and Resident #30 each stated during a group interview that they did not have a choice in who their physician could be while in the facility and that they had to see the facility’s MD. Resident #15 said she had a primary care physician in town that she wanted to continue seeing, but she was told she could not see that physician. Resident #28 and Resident #30 each said they were required to see the facility’s MD instead of choosing their own physician. Record review for each of the three residents, including the admission agreement and EMR, showed no documentation that they were provided a choice of attending physician. Resident #15 had diagnoses including COPD, cirrhosis of the liver, and osteoarthritis, and her MDS showed she was cognitively intact with a BIMS score of 15. Resident #28 had diagnoses including type 2 diabetes mellitus, asthma, osteoarthritis, and TIA/cerebral infarction, and was also cognitively intact with a BIMS score of 15. Resident #30 had diagnoses including type 2 diabetes mellitus, wedge compression fracture of T11-T12 and L3, and hypertension, and his MDS likewise showed a BIMS score of 15. The NHA stated residents were able to choose their attending physician when admitted, but also said the facility had one physician residents could choose from and was not aware that these residents wanted different physicians.
Psychotropic Medication Documentation and PRN Behavior Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure four residents were free from unnecessary psychotropic medication use and chemical restraint concerns. Survey review found that the facility did not document a physician’s rationale for the continued use of psychotropic medications for three residents, did not document resident-specific care approaches with medication-specific target behaviors and person-centered interventions for those residents, and did not ensure one resident’s PRN antipsychotic use had corresponding documentation of identified behaviors and non-pharmacological interventions. For one resident with PTSD, anxiety, and depression, the record showed buspirone, Valium, duloxetine, and Lexapro orders with behavior-monitoring language, but the orders did not identify resident-specific non-pharmacological interventions for specific behaviors. The resident’s PASRR described a history of self-harm, suicidal thoughts, mood swings, loss of interest, and low energy, and recommended therapeutic interventions, coping skills, psychiatric oversight, increased socialization, and activities such as puzzles, games, and painting. The EMR review did not show documented behaviors during the review period, and it did not show a physician rationale to justify continued psychotropic use. For another resident with schizoaffective disorder, dementia, anxiety, and depression, the care plan and orders listed generic interventions and behavior targets such as screaming, hallucinations, kicking, and yelling, but the resident-specific behaviors and interests identified in the PASRR, including hearing the devil inside her head and being soothed by prayer and rosary use, were not incorporated into the behavior-monitoring orders or care plan. The record also lacked documentation of non-pharmacological interventions used for the resident’s behaviors and lacked a physician rationale for continued psychotropic use despite notes stating the resident was stable and not experiencing unwanted behaviors. A third resident with vascular dementia, anxiety, and PTSD had orders for Abilify, mirtazapine, sertraline, clonazepam, and behavior monitoring tied to verbal aggression, exit seeking, tearfulness, and hitting staff, but the orders remained generic and did not reflect the resident’s individualized approaches such as listening to 80’s rock music or watching a favorite program when crying or confused. The EMR again did not show a physician rationale for continued psychotropic use despite notes indicating pleasant mood and no unwanted behaviors. For the resident who died during the stay and had dementia and depression, the record showed Lexapro, Seroquel, and PRN injectable haloperidol ordered for behaviors such as swinging at staff and agitation. The PRN haloperidol order did not list a diagnosed specific condition, only behaviors, and the order for non-pharmacological interventions was not initiated until after the resident had already been receiving psychotropic medications. MAR and order administration notes showed multiple PRN haloperidol administrations, but several entries lacked documentation of attempted non-pharmacological interventions before the medication was given, and one note only documented encouragement to sit down without identifying the other ordered interventions or their effectiveness.
Failure to Address Suicidal Ideation and Individualized Psychosocial Needs
Penalty
Summary
The facility failed to ensure that residents with mental disorders, psychosocial adjustment difficulties, and trauma histories received appropriate treatment and services to support their mental and psychosocial well-being. For one resident with vascular dementia, anxiety, and PTSD, the record showed repeated depression screens indicating little interest, depressed mood, poor appetite, sleep problems, low energy, and feelings of worthlessness, along with notes describing chronic behaviors potentially causing harm, tearfulness, withdrawal, and anxiety. A behavior note documented that the resident stated she was going to kill herself, but the record did not show documented interventions to keep her safe afterward or ongoing monitoring for suicidal ideation. A second resident with PTSD, anxiety, depression, and a documented history of trauma, self-harm, suicidal thoughts, and numerous suicide attempts had a PASRR evaluation identifying the need for therapeutic interventions, psychiatric oversight, coping skills development, and a safety plan. The resident told staff she had previously seen a therapist at the facility, but that therapy had stopped and no new arrangements had been made. She also reported that staff had not asked about her PTSD triggers or what interventions would help her. The record showed depression screens with ongoing depressive symptoms, but no follow-up documentation after those screenings, and the care plan and physician orders did not reflect the resident’s suicidal history or the specialized services identified in the PASRR. The facility also failed to provide individualized care approaches for a resident with autistic disorder, dementia with mood disturbance, anxiety disorder, major depressive disorder, and cognitive communication deficit. The resident had a history of inappropriate sexual behaviors and was documented as having sexually inappropriate contact with the DON when he squeezed her breast during a dining activity. Although the resident was placed on 15-minute behavior monitoring for 24 hours, the care plan was not revised to reflect a person-centered intervention specific to that sexual behavior. Staff interviews showed that interventions were inconsistently understood and that the nursing staff did not know what person-centered interventions were in place for the resident’s behaviors.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
