Eagle Ridge Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Junction, Colorado.
- Location
- 2425 Teller Ave, Grand Junction, Colorado 81501
- CMS Provider Number
- 065286
- Inspections on file
- 24
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 4 (1 serious)
Citation history
Health deficiencies cited at Eagle Ridge Post Acute during CMS and state inspections, most recent first.
A resident with type 1 DM and a history of low BG had orders for Lantus 29 units HS and Humalog per sliding scale before meals. An RN mistakenly administered 29 units of Humalog instead of the ordered Lantus at bedtime, then administered the Lantus as well without first consulting a provider. The RN instructed the resident to self-monitor BG every 20–30 minutes and encouraged intake of sugary foods, but did not perform or document serial BG checks, vital signs, or a full assessment. Despite notifying the DON and the on-call service, the RN did not immediately send the resident to the ED as directed, instead delaying EMS transport for several hours while the resident’s BG dropped to severely hypoglycemic levels, ultimately requiring EMS-administered oral glucose and hospital monitoring for recurrent hypoglycemia.
The facility failed to ensure required training was completed and documented for most staff, including annual abuse identification/prevention/reporting, dementia management, resident rights, QAPI, effective communication for all direct care staff, infection control, compliance and ethics, and behavioral health. Record review showed large numbers of staff without evidence of completion, missing sign-in sheets for in-services, and training modules without documentation of use. In interviews, the NHA reported that most training, including abuse and dementia, had been completed and described onboarding and lunch-and-learn processes, but could not locate records to verify staff participation. The regional nurse consultant acknowledged that the existing training plan was not effective in ensuring staff received all required education.
The facility did not provide required annual training on abuse, neglect, exploitation, misappropriation of resident property, and dementia care to most staff. Policy required facility-wide training on abuse prevention, identification, reporting, stress management, and managing verbally or physically aggressive resident behavior. When surveyors reviewed training records, they found that 75 of 83 staff had not received annual abuse training since 2024, and the available materials did not show comprehensive education on all types of abuse, prevention strategies, timely reporting requirements, or evidence-gathering methods. In interviews, the NHA and ADON reported that training was primarily done at onboarding and stated that all staff had received abuse and dementia care training, but this conflicted with the documented records showing the last extensive abuse-prevention training occurred in 2024.
A resident with a known fish allergy was served a meal containing tilapia after staff failed to check the diet ticket for allergies, resulting in the resident experiencing anaphylactic shock and requiring ICU hospitalization.
The facility failed to promptly notify representatives for two residents about significant changes, including a new anticoagulant prescription after a cardiology appointment and a transfer to the hospital for hip pain and mobility issues. In both cases, the representatives learned of the events from sources other than facility staff, and there was no documentation in the EMR of timely notification.
A resident with severe cognitive impairment and a history of wandering was not protected from verbal and physical abuse by another resident with dementia and behavioral symptoms. Despite multiple altercations, care plans did not address the risk of abuse, documentation was incomplete, and staff were not consistently informed or educated about necessary interventions to prevent further incidents.
A resident with complex medical and behavioral needs was transferred to the hospital after exhibiting aggressive behaviors. The facility refused to readmit the resident after stabilization, did not obtain physician documentation for discharge, failed to provide required ombudsman contact information, and did not reassess the resident for return. The discharge process lacked regulatory compliance and proper communication with the resident's representative.
A resident with a history of depression, developmental delay, and behavioral disturbances did not receive required psychiatric consultation or individual therapy, despite escalating behaviors and a care plan specifying these services. Facility staff confirmed that mental health counseling was not provided due to a lapse in contracted services, and documentation showed ongoing behavioral incidents without appropriate specialized interventions.
The facility failed to promptly address resident grievances regarding long wait times for call light responses, particularly during night shifts and weekends. Multiple residents reported excessive delays, with some waiting over 45 minutes for assistance. Despite the facility's grievance policy, there was inadequate follow-up and resolution of these complaints, as confirmed by call light logs and resident council minutes. Staff interviews revealed a lack of awareness and communication regarding the grievances, contributing to the deficiency in care.
A resident with paraplegia and quadriplegia in an LTC facility was not assisted in turning in bed as requested, despite being dependent on staff for all care. The facility's policy emphasized the resident's right to self-determination, but staff cited constraints and did not accommodate his requests, leading to the resident's frustration. Interviews revealed that the resident's care preferences were not consistently honored, contributing to the deficiency.
A resident did not receive a full course of prescribed antibiotics following surgery due to the facility running out of the medication. Despite having a backup system, the facility failed to administer all doses, and there was no documentation of notifying the physician or pharmacy. Staff interviews revealed a lack of communication and understanding of the medication refill process.
A resident experienced severe weight loss due to inadequate nutritional care in an LTC facility. Despite significant weight loss over several months, the facility failed to assess the resident or implement new nutrition interventions. The resident expressed dissatisfaction with meals, leading to skipped meals and hunger. Staff interviews revealed a lack of communication and follow-up on the resident's weight loss, with no consistent weight monitoring or updated care plans.
The facility failed to maintain an effective infection control program, with housekeeping staff not adhering to proper cleaning protocols and staff not using PPE for residents on enhanced barrier precautions. Additionally, residents were not offered hand hygiene before meals, and soiled linens were not changed after wound care. The facility also lacked an effective water management plan, indicating significant gaps in infection control practices.
The facility's QAPI program failed to effectively identify and address compliance concerns, leading to multiple deficiencies in resident care, staff training, and infection control. Interviews revealed that the QAPI committee did not conduct thorough reviews, and several areas of concern were overlooked, resulting in failures across various operational aspects, including resident grievances, medical equipment provision, and emergency preparedness.
The facility did not have a designated infection preventionist (IP) with adequate time to manage the infection prevention and control program, affecting all 74 residents. The DON was serving as the IP but could not effectively fulfill both roles. The ROM recognized the issue and was working to hire another staff member for the IP role.
The facility failed to provide food that was palatable, attractive, and at the correct temperature. Residents reported issues with food being under-seasoned, cold, and bland. Surveyors observed that meals were not served at appropriate temperatures, with specific issues like mushy lima beans and overcooked garlic toast. Staff interviews confirmed improper food storage practices, contributing to these deficiencies.
The facility failed to address grievances related to call light response times, as residents reported long waits for assistance. Despite some staff education and attempts to resolve the issue, the problem persisted, with call light logs confirming prolonged wait times. Staffing issues, particularly during night shifts, contributed to the delays, leading to the deficiency.
The facility failed to coordinate PASRR Level II evaluations for five residents with documented mental health needs, resulting in a deficiency. These residents, with diagnoses such as anxiety, bipolar disorder, and major depressive disorder, were identified as needing Level II evaluations, which were not completed. The Social Services Director cited unfamiliarity with the PASRR system as a reason for the oversight.
The facility did not complete annual performance reviews or provide in-service education based on these reviews for several CNAs. The DON was unaware of the requirement to link training to performance reviews, and the NHA acknowledged the need for a better tracking system. One CNA reported never having completed a performance evaluation.
The facility failed to maintain sanitary conditions in the kitchen and unit refrigerators. The dietary director did not follow proper hand hygiene protocols, using the same gloves for multiple tasks without washing hands. Additionally, food items in the kitchen and unit refrigerators were found unlabeled and undated, indicating improper food storage practices. The dietary director acknowledged these issues and expressed uncertainty about the shelf life of certain items.
The facility failed to maintain safe operating conditions for patient care equipment by using non-medical grade blood pressure cuffs. An LPN and an RN were observed using blood pressure cuffs not rated for medical use on residents. The nursing home administrator confirmed the lack of documentation supporting the safety or accuracy of these devices for medical use.
The facility failed to provide annual training on abuse prevention and dementia management to certain staff members, including the activities assistant, cook, and housekeeper. Training records and staff interviews revealed that these staff members had not participated in the required training over the past year, despite facility policies mandating such education. The nursing home administrator and director of nursing were unable to provide evidence of completed training and acknowledged the oversight.
The facility failed to ensure CNAs received the required 12 hours of annual in-service training, including dementia management and abuse prevention. A review of training records showed that four CNAs did not meet these requirements. Interviews revealed a lack of awareness and documentation regarding training needs, with the DON unaware of the need to document training lengths and the NHA acknowledging training as a work in progress.
A resident experienced an unwitnessed fall while transferring from bed to scooter, but the facility failed to notify the resident's representative, who was also the power of attorney and emergency contact. The facility's policy requires such notifications, but documentation showed only the resident was informed. The DON confirmed the family should have been contacted.
A resident at moderate risk for falls experienced two falls during her stay at an LTC facility. The facility failed to assess and report the falls, particularly after the resident sustained facial injuries. The resident was also allowed to smoke unsupervised, contrary to the facility's policy, leading to a second fall. The care plans did not include necessary interventions for fall prevention or safe smoking practices, indicating a lapse in ensuring resident safety.
A facility failed to manage a resident's personal funds account properly by not obtaining signed authorization for withdrawals. The resident had three unauthorized withdrawals, and the business office manager admitted to not requiring receipts or signed authorization from the resident's legal representative. The BOM was unaware of the need for resident authorization and planned to audit accounts to update consent forms.
A facility failed to provide a resident with a Notice of Medicare Provider Non-Coverage (NOMNC) at least two days before the termination of Medicare Part A services, as required. The resident received the notice on the last day of coverage, preventing an opportunity to appeal. The admission/discharge coordinator was unaware of the notification requirement and lacked a system to confirm or track the delivery of NOMNCs.
A resident reported feeling threatened by a staff member during a billing discussion, but the facility failed to investigate the allegation as required by their abuse prevention policy. The resident, who was cognitively intact and had a history of paraplegia and depressive episodes, expressed fear of retaliation. The NHA did not consider the incident as abuse initially, despite the facility's policy stating that threats are considered abuse. An investigation was only initiated during a survey, highlighting a delay in addressing the resident's concerns.
A resident discharged to another LTC facility had an incomplete discharge summary, missing key information such as functional status, continence, vision, behavior, cognitive status, and lab results. The interdisciplinary team was responsible for completing the summary, but several sections were left unfinished, as confirmed by staff interviews.
A resident over 65 with chronic conditions did not receive new eyeglasses despite having a prescription from an eye doctor. The facility failed to assist the resident in obtaining the glasses, resulting in the resident experiencing blurry vision. The oversight was confirmed through interviews and record reviews, revealing a lack of documentation for the replacement of the eyeglasses.
A facility failed to discontinue a resident's PRN lorazepam order after 14 days, as required. The resident, with diagnoses including COPD and major depressive disorder, had a 90-day PRN order without documented rationale. Staff interviews revealed a lack of awareness about the 14-day limit for PRN psychotropic medications, and the pharmacist had not reviewed the order due to being behind schedule.
The facility failed to properly secure medication storage and maintain consistent temperature logs for medication refrigerators. A medication cart was found unlocked, and there were gaps in temperature documentation despite a performance improvement plan. Staff interviews confirmed the need for better adherence to procedures.
Two residents with dysphagia were not provided with the correct mechanically altered diets as per their physician orders. One resident received a regular sandwich and soup, while another was served regular spaghetti and meatballs. The dietary director admitted to not offering the prescribed diet to reduce food waste and was unaware of serving incorrect textures. Staff interviews highlighted the importance of following diet orders to prevent aspiration or choking.
A facility failed to ensure hospice agency notes were accessible to staff, affecting care coordination for a resident with COPD and prostate cancer. The resident was unaware of receiving hospice services, and there was no physician's order in the EMR. Staff interviews revealed a lack of awareness and documentation, with hospice notes initially sent to the wrong contact. The issue was resolved after updating contact information.
A resident with limited range of motion did not receive restorative therapy services, despite recommendations from a physical therapy discharge summary. The resident, who had conditions such as COPD and muscle weakness, expressed concerns about becoming weaker and more dependent. Staff interviews revealed a lack of awareness and implementation of restorative therapy services, attributed to communication issues and staff turnover.
The facility did not post nurse staffing information daily as required. Observations showed no postings on two days, and records revealed a lack of maintained staffing data for 18 months. The DON, unaware of the requirement, stated that the facility had not used the necessary form for over four years.
Significant Insulin Medication Error and Delayed Response to Hypoglycemia
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to insulin administration. The resident, who had type 1 diabetes mellitus and a history of low blood glucose levels, had physician’s orders for Lantus (insulin glargine) 29 units subcutaneously at bedtime and Humalog (lispro) insulin per sliding scale at 6:00 a.m., 11:00 a.m., and 4:00 p.m. On the evening in question, the RN responsible for medication administration drew up and administered 29 units of Humalog, a rapid-acting insulin, instead of the ordered 29 units of Lantus, a long-acting insulin, at the resident’s bedtime medication pass. After discovering that the wrong insulin had been given, the RN informed the resident of the error and then administered the Lantus insulin that had originally been ordered, without first consulting the resident’s physician. The RN documented that the resident was instructed to check her own blood glucose every 20–30 minutes and report the results, and she was encouraged to eat sugar-rich foods. The RN did not perform or document a full nursing assessment, including serial blood glucose checks performed by staff, vital signs, or evaluation of the resident’s cognitive or physical status, despite the known medication error and the resident’s history of low blood sugars. The RN notified the DON and called the on-call physician service but did not immediately send the resident to the emergency room as directed by the DON and as required by facility protocol for a significant insulin error and hypoglycemia. Instead, the RN waited approximately four and a half hours before arranging EMS transport, during which time the resident’s blood glucose fluctuated and dropped to 54 mg/dL, with no documented staff monitoring of vital signs or continuous assessment. EMS ultimately found the resident in a hypoglycemic state with a blood glucose of 42 mg/dL and provided oral glucose before transporting her to the hospital, where she was monitored and treated for recurrent hypoglycemia related to the excessive and incorrect insulin administration. Facility investigation and staff interviews confirmed that the RN failed to follow medication administration standards, physician orders, and the facility’s Management of Hypoglycemia policy. The investigation documented that there was no record of ongoing blood glucose monitoring by staff, no documentation of vital signs such as heart rate and blood pressure, and no timely implementation of emergency measures following the insulin overdose. The medical director later stated she was not notified at the time of the error and that, given the excessive amount of incorrect insulin, the resident could be at cardiac and neurologic risk, underscoring the seriousness of the medication error and the lack of appropriate clinical response by facility staff at the time of the incident.
Widespread Failure to Complete and Document Required Staff Training
Penalty
Summary
The facility failed to provide, implement, and maintain an effective training program for new and existing staff as required by its own In-Service Training policy. The policy, revised in April 2021, required all staff to participate in initial orientation and annual in-service training on topics including effective communication, resident rights, abuse prevention and reporting, QAPI, infection prevention, behavioral health, and compliance and ethics. Record review showed that 75 of 83 staff did not receive the required annual abuse identification, prevention, and reporting training; 39 of 83 staff did not complete dementia management training; 31 of 83 staff did not complete resident rights training; 30 of 83 staff did not complete QAPI training; 49 of 49 direct care staff did not complete effective communication training; 20 of 83 staff did not complete infection control training; 16 of 83 staff did not complete compliance and ethics training; and 13 of 49 direct care staff did not complete behavioral health training. Further review of training records revealed missing or incomplete documentation for several required topics. For dementia training, 39 staff lacked documentation of completion and no alternative in-service records were provided. For resident rights, the facility produced an in-service training document but no sign-in sheet to verify attendance. For QAPI, an in-service document and sign-in sheet were provided, but 30 staff still lacked evidence of completion. No direct care staff had documented completion of effective communication training, and although a copy of the training content existed, there was no proof it had been used. Infection prevention records showed some staff completed online and in-service training, but 20 staff still lacked required training. Compliance and ethics training records listed all staff on an online roster, but many had no completion dates and no documentation of use was provided. Behavioral health training records showed 13 staff without required online training and no in-service documentation. In interviews, the NHA reported that most training was done during onboarding, stated that about 91% of trainings were completed, and claimed all abuse and dementia trainings were finished, but she could not produce records to support these statements, and acknowledged that some training sessions such as lunch-and-learns were not documented. The regional nurse consultant stated the current training plan was not effective to ensure all staff were sufficiently trained as required.
Failure to Provide Required Annual Abuse and Dementia Training to Staff
Penalty
Summary
The facility failed to provide required annual staff training on abuse, neglect, exploitation, misappropriation of resident property, and dementia care, as required by its own Abuse policy and regulatory standards. The written policy, revised in April 2021, stated that the facility’s abuse, neglect, and exploitation prevention program included staff orientation and training on abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. Surveyors requested current training records for annual abuse and dementia training, and the records provided did not demonstrate that staff received thorough abuse training covering identification of all types of abuse, steps and measures to prevent abuse and neglect, techniques to prevent resident-to-resident altercations, requirements for timely reporting of abuse, and methods of gathering evidence for a complete investigation. Record review showed that 75 of 83 total staff members had not been provided annual abuse training since 2024. During interviews, the NHA and ADON stated that most training was done during onboarding and that all staff had been provided abuse and dementia care trainings, indicating they believed the trainings were completed. However, this statement was inconsistent with the documented training records, which showed that the last extensive training on abuse prevention occurred in 2024 and that the majority of staff lacked the required annual abuse training thereafter.
Failure to Prevent Allergen Exposure Resulting in Resident Hospitalization
Penalty
Summary
A deficiency occurred when a resident with a documented allergy to fish was served a meal containing tilapia. The resident, who had a history of anaphylaxis and other medical conditions including cognitive communication deficit and muscle weakness, consumed the fish during lunch. The resident was not aware the meal contained fish until after eating it, which led to the onset of itching and difficulty breathing. Staff interviews and facility investigation revealed that both the cook and the certified nurse aide involved in preparing and serving the meal did not check the diet ticket for allergies prior to sending and serving the tray. The cook had previously received a written warning and corrective education for a similar incident involving another resident and a known allergen. The failure to check the diet ticket and confirm the resident's allergies directly resulted in the resident being exposed to a known allergen. Following the meal, the resident developed symptoms consistent with anaphylactic shock, including altered consciousness, facial swelling, difficulty breathing, and low oxygen saturation. Emergency medical services were contacted, and the resident required hospitalization in the intensive care unit for treatment of anaphylaxis. The incident was confirmed through record review, staff interviews, and medical documentation.
Failure to Notify Representatives of Significant Changes and Events
Penalty
Summary
The facility failed to ensure timely notification of residents' representatives regarding significant changes in condition, medical appointments, and medication changes for two residents. In one case, a resident with multiple diagnoses, including diabetes, dementia, and atrial fibrillation, was sent to a cardiology appointment and subsequently started on an anticoagulant medication. There was no documentation in the electronic medical record (EMR) that the resident's representative was notified of either the appointment or the new medication order. Both the resident and the former representative confirmed that the representative only learned of these events after being informed by the resident, not by the facility. In another instance, a resident with a history of falls and muscle weakness reported hip pain and difficulty bearing weight. Although the facility documented the resident's symptoms and planned for further assessment and notification, there was no evidence in the EMR that the representative was informed of the change in condition or the subsequent transfer to the hospital for X-rays. The representative stated he was not notified by the facility about the resident's change in mobility or hospital transfer until several hours after the event, learning of the situation first from the outpatient physician's office. Facility policy requires prompt notification of residents, their attending physicians, and representatives regarding changes in condition or status. However, interviews with facility leadership revealed there was no standardized process for such notifications or for documenting them in the EMR. The lack of timely and documented communication with residents' representatives regarding significant changes and events led to the identified deficiencies.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment and a history of wandering from verbal and physical abuse by another resident. The resident, who had diagnoses including dementia and Alzheimer's disease, was involved in multiple altercations with another resident who also had severe cognitive impairment, hallucinations, and delusions. Despite documented incidents of verbal threats and physical aggression, the care plans for both residents did not adequately address the risk of abuse or specify interventions to prevent further altercations. The facility's investigations confirmed that one resident verbally threatened and later physically assaulted the other, including an incident where staff witnessed the aggressor grabbing and choking the victim. Documentation in the electronic medical records was incomplete, with key incidents not fully recorded or followed up in progress notes. The care plans lacked updates to reflect the ongoing risk, and interventions such as the use of a stop sign barrier were delayed and not consistently implemented. Staff interviews revealed a lack of clear communication and documentation regarding the need for increased supervision and specific interventions to keep the residents apart. Some staff were unaware of the residents' history of altercations or the need for purposeful rounding and redirection. The director of nursing acknowledged that the residents should have been care planned for their risk of abuse, and the nursing home administrator noted deficiencies in timely staff education and documentation following the incidents.
Failure to Ensure Safe and Compliant Discharge Process
Penalty
Summary
The facility failed to ensure a safe and regulatory-compliant discharge process for a resident who was transferred to the hospital following behavioral incidents. The resident, who had a history of depression, developmental delay, suicide attempt, skin graft failure, muscle contractures, and a permanent tracheostomy, exhibited escalating behaviors including yelling, cursing, threatening staff, and attempting to tamper with his tracheostomy device. Following these events, the resident was transferred to the hospital by EMS after expressing threats to harm staff. Despite the hospital determining the resident was stable and did not require inpatient admission, the facility refused to allow the resident to return, citing inability to meet his needs and concerns for the safety of others. The facility did not provide documentation from a physician agreeing to the discharge, nor did it include a physician's order for discharge or a physician's signature on the discharge form. The discharge notice was issued 11 days after the resident's transfer, and the section of the form for ombudsman contact information was left blank. Additionally, the facility listed a receiving facility for discharge, but that facility denied the resident's admission. There was no evidence in the medical record that the facility reassessed the resident for readmission after he was stabilized at the hospital and ready to return. Interviews with the resident's representative, hospital staff, and facility staff confirmed that the facility did not follow its own discharge policy or regulatory requirements. The resident's representative was not informed of the right to appeal the discharge, and the admissions assistant expressed discomfort with the discharge process due to lack of proper notice and documentation. The NHA acknowledged that not all regulations were followed in the discharge process, and efforts to place the resident in another facility were unsuccessful. The resident remained at the hospital at the time of the interviews.
Failure to Provide Required Mental Health Services
Penalty
Summary
The facility failed to provide appropriate mental health treatment and services to a resident with a diagnosed mental disorder and psychosocial adjustment difficulties. The resident, under the age of 65, had a history of depression, developmental delay, suicide attempt, and required a permanent tracheostomy. The resident exhibited significant behavioral symptoms, including yelling, threatening, cursing, throwing items, striking out, grabbing others, and inappropriate sexual behavior. The care plan included interventions such as antipsychotic medications, behavior monitoring, and psychiatric consultation as indicated. The PASRR Level II determination specifically required specialized services, including psychiatric case consultation, individual therapy, and a neuropsychological assessment. Despite these documented needs and the resident's escalating behaviors, the facility did not arrange for psychiatric case consultation or individual therapy. Progress notes over several months documented repeated behavioral incidents, including aggression toward staff and other residents, and attempts to tamper with the resident's tracheostomy. Staff interviews confirmed that the resident did not receive individual therapy services during his stay, as the facility lacked a contract with a mental health provider for an extended period. The social services director and nursing home administrator both acknowledged the absence of these services, noting that a new contract for mental health services was only recently established, and that the previous provider had stopped coming to the facility some time ago. The lack of mental health services persisted even as the resident's behaviors increased, and there was no evidence in the medical record that the required specialized services were provided. Staff attempted to manage the resident's behaviors with medication adjustments and non-pharmacological interventions such as music, but these did not substitute for the required psychiatric and therapeutic interventions. The deficiency was identified through record review and staff interviews, which confirmed the facility's failure to provide the necessary mental health counseling and therapy services as required by the resident's care plan and regulatory requirements.
Facility Fails to Address Resident Grievances on Call Light Delays
Penalty
Summary
The facility failed to ensure prompt action was taken upon the filing of grievances by residents, specifically regarding the timeliness of call light responses. Multiple residents reported excessive wait times for assistance, with some waiting up to 45 minutes or more for staff to respond to their call lights. Resident interviews revealed that these delays were a common issue, particularly during night shifts and weekends, and that grievances submitted by residents were not adequately addressed or resolved by the facility. The facility's grievance policy required that grievances be reviewed and investigated within seven working days, with findings reported to the administrator. However, the facility did not adhere to this policy, as evidenced by the lack of timely follow-up on grievances submitted by residents. Resident council minutes also documented concerns about long wait times for staff assistance, but there was no evidence of action or response from the facility to address these concerns. Additionally, the facility's call light logs confirmed prolonged response times, further substantiating the residents' complaints. Interviews with facility staff, including the NHA, SSD, and DON, revealed a lack of awareness and communication regarding the grievances and the ongoing issue of delayed care. The NHA admitted to not thoroughly reviewing resident council minutes and not having an action plan to address the concerns raised. The SSD and DON were also unaware of specific grievances related to delayed care, indicating a breakdown in the grievance handling process. This failure to address and resolve grievances in a timely manner contributed to the deficiency in providing adequate care to residents.
Failure to Honor Resident's Dignity and Care Preferences
Penalty
Summary
The facility failed to ensure the dignity and respect of a resident who was dependent on staff for all care. The resident, who was cognitively intact and had diagnoses including complete paraplegia and incomplete quadriplegia, requested assistance to be turned in bed. However, the nursing staff informed the resident that his next scheduled turn was at a later time, which led to the resident expressing anger and frustration. The facility's policy emphasized the resident's right to self-determination and participation in care planning, but this was not upheld in the resident's case. The resident's care plans included interventions for frequent turning and repositioning to prevent pressure ulcers, as well as providing choices about his care. Despite these plans, the staff did not accommodate the resident's requests for repositioning, citing constraints such as the need for two staff members and a hoyer lift. Progress notes documented multiple instances where the resident's requests were not met, leading to his aggravation and dissatisfaction with the care provided. Interviews with staff members revealed that the resident was known to refuse care at times, but it was acknowledged that his requests should be accommodated. The Director of Nursing confirmed that the resident had the right to request repositioning and that it was crucial for his skin health. The DON also stated that it was unacceptable for staff to deny such requests and that care should be reoffered if initially refused. The inconsistency in honoring the resident's preferences and the failure to accurately document his care refusals contributed to the deficiency.
Failure to Administer Full Course of Antibiotics
Penalty
Summary
The facility failed to ensure that a resident received a full three-week course of antibiotics as recommended by the hospital following a surgical procedure. The resident, who was cognitively intact, had been admitted with a wound on her left big toe, which led to an amputation due to osteomyelitis. Post-surgery, the hospital prescribed a three-week antibiotic regimen, which included both intravenous and oral antibiotics. However, the facility did not administer all the required doses of the oral antibiotic, Augmentin, as prescribed. The medication administration record indicated that the resident received only 26 out of the 32 prescribed doses of Augmentin. The facility ran out of the medication on multiple occasions, and there was no documentation in the resident's electronic medical record indicating that the physician or pharmacy was notified about the missed doses. Despite having a backup medication system in place, the facility failed to utilize it to ensure the resident received the necessary medication. Interviews with staff revealed a lack of communication and understanding of the medication refill process. The medical director was unaware of the missed doses, and the licensed practical nurses were not informed about the medication shortage. The director of nursing stated that the staff should have contacted the pharmacy and informed her about the situation, but this did not occur. The failure to administer the full course of antibiotics was identified as a significant medication error.
Failure to Address Severe Weight Loss in Resident
Penalty
Summary
The facility failed to ensure that a resident received the necessary care and services to meet their nutritional needs, resulting in severe weight loss. The resident, who was admitted with chronic obstructive pulmonary disease (COPD), diabetes, and generalized muscle weakness, experienced a significant weight loss of 26 pounds (17.4%) over three months and 12.2 pounds (9%) in one month. Despite this severe weight loss, the facility did not assess the resident or implement any new nutrition interventions after the weight loss was documented on February 5, 2024. The resident expressed dissatisfaction with the meals provided, specifically mentioning the blandness of scrambled eggs served frequently for breakfast, which led to skipped meals and feelings of hunger. Observations confirmed that the resident often left the scrambled eggs untouched. The facility's records showed that the resident's weight was not monitored consistently, with no weights recorded for over four months after the significant weight loss was identified. The care plan did not reflect any new interventions to address the resident's nutritional needs following the weight loss. Interviews with staff revealed a lack of communication and follow-up regarding the resident's weight loss. The Registered Dietitian (RD) had verbally requested additional weights but did not document these requests, and the Director of Nursing (DON) acknowledged that the facility failed to identify and address the significant weight loss. The DON also noted that the facility had issues with obtaining and documenting weights, which had been identified by the Quality Assurance and Performance Improvement (QAPI) committee but not yet addressed with a correction plan.
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 during room cleaning. They also failed to use disinfectant chemicals according to the manufacturer's instructions, not allowing the required dwell time for effective disinfection. Additionally, there was a communication barrier due to language differences, which hindered proper training and adherence to cleaning protocols. The facility also failed to ensure that staff donned appropriate personal protective equipment (PPE) when providing direct care to residents on enhanced barrier precautions (EBP). Observations revealed that staff assisted residents without wearing PPE, and there was a lack of clear signage and communication regarding which residents required EBP. Interviews with staff indicated a lack of understanding and training on EBP protocols, leading to non-compliance with infection control measures. Furthermore, the facility did not offer hand hygiene to residents before meals, and there was a failure to change soiled linens after wound dressing changes. Observations showed that residents were not provided with hand hygiene opportunities before eating, and soiled bedding was not replaced after wound care, potentially leading to contamination. Additionally, the facility lacked an effective water management plan, with inadequate documentation and assessment of potential risks for waterborne pathogens, such as Legionella, indicating a significant gap in infection control practices.
Ineffective QAPI Program and Multiple Deficiencies
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program, which is crucial for identifying and addressing compliance concerns to improve the quality of care, quality of life, and resident safety. The QAPI committee did not effectively identify and address issues related to residents' quality of care, quality of life, staff training, and infection prevention and control. The facility's policy outlined a comprehensive approach to problem-solving, including defining problems, analyzing root causes, setting measurable goals, implementing interventions, and monitoring performance. However, these steps were not effectively executed. The report highlights several specific deficiencies across various areas of the facility's operations. These include failures in responding to resident council grievances, obtaining proper consent for personal fund spending, notifying representatives of changes in resident conditions, and providing necessary medical equipment and services. Additionally, the facility did not adequately investigate potential abuse allegations, complete required assessments and documentation, or provide necessary training and evaluations for staff. There were also significant lapses in infection control practices, food service, and emergency preparedness. Interviews with the Nursing Home Administrator (NHA), Regional Operations Manager (ROM), and Director of Nursing (DON) revealed that while the QAPI committee met monthly and included an interdisciplinary team, the process was not thorough. The ROM admitted that the QAPI plan failed, as not all concerns discussed in morning meetings were brought to the committee for a full review. The DON acknowledged that some areas of concern were overlooked and emphasized the need for the committee to hold each other accountable and address all potential issues with fresh perspectives.
Inadequate Infection Preventionist Staffing
Penalty
Summary
The facility failed to ensure a qualified infection preventionist (IP) was designated to manage the infection prevention and control program (IPCP), potentially affecting all 74 residents. The facility's policy, revised in October 2018, required adherence to current infection prevention and control standards. However, observations during the survey period revealed multiple infection control failures. Interviews with the Director of Nursing (DON) and the Regional Operations Manager (ROM) highlighted that the DON was also serving as the IP, but lacked sufficient time to fulfill the IP responsibilities effectively. The ROM acknowledged the issue and mentioned efforts to hire another staff member to assume the IP role.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that residents consistently received food that was palatable, attractive, and served at the appropriate temperature. Multiple residents reported dissatisfaction with the food, describing it as under-seasoned, cold, bland, and sometimes over-seasoned or undercooked. Specific complaints included meals being delivered cold to rooms, food being processed and bland, and some residents skipping meals due to poor taste. These resident interviews highlighted a consistent issue with the quality and temperature of the food served. Observations by surveyors confirmed these complaints. A test tray evaluation revealed that the spaghetti and meatballs were served at 130 degrees Fahrenheit, below the desired temperature of 135 degrees Fahrenheit. The lima beans were mushy, bland, and appeared gray, while the garlic toast was overcooked, hard, and partially burnt. The chocolate pudding was not cold enough, measured at 54.5 degrees Fahrenheit, which is above the required temperature for cold foods. Staff interviews revealed that the pudding was not stored properly during meal service, contributing to the temperature issue. The dietary director acknowledged these temperature discrepancies and the need for proper food storage and serving practices.
Facility Fails to Address Call Light Response Time Grievances
Penalty
Summary
The facility failed to promptly address grievances related to call light response times, as reported by residents during council meetings. Residents expressed frustration over long wait times for assistance, with some waiting between five minutes to two hours. The facility's policy required grievances to be investigated and resolved, but the residents felt their concerns were not adequately addressed, as evidenced by unresolved issues documented in resident council minutes from December 2023 to June 2024. Interviews with residents revealed consistent complaints about call light response times, with several residents reporting waits of over an hour. The facility's grievance forms and resident council minutes indicated that the issue was ongoing, with no effective interventions implemented. Despite some staff education and attempts to address the problem, the residents continued to experience delays, and the facility's response was deemed insufficient. The facility's call light logs and audits further confirmed the residents' concerns, showing numerous instances of prolonged wait times. Staff interviews highlighted issues with staffing levels, particularly during night shifts, contributing to the delays. The facility's failure to implement a systematic approach to resolving the grievances and ensuring timely call light responses led to the deficiency.
Failure to Coordinate PASRR Level II Evaluations
Penalty
Summary
The facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program for five residents, resulting in a deficiency. These residents, identified as #26, #36, #4, #18, and #22, were all documented as needing a PASRR Level II evaluation, which was not completed. The PASRR Level I identification screens for these residents indicated the necessity for a Level II evaluation due to their mental health diagnoses, including generalized anxiety disorder, bipolar disorder, major depressive disorder, and intellectual disabilities. Resident #26, aged 71, was cognitively intact but experienced feelings of depression. Despite a PASRR Level I screen indicating the need for a Level II evaluation, no documentation of such an evaluation was found in the resident's electronic medical record (EMR). Similarly, Resident #36, aged 84, with severe cognitive impairment and depression, also lacked documentation of a completed Level II PASRR. Resident #4, aged 86, with moderate cognitive impairments and depression, had a provisional PASRR but no completed Level II evaluation. Resident #18, over 65 years old, was cognitively intact but also lacked a Level II PASRR despite the need being documented. Lastly, Resident #22, who passed away, had a PASRR Level I screen indicating a Level II was needed, but no evaluation was completed before their death. Interviews with the Social Services Director (SSD) revealed a lack of follow-up on PASRR evaluations, attributed to the SSD's unfamiliarity with the system due to being from another state. The SSD acknowledged the importance of completing PASRR evaluations to ensure residents receive appropriate mental health care. The deficiency was identified during a survey, highlighting the facility's failure to ensure necessary PASRR Level II evaluations were conducted for residents with documented mental health needs.
Deficiency in CNA Performance Reviews and Training
Penalty
Summary
The facility failed to conduct annual performance reviews and provide regular in-service education based on these reviews for four out of five certified nurse aides (CNAs) reviewed. Specifically, CNAs hired on various dates did not have completed performance reviews or in-service education plans tailored to the outcomes of such reviews. During interviews, the Director of Nursing (DON), who was also acting as the staff development coordinator, admitted to being unaware of the requirement to base in-service training on performance reviews. The Nursing Home Administrator (NHA) acknowledged the need for improvement in staff training and mentioned the absence of a reliable tracking system for performance evaluations. Additionally, one CNA reported never having completed a performance evaluation at the facility.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen and unit refrigerators, as observed during a survey. The dietary director (DD) did not adhere to proper hand hygiene protocols while preparing food. Specifically, the DD was observed putting on gloves without washing hands, using the same gloves for multiple tasks, and handling food items without changing gloves or washing hands in between tasks. This lack of proper hand hygiene was acknowledged by the DD during an interview, where he admitted to not realizing the extent of his glove usage and the need for hand hygiene. In addition to hand hygiene issues, the facility did not properly label and store food items in the main kitchen refrigerator, freezer, and unit refrigerators. Observations revealed several food items, including a large bowl of meat and sauce, condiment containers, chopped lettuce, a chocolate pie, and cartons of egg whites, were either unlabeled or undated. Similar issues were found in the walk-in freezer, where items like puff pastry, raw beef hamburger patties, frozen potatoes, and egg rolls were uncovered and undated. Furthermore, thawed Mighty Shakes in unit refrigerators were not dated, indicating a lack of adherence to proper food storage and date marking protocols. Interviews with the DD revealed that dietary staff were required to label all food not in its original packaging, but this was not consistently done. The DD also admitted to being unsure about the shelf life of thawed health shakes and relied on the manufacturer's use-by date. The DD expressed an intention to personally oversee food delivery orders to ensure proper labeling and dating, highlighting a gap in the current food storage and handling practices at the facility.
Use of Non-Medical Grade Blood Pressure Cuffs
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, specifically regarding the use of blood pressure cuffs. Observations revealed that a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) used blood pressure cuffs not rated for medical use to take residents' blood pressure readings. The LPN used an Equate model VA-4000WM blood pressure cuff, while the RN used an Ever Ready First Aid wrist blood pressure cuff. Both devices were not rated for medical use, as confirmed by the nursing home administrator. Interviews with the staff further confirmed the use of non-medical grade blood pressure cuffs. The LPN and RN admitted to using these devices for obtaining blood pressure readings on residents. The nursing home administrator acknowledged that there was no documentation to support the safety or accuracy of these devices for medical use in the facility. This lack of proper equipment and documentation led to the deficiency in maintaining safe operating conditions for patient care equipment.
Deficiency in Staff Training on Abuse and Dementia Management
Penalty
Summary
The facility failed to provide necessary training to its staff on critical areas such as abuse, neglect, exploitation, and dementia management. Specifically, the activities assistant, cook, and housekeeper did not receive annual training on abuse prevention and reporting, while the cook, dietary aide, and maintenance assistant did not receive training on dementia management. This deficiency was identified through a review of training records and staff interviews, which revealed that these staff members had not participated in the required training over the past 12 months. The facility's policies, including the Abuse, Neglect, Exploitation and Misappropriation Prevention Program and the Dementia Clinical Protocol, mandate annual training for staff on these topics. However, the nursing home administrator and director of nursing were unable to provide evidence of completed training for the involved staff members. The director of nursing, who was also the staff development coordinator, acknowledged the lack of training and mentioned that the facility offered a four-hour dementia class and used an electronic system for abuse training. The nursing home administrator admitted to being unaware of the requirement for non-clinical staff to receive such training and was in the process of developing a new tracking system for training.
Deficiency in CNA Training Compliance
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNAs) received the required 12 hours of annual in-service training, including specific training in dementia management and resident abuse prevention. This deficiency was identified through a review of training records for five randomly selected CNAs, where it was found that four CNAs did not meet the training requirements. CNA #2, hired on May 16, 2023, completed only six hours and 45 minutes of training. CNA #5, hired on August 18, 2021, attended a four-hour dementia class, but the facility could not provide a complete training record for abuse, neglect, or exploitation. CNA #4, hired on April 6, 2017, completed four hours and 30 minutes of training and had no record of abuse, neglect, or exploitation training. CNA #1, hired on April 6, 2023, completed six hours and 30 minutes of training. Interviews with staff revealed a lack of awareness and documentation regarding the training requirements. The Director of Nursing (DON), who was also acting as the staff development coordinator, admitted to being unaware of the need to document the length of the training provided to CNAs. The Nursing Home Administrator (NHA) acknowledged that staff training was an area needing improvement and was a work in progress. CNA #5 mentioned that training was assigned on the computer, and she completed a four-hour dementia training session. These findings indicate a systemic issue in the facility's training program, leading to non-compliance with regulatory requirements for CNA training.
Failure to Notify Resident Representative of Fall
Penalty
Summary
The facility failed to inform the designated resident representative of a change in condition for one of the residents reviewed. Specifically, the facility did not notify the responsible party of a resident after an unwitnessed fall occurred. The facility's policy on managing falls, revised in March 2018, requires that a fall is defined as unintentionally coming to rest on the ground, floor, or lower level, and that notification should be made to the resident's representative. However, in this case, the resident's representative was not informed of the fall, which was concerning given the resident's post-surgery care needs following a neck injury. The resident, who was cognitively intact and required assistance for transferring, experienced an unwitnessed fall while attempting to transfer from her bed to her scooter. The incident was documented in the nurse's notes, indicating no injuries occurred, and the resident did not hit her head. Despite this documentation, the resident's representative, who was also the power of attorney and emergency contact, was not notified of the fall. Interviews with the director of nursing confirmed that the notification should have been made to the resident's family, as per the facility's policy.
Failure to Prevent Falls and Ensure Safe Smoking Practices
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent falls for Resident #173, who was identified as being at moderate risk for falls. The resident, who had a history of spinal fusion, an acquired absence of the left leg below the knee, and dependence on a wheelchair, experienced two falls during her stay. The first fall occurred when she attempted to transfer from her bed to her scooter, and the second fall happened outside while she was smoking alone at night. Despite these incidents, the facility did not assess the resident after the potential falls, nor did they report the falls or monitor the resident for injuries, particularly after facial injuries were identified. The facility's policies on fall risk management and smoking were not adequately followed. The resident's care plan did not include interventions to address her moderate risk for falls, and the smoking care plan failed to outline safe smoking practices. The resident was allowed to smoke unsupervised, contrary to the facility's policy that required direct supervision for residents with smoking privileges. This lack of supervision contributed to the resident's second fall, where she slipped off her scooter while reaching for a cigarette. Interviews with the resident and her representative revealed that the resident had facial bruising and swelling after the second fall, which was not documented or reported by the staff. The Director of Nursing (DON) confirmed that the incident was not reported, and the resident was not assessed for injuries following the fall. The DON acknowledged that the nurse should have reported the incident and assessed the resident, highlighting a breakdown in communication and adherence to facility policies. The failure to document and address the resident's falls and injuries indicates a significant lapse in the facility's duty to ensure resident safety and prevent accidents.
Failure to Obtain Authorization for Resident's Personal Fund Withdrawals
Penalty
Summary
The facility failed to ensure that a resident's personal funds account was managed adequately, specifically by not obtaining signed authorization for withdrawals. Resident #19 had three unauthorized withdrawals from their personal needs account, with amounts of $94.00, $105.00, and $110.00, respectively, on different dates. The facility did not provide receipts or signed authorization from the resident for these transactions. During an interview, the business office manager (BOM) stated that the resident's legal representative requested funds each month to pay the resident's bills but did not provide receipts. The BOM admitted to not asking for receipts and was unaware that the resident needed to sign a personal funds withdrawal for their legal representative to use the funds. The BOM mentioned auditing all resident accounts to update consent forms and ensure proper authorization for personal fund usage.
Failure to Provide Timely Medicare Coverage Notice
Penalty
Summary
The facility failed to inform a resident of changes in their Medicare Part A coverage in a timely manner, specifically by not providing a Notice of Medicare Provider Non-Coverage (NOMNC) at least two days prior to the termination of services. The resident, identified as #216, was discharged from Medicare Part A funded therapy services and received the NOMNC on the same day her benefits ended, which did not comply with the required notification timeframe. This failure prevented the resident from having the opportunity to appeal the decision regarding the termination of services. Interviews with the admission/discharge coordinator (ADC) revealed a lack of awareness regarding the requirement to provide the NOMNC at least two days before benefits expired. The ADC stated that she typically sent the NOMNC 72 hours before benefits ended but did not have a system to confirm the delivery or track the forms. Additionally, the NOMNC was sent to the resident's medical durable power of attorney (MDPOA), who was out of state and unable to sign it, leading to the resident signing the notice on the last day of coverage. This oversight highlights a gap in the facility's process for ensuring timely notification of coverage changes.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident who reported feeling threatened by a staff member. The resident, who was cognitively intact and had a history of paraplegia and depressive episodes, reported that a staff member raised her voice and threatened him during a discussion about a billing issue. The resident expressed fear of retaliation and filed a grievance with the nursing home administrator (NHA), who informed him that the staff member would no longer be assigned to his care. Despite the resident's grievance and the facility's policy requiring all allegations of abuse to be investigated, the NHA did not initiate an investigation into the incident. The NHA believed the situation did not constitute abuse and noted that the resident had changed his story and requested to drop the matter. However, the facility's policy clearly states that threats are considered abuse and should be investigated. The failure to investigate the allegation was acknowledged by the NHA during an interview, where she admitted that threats should have been treated as abuse. The staff member involved was only suspended and an investigation initiated during the survey, indicating a delay in addressing the resident's concerns and a breach of the facility's abuse prevention and investigation protocols.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure a complete discharge summary for a resident who was discharged to another long-term care facility. The resident, an 83-year-old individual, was admitted with diagnoses including hyperkalemia, benign prostatic hyperplasia, and major depressive disorder. At the time of discharge, the resident was cognitively intact with a BIMS score of 13 out of 15 and required supervision with activities of daily living. However, the discharge summary was incomplete, missing critical information such as the resident's physical and mental functional status, continence status, vision status, behavior, cognitive status, and pertinent lab results. Interviews with facility staff revealed that the interdisciplinary team (IDT) was responsible for completing the discharge summary, with each member tasked with filling out their respective sections. The social service director confirmed that the discharge summary was not fully completed, and the corporate clinical manager acknowledged the oversight after reviewing the document. The deficiency was identified during a review of the resident's records and staff interviews, highlighting a lapse in the facility's discharge procedures.
Failure to Provide New Eyeglasses for Resident
Penalty
Summary
The facility failed to ensure that a resident received necessary vision services, specifically the provision of new eyeglasses. The resident, who is over 65 years old and has diagnoses including chronic obstructive pulmonary disease and malignant neoplasm of the prostate, was admitted to the facility with adequate vision when using eyeglasses. However, during an interview, the resident reported that his current glasses were outdated and his vision was blurry. Despite having seen an eye doctor and receiving a new prescription for eyeglasses on February 8, 2023, the facility did not assist the resident in obtaining the new glasses. A review of the resident's electronic medical record did not show any documentation indicating that the eyeglasses had been replaced. Interviews with the social service director and the regional operations manager confirmed that the facility missed obtaining the new eyeglasses for the resident. The oversight was identified during the survey, and it was acknowledged that the resident had not received the necessary assistive device to maintain his vision abilities.
Failure to Discontinue PRN Psychotropic Medication After 14 Days
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, specifically regarding the use of PRN lorazepam. The resident, who was over 65 years old and had diagnoses including COPD, major depressive disorder, and chronic systolic heart failure, was cognitively intact with a BIMS score of 15 out of 15. Despite this, the resident's PRN order for lorazepam was set for 90 days without a documented rationale, contrary to the requirement that PRN psychotropic medications should be limited to 14 days unless a specific reason is documented by the physician. Interviews with facility staff revealed a lack of awareness and oversight regarding the appropriate duration for PRN psychotropic medications. The DON was unsure of the correct duration and relied on the corporate consultant for clarification, who confirmed the 14-day requirement. The facility had recently switched pharmacies, and the NHA was unaware if the pharmacist had reviewed the PRN orders for compliance. The pharmacist admitted to being behind on medication reviews and had not yet addressed the 90-day order for the resident's lorazepam.
Deficiency in Medication Storage and Temperature Logging
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored properly according to professional standards. Specifically, the central hall medication cart was observed in an unlocked position, which was later locked by a registered nurse. This indicates a lapse in maintaining the security of medication storage, as both registered nurses and licensed practical nurses acknowledged that medication carts should always be locked when not in use. Additionally, the facility did not maintain a consistent medication refrigerator temperature log for one of the medication refrigerators. Out of 102 days, temperatures were documented on only 88 days, with a notable gap of nine days where temperatures were not recorded. Despite a performance improvement plan initiated to address this issue, the facility still failed to document temperatures for eight days after the plan was put in place. Interviews with staff, including the director of nursing and the nursing home administrator, confirmed the responsibility of night shift nurses to log temperatures and highlighted the need for further education on proper procedures.
Failure to Provide Correct Mechanically Altered Diets
Penalty
Summary
The facility failed to provide two residents with the correct mechanically altered diet texture as per their physician orders. Resident #62, who has a history of dysphagia and moderate cognitive impairments, was observed during a lunch meal receiving a regular sandwich and soup instead of the prescribed mechanical soft diet. The dietary director admitted to not offering the mechanically altered food to Resident #62, as the resident had previously refused it, and the director wanted to reduce food waste. This decision was made despite the resident's care plan indicating a risk for aspiration and choking. Similarly, Resident #4, who also has a history of dysphagia following a cerebral infarction, was observed being served regular texture spaghetti with whole meatballs and garlic toast, contrary to the mechanical soft diet prescribed. The cook initially plated the incorrect meal, and it was only corrected after prompting. The dietary director acknowledged the mistake, stating he was unaware of serving the incorrect texture to Resident #4. Interviews with facility staff, including the nursing home administrator, director of nursing, and registered dietitian, revealed a lack of adherence to physician orders for mechanically altered diets. The staff emphasized the importance of following these orders to prevent aspiration or choking. The dietary director recognized the need for additional training for the dietary department to ensure compliance with diet orders and tracking of any resident refusals in the electronic medical record.
Failure to Coordinate Hospice Care Documentation
Penalty
Summary
The facility failed to ensure that hospice agency notes regarding a resident's care were easily accessible to the facility staff, which hindered effective coordination of care with the hospice agency. The resident, over 65 years old, was admitted with diagnoses including chronic obstructive pulmonary disease with exacerbation and malignant neoplasm of the prostate. Despite being documented as receiving hospice services, the resident was unaware of this, and there was no physician's order for hospice care services in the electronic medical record (EMR). The care plan identified the resident as having an end-of-life care plan and receiving hospice services, but it did not specify the involvement of the hospice care team. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's hospice services. A licensed practical nurse confirmed the absence of a physician's order for hospice services and was unaware of the resident's hospice status due to missing notes. The director of nursing acknowledged the resident was receiving hospice services but noted the absence of a physician's order in the EMR. The social service director confirmed the resident was on hospice services, and the corporate consultant discovered that hospice progress notes were being sent to the facility's previous medical records director. The new medical records director later received the hospice notes after updating contact information with the hospice services provider.
Failure to Provide Restorative Therapy Services
Penalty
Summary
The facility failed to provide restorative therapy services to a resident with limited range of motion, leading to a deficiency in care. The resident, who was over 65 years old and had diagnoses including COPD, diabetes, and generalized muscle weakness, was not receiving the necessary restorative therapy services to prevent physical decline. Despite recommendations from a physical therapy discharge summary for a restorative therapy program, the resident did not have an order for such services, and staff interviews revealed a lack of awareness and implementation of restorative therapy services. The resident expressed concerns about becoming weaker and more dependent on staff since her readmission, indicating a desire to work towards greater independence. Interviews with staff, including a CNA, LPN, PT, and the DOR, highlighted a lack of communication and understanding regarding the provision of restorative therapy services. The PT department had previously communicated and educated nursing staff on the resident's needs, but due to significant turnover in the physical therapy department, these recommendations were not effectively implemented. The DON acknowledged the absence of restorative therapy services for the resident and attributed it to communication issues stemming from staff turnover. The facility's leadership, including the NHA, ROM, and DON, recognized the deficiency and identified restorative therapy services as an area needing improvement within the facility's quality assurance and performance improvement committee.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post nurse staffing information daily. Observations on two consecutive days revealed the absence of nurse staffing postings. A review of records indicated that the facility had not maintained staffing data for the required 18 months. During an interview, the Director of Nursing (DON) admitted that the facility had not utilized staff posting in over four years. The DON, who was temporarily covering as the staff development coordinator, was unaware that staffing data needed to be posted in a visible area for residents and families. She mentioned that a form used for staffing data posting had not been used in over four years.
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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