Falcon Heights Rehabilitation And Nursing Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Colorado Springs, Colorado.
- Location
- 1795 Monterey Rd, Colorado Springs, Colorado 80910
- CMS Provider Number
- 065168
- Inspections on file
- 23
- Latest survey
- February 25, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Falcon Heights Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
Two residents with significant cognitive and psychiatric histories, including schizoaffective disorder, dementia, bipolar disorder, traumatic brain injury, and prior aggressive behaviors, were physically abused by other residents in shared areas. In one case, a resident with expressive aphasia and severe cognitive impairment was struck multiple times in the chest and shoulder by another resident with a documented history of aggression while they waited in the dining room. In the other case, during a supervised smoking break, a cognitively intact but behaviorally aggressive resident became agitated over another resident’s leg position, then stood, grabbed the resident by the shirt, and punched him in the face multiple times, causing facial redness, while staff on site were unable to intervene in time to prevent the blows.
A resident in a memory care unit with severe cognitive impairments and behavioral disturbances physically abused another resident on two occasions. Despite immediate staff intervention and separation of the residents, the facility's investigations did not substantiate the incidents as abuse. The assailant's care plans lacked identification of behavior triggers and effective interventions, contributing to the incidents.
A resident with severe cognitive impairment was involved in multiple unreported incidents of potential abuse, including striking and shoving other residents. Despite staff awareness of reporting procedures, the facility failed to report these incidents to the State Agency as required by policy.
A resident with severe cognitive impairments and multiple diagnoses was involuntarily discharged to a hospital without the required physician's discharge order or proper documentation. The facility failed to include a physician's signature on the discharge notice and did not retain necessary discharge paperwork in the resident's EMR, as confirmed by the NHA.
The facility failed to maintain resident dignity for two residents. One resident, with a history of stroke and tremors, was not provided meal assistance in a dignified manner, as staff stood over her despite her preference for them to sit. Another resident, with hemiplegia, reported an LPN refused to assist with a blanket, insisting on independence. These actions did not align with the facility's dignity policy.
The facility failed to provide residents with palatable and properly prepared meals, leading to dissatisfaction among several residents. Complaints included late meal delivery, incorrect diet trays, and unappetizing food. A test tray evaluation confirmed issues with food quality, such as dryness and blandness. The dietary account director admitted to overcooked and watery food items, highlighting a deficiency in food preparation and service.
The facility failed to maintain sanitary conditions in the kitchen by not accurately testing the chemical sanitizer solution's concentration in the dishwasher and sanitizer buckets. Observations showed inadequate testing frequency and low sanitizer concentration levels, contrary to the manufacturer's recommendations. Staff interviews revealed a lack of routine checks and documentation, leading to unsanitary conditions.
The facility failed to honor residents' right to choose their attending physician when it changed medical provider groups without informing or obtaining consent from residents. Interviews with several residents revealed they were unaware of the change and had not been consulted. The facility's administration confirmed the change was a corporate decision, and no meetings or letters were provided to inform residents or obtain their consent.
The facility failed to maintain a safe and homelike environment, with several room doors being difficult to open and close due to misalignment, and damaged floors not being repaired. Observations showed issues with room doors and missing flooring in the dining room. Interviews with two residents and a CNA confirmed ongoing problems with door operability, which had been reported to the maintenance supervisor. The NHA and MS acknowledged the issue, with plans to replace the doors.
The facility failed to maintain a safe environment for residents, particularly in smoking practices and medication management. A resident was left with medication at her bedside without a proper self-administration assessment, and another resident reported burning her fingers while smoking unsupervised. Additionally, two residents had medications at their bedside without physician orders or assessments, raising concerns about unauthorized access. Staff interviews revealed a lack of adherence to policies, contributing to these deficiencies.
The facility failed to properly store and label medications, with observations revealing expired medications and an undated insulin pen across several medication carts and a storage room. Staff interviews indicated a lack of adherence to medication management protocols.
The facility failed to ensure proper hand hygiene practices among nursing and housekeeping staff, leading to deficiencies in infection prevention. Nurses did not perform hand hygiene during medication administration, and a housekeeper did not change gloves or perform hand hygiene between cleaning tasks. These actions were confirmed by staff interviews and observations.
The facility failed to ensure adequate ventilation in three resident shower rooms, as the exhaust fans were not functioning effectively, leading to strong odors and humidity. The maintenance supervisor was unaware of the issue due to the fans not being included in the maintenance tracking system.
A resident with multiple health issues experienced a deterioration in condition, but the on-call physician did not return calls for treatment orders. The retired medical director was contacted and ordered a chest x-ray, leading to the resident being sent to the ER. The facility's change in medical groups without informing residents contributed to delays in care, as the new group did not return calls after hours, causing frustration among staff.
The facility failed to protect two residents from physical abuse by each other on two occasions. The first incident was deemed accidental, but a witness confirmed one resident hit the other. The second incident involved a verbal exchange and physical retaliation, with no documentation on whether it was substantiated. The facility did not update care plans or implement interventions to prevent further altercations, contributing to the deficiency.
Two residents in the facility did not receive adequate assistance with activities of daily living. One resident, with multiple health conditions, did not receive showers according to his preferences, and his care plan lacked documentation of these preferences. Another resident, also with significant health issues, did not receive proper fingernail care, as her nails were observed to be long and soiled. Staff interviews revealed a lack of accountability and documentation, and the DON acknowledged ongoing issues despite previous audits.
A resident with multiple medical conditions was not provided with adequate activities as per their care plan. Despite preferences for music and religious activities, the resident was often left with only a radio playing, which was not a care-planned activity. The facility failed to consistently provide one-to-one visits and group activity participation, with staff marking the resident as unavailable rather than documenting refusals. Interviews revealed a lack of adherence to the care plan and incorrect assumptions about the resident's television functionality.
A resident with chronic pain conditions did not receive a prescribed pain-relieving cream as ordered, despite the MAR indicating otherwise. The resident, who was alert and oriented, reported not receiving the medication, and an LPN admitted to inaccurately marking the MAR. The DON confirmed the medication should have been administered as ordered and expressed concern about other potential medication administration errors.
A medication error rate of 8% was observed in an LTC facility, exceeding the acceptable threshold of 5%. An LPN administered only one tablet of Lexapro instead of two as prescribed, and levothyroxine sodium was given after the resident had eaten, contrary to the requirement for it to be taken on an empty stomach. The DON confirmed the errors and the need for adherence to physician orders.
Failure to Prevent Resident-on-Resident Physical Abuse in Common Areas
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by other residents, despite existing policies intended to prohibit and prevent abuse. The facility’s Abuse, Neglect, and Exploitation policy required identification, assessment, care planning, and monitoring of residents with behaviors that might lead to conflict, as well as deployment of sufficient, trained staff and attention to environmental factors that could make abuse more likely. In practice, residents with known behavioral histories and cognitive impairments were in shared environments such as the dining room and smoking area where altercations occurred. The report documents that these incidents were substantiated as physical abuse. In the first incident, an altercation occurred in the dining room between Resident #7, who had schizoaffective disorder, depression, severe cognitive impairment, expressive aphasia, and a history of being both an aggressor and a recipient of physical aggression, and Resident #9, who had stroke with left-sided paralysis, bipolar disorder, depression, anxiety, and a documented history of taking items from staff, swinging at staff, and throwing objects at other residents. Resident #7 had verbal behavioral symptoms toward others and a behavior of agitating other residents by pointing and muttering. Resident #9 had a history of behavioral outbursts during psychotic episodes. While residents were in the dining room waiting for dinner, a witness reported that Resident #9 hit Resident #7 several times in the chest and shoulder. Resident #7 was unable to verbally report the incident due to expressive aphasia. Prior to this altercation, both residents had care plans identifying behavioral issues, but the interventions in place at the time did not prevent the physical abuse. Resident #7’s mood and behavior care plan, initiated earlier, identified her as both an aggressor and a recipient of physical aggression, and Resident #9’s care plan documented prior physical aggression toward staff and other residents. The interdisciplinary team later attributed the altercation to impulsivity and behavioral histories, but at the time of the event, Resident #7 and Resident #9 were together in the dining room without effective preventive measures that would have kept Resident #7 free from physical abuse. In the second incident, a physical altercation occurred between Resident #10 and Resident #11 during a supervised smoking break. Resident #11 had a history of traumatic brain injury, Parkinson’s disease, dementia, schizophrenia, depression, and anxiety, with severe cognitive impairment and documented verbal behaviors toward others. His care plans noted verbal aggression, triggers such as others staring at him and waiting for cigarettes, and difficulty understanding others due to cognitive and communication deficits. Resident #10 had mood disorder, depression, anxiety, personality disorder, and a documented history of anxiety with verbal aggression and physical aggression toward other residents, including a care plan specifically addressing physical aggression. During the smoking break, Resident #10 became agitated when Resident #11’s legs were in close proximity. Resident #10 stood up from his wheelchair and attempted to swing at Resident #11, who responded by placing his foot against Resident #10’s chest to create distance. Resident #10 then pulled himself closer, grabbed Resident #11 by the shirt, and punched him in the face near his right eye multiple times. A staff member was present supervising the smoking break but was unable to intervene in time to prevent the blows. Resident #11 was later found to have a small red area on the right side of his face and redness on his right cheek and jaw. Both residents had known histories of aggression and impulsivity, and the interdisciplinary team later attributed the altercation to a misunderstanding of personal space, but at the time of the event, the supervision and existing behavioral interventions did not prevent Resident #11 from being physically abused by Resident #10.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident on two separate occasions. The first incident occurred when a resident pushed another resident to the floor, which was witnessed by a certified nurse aide. Despite the immediate response by staff to separate the residents and assess them for injuries, the facility's investigation did not substantiate the occurrence as abuse, even though the physical act of pushing was confirmed. In the second incident, a nurse witnessed the same resident approach the victim with agitation and push them in the face. Again, the residents were separated, and no injuries were reported. The assailant was placed on one-to-one staff observation and later transported to the hospital for evaluation, where a new antipsychotic medication was prescribed. Despite these actions, the facility's investigation once more failed to substantiate the incident as abuse. The assailant, who resided in the memory care unit, had a history of severe cognitive impairments and behavioral disturbances, including physical aggression. The care plans for the assailant did not adequately identify behavior triggers or effective interventions, which contributed to the incidents. The victim, also with severe cognitive impairments, was not injured in the altercations but was not adequately protected from the aggressive behavior of the other resident.
Failure to Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency as required by state law. Specifically, the facility did not report an allegation of abuse involving a resident who had severe cognitive impairment and a history of hallucinations, delusions, and verbal behaviors directed at others. The resident was involved in multiple incidents where he struck another resident, shoved a resident in a wheelchair, and grabbed another resident's arm in an aggressive manner. These incidents were documented in the resident's electronic medical record but were not reported to the State Agency. Interviews with facility staff, including a CNA and an RN, revealed that they were aware of the procedures for reporting abuse and would report such incidents to the Director of Nursing or the Nursing Home Administrator. However, the Nursing Home Administrator admitted that the documented incidents involving the resident were not reported to the State Agency. The facility's policy required that all alleged violations involving abuse be reported immediately, but this was not adhered to in the case of the resident's actions.
Failure to Provide Proper Discharge Documentation for a Resident
Penalty
Summary
The facility failed to provide a written discharge notice, including a physician's discharge order, for one of the residents, identified as Resident #5, out of a sample of 13. The discharge was facility-initiated and involuntary, yet the necessary documentation, such as a physician's signature on the Nursing Home Notice of Involuntary Transfer or Discharge, was missing. Additionally, there was no attached written physician's order, which is a requirement when a resident is discharged under such circumstances. Resident #5, who was over 65 years old and had severe cognitive impairments, was admitted with diagnoses including Alzheimer's disease, chronic kidney disease, severe vascular dementia, and type 2 diabetes mellitus. The resident exhibited severe cognitive impairments, hallucinations, delusions, and aggressive verbal behaviors. On the day of discharge, the resident was involved in multiple altercations and was ultimately sent to the hospital due to increased agitation and aggressive behavior. The facility's documentation was incomplete, as there were no physician discharge orders, discharge paperwork, or transfer forms (e-interact) available in the resident's electronic medical record. The nursing home administrator confirmed the absence of these documents during an interview. The facility's policy required these documents to be completed and retained, but this was not adhered to in the case of Resident #5.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to promote and maintain resident dignity for two residents, leading to deficiencies in providing care in a dignified, respectful, and individualized manner. Resident #35, who has a history of cerebral infarction, dysphagia, bipolar disorder, PTSD, and ataxia, was not provided meal assistance in a dignified manner. Observations revealed that staff, including a CNA and an OT, stood over the resident while assisting with meals, despite the availability of a folding chair in the room. The resident expressed feeling belittled when staff stood over her, as she preferred them to sit at her level during meal assistance. The care plan indicated the resident required specific adaptive utensils due to tremors, yet staff did not consistently provide the dignified dining experience outlined in the facility's policy. Resident #51, who has hemiplegia following a cerebral infarction, reported being treated without dignity and respect when asking for assistance. The resident, who is cognitively intact, recounted an incident where an LPN refused to help cover his feet with a blanket, insisting he could do it himself and choosing to watch instead. The nursing progress note corroborated this account, documenting the LPN's refusal to assist and her insistence on the resident's independence. The NHA acknowledged that the LPN's behavior was inappropriate and that all residents should be treated with dignity and respect, regardless of their level of independence. These incidents highlight the facility's failure to adhere to its dignity policy, which emphasizes providing care that enhances residents' well-being and self-esteem. The staff's actions in both cases did not align with the policy's requirement to support residents in exercising their rights and ensuring a dignified experience. The deficiencies were identified through observations, resident interviews, and staff interviews, revealing a gap between the facility's stated policies and the actual care provided.
Deficiency in Food Quality and Service
Penalty
Summary
The facility failed to ensure that residents consistently received food that was palatable in taste, texture, appearance, and temperature. Multiple residents reported dissatisfaction with the meals, citing issues such as late delivery, incorrect diet trays, and unappetizing food. One resident mentioned receiving cold hamburgers and hot dogs, while another noted that the food was often served late and lacked condiments. A resident who attended dialysis appointments reported that the kitchen staff frequently forgot to prepare his dinner, leaving him with inadequate food options, which resulted in him feeling hungry and unwell. Additionally, residents complained about the bland and flavorless nature of the food and drinks. A test tray evaluation by surveyors confirmed the residents' complaints, revealing that the food was dry, bland, and watery. The dietary account director acknowledged that the encrusted pork loin was overcooked and that the gravy was watery due to being prepared in haste. The regional dietary manager emphasized the importance of ensuring the right food texture and taste to prevent residents from not eating their meals. The nursing home administrator indicated that more education would be provided to the kitchen staff, but the report focuses on the deficiency in food preparation and service that led to resident dissatisfaction.
Failure to Maintain Sanitary Conditions in Kitchen
Penalty
Summary
The facility failed to ensure that food items were stored and served under sanitary conditions in the main kitchen. Specifically, the staff did not correctly and accurately test the chemical sanitizer solution's concentration in the dishwasher, three sink compartments, and sanitizer buckets. Observations revealed that the dishwasher's chemical concentration was not consistently tested throughout the day, as required by the manufacturer's recommendations. The dishwasher initially registered a concentration of 10 ppm, which was below the required 150 ppm, indicating that the machine needed to be primed. Additionally, the sanitizer solution in the red and green buckets used for cleaning equipment and surfaces was also found to be at an inadequate concentration of 10 ppm. Interviews with the dietary aide and dietary account manager revealed that the staff did not routinely check the chemical concentration of the sanitizer when filling the buckets. The kitchen had an automatic solution dispenser, but the staff did not test the solution each time they filled the buckets, nor was there a log for documenting the test strip results for the red sanitizing buckets. The facility's policy required that temperature and sanitizer concentration logs be completed as appropriate, but the logs were only completed once a day, contrary to the manufacturer's recommendation of testing at least three times a day. This lack of adherence to proper testing protocols led to the deficiency in maintaining sanitary conditions in the kitchen.
Failure to Honor Residents' Right to Choose Attending Physician
Penalty
Summary
The facility failed to honor the residents' right to choose their attending physician when it changed medical provider groups. This deficiency was identified through interviews and record reviews, revealing that residents across five hallways were not informed or given the opportunity to consent to the change in their primary care provider (PCP). The facility's policy, which mandates informing residents in writing about their attending physician during admission, upon changes, and upon request, was not followed. Interviews with several cognitively intact residents indicated that they were unaware of the change and had not been consulted or informed about the new physician assigned to them. The facility's administration, including the Nursing Home Administrator (NHA) and the Regional Clinical Consultant (RCC), confirmed that the change in the medical provider group was a corporate decision made on June 1, 2024, and that they were not given a choice in the matter. The NHA admitted that no meetings or letters were provided to inform residents or obtain their consent. Additionally, a group interview with alert and oriented residents corroborated that they were not informed about the change in medical provider groups, nor were they asked for their permission. The facility was unable to provide documentation proving that residents and their responsible parties had been informed or that consent was obtained for the change in physicians.
Facility Fails to Maintain Safe and Homelike Environment
Penalty
Summary
The facility failed to maintain a safe, comfortable, and homelike environment for residents, staff, and the public on four of five units. Specifically, the facility did not provide necessary maintenance services to ensure that resident room doors were easily operable and that damaged floors were repaired. Observations revealed that several room doors were difficult to open and close due to misalignment, and there were issues with missing and chipped paint on doors and door frames. Additionally, the main dining room had missing flooring by the entrance. Interviews with residents and staff highlighted ongoing issues with the room doors. Two residents reported that their bedroom doors had been difficult to open and close for several months, and despite reporting these issues to staff, no corrective action had been taken. A CNA confirmed that most room doors required significant effort to open and close, and these issues had been reported to the maintenance supervisor. The nursing home administrator and maintenance supervisor acknowledged the problem, noting that some doors had been replaced and others were scheduled for replacement.
Deficiencies in Resident Safety and Medication Management
Penalty
Summary
The facility failed to ensure a safe environment for residents, particularly in relation to smoking practices and medication administration. Resident #35, who was cognitively intact but required assistance with personal hygiene and dressing, was observed with medication left at her bedside without a proper self-administration assessment. Despite a physician's order allowing her to keep Creon at her bedside being discontinued, the medication was still left unattended, posing a risk. Additionally, Resident #35 reported burning her fingers while smoking unsupervised, contrary to the facility's policy requiring direct supervision for unsafe smokers. Resident #43, who was also cognitively intact, was found with multiple medications at her bedside, including eye drops, nasal spray, and dairy relief pills, without a physician's order or self-administration assessment. During an interview, Resident #43 mentioned that other residents, including one with severe cognitive impairment, frequently entered her room, raising concerns about the accessibility of medications to unauthorized individuals. The facility's failure to conduct proper assessments and secure medications contributed to this deficiency. Similarly, Resident #66, who was independent with activities of daily living, had Aspercreme Lidocaine spray at her bedside without a physician's order or self-administration assessment. The facility did not have a system in place to ensure that medications kept at the bedside were authorized and secure, as evidenced by the lack of lock boxes and comprehensive care plans for self-administration. Interviews with staff, including the DON and LPN, revealed a lack of awareness and adherence to policies regarding medication administration and supervision, further highlighting the facility's deficiencies in maintaining a safe environment.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored and labeled according to professional standards. During observations, it was found that three out of five medication carts and one of two medication storage rooms contained improperly labeled or expired medications. Specifically, an open Tresiba FlexTouch insulin pen was not labeled with the date it was opened, and several expired medications, including liquid haloperidol, lorazepam vials, Tylenol, and a vitamin supplement, were found in the medication carts and storage room. Interviews with staff revealed a lack of awareness and adherence to proper medication management protocols. An LPN acknowledged that the insulin pen should have been dated upon opening but was unsure of the duration it remained effective. Another LPN admitted to checking for expired medications but failed to remove them from the cart. The DON confirmed that expired medications and supplies should have been removed and that the insulin pen should have been dated when opened.
Inadequate Hand Hygiene Practices in Nursing and Housekeeping
Penalty
Summary
The facility failed to maintain a sanitary environment to prevent the transmission of communicable diseases and infections in three of five hallways. Specifically, nursing staff did not perform proper hand hygiene during medication administration. On two separate occasions, a registered nurse and a licensed practical nurse were observed preparing and administering medications to multiple residents without performing hand hygiene before or between each resident. Both nurses acknowledged during interviews that they should have performed hand hygiene between preparing medications for each resident, as confirmed by the director of nursing. Additionally, the facility's housekeeping staff did not adhere to proper hand hygiene protocols while cleaning resident rooms. A housekeeper was observed cleaning multiple rooms without changing gloves or performing hand hygiene between tasks, such as mopping and sweeping. The infection preventionist confirmed that housekeeping staff should remove gloves, perform hand hygiene, and apply new gloves when moving from room to room and after cleaning bathrooms. These lapses in hand hygiene practices were identified as deficiencies in the facility's infection prevention and control program.
Inadequate Ventilation in Resident Shower Rooms
Penalty
Summary
The facility failed to provide adequate ventilation in three of four resident shower rooms, as observed during inspections. The exhaust fans in the shower rooms on the 300, 400, and 600 halls were not functioning effectively, as evidenced by the lack of audible sound and the presence of a strong urine odor and humidity in the rooms. The maintenance supervisor was unaware of the malfunctioning exhaust fans because they had not been included in the system used to track maintenance and repairs. The nursing home administrator acknowledged that the exhaust fans should be in good working condition to eliminate odors in the resident's shower rooms.
Failure to Provide Timely Medical Care
Penalty
Summary
The facility failed to provide treatment and services in accordance with professional standards of practice for a resident who experienced a change in condition. The resident, who was 77 years old and had multiple diagnoses including chronic obstructive pulmonary disease, pulmonary hypertension, and heart failure, experienced a deterioration in condition. Despite the nurse's attempts to contact the on-call physician twice, leaving extensive messages, the physician did not return the calls. Consequently, the retired medical director was contacted, who ordered a chest x-ray and advised sending the resident to the emergency room. The resident was diagnosed with acute on chronic heart failure, pneumonia, chronic obstructive pulmonary disease, chronic anemia, and renal insufficiency during hospitalization. The retired medical director noted that the standard of care would require a physician visit within 24 to 48 hours after hospitalization, but the resident was not seen for more than 10 days after the initial change of condition. The facility's decision to change medical groups without informing or obtaining consent from residents or their responsible parties contributed to the delay in care. Interviews with the Director of Nursing (DON) and the retired medical director revealed that the new medical group did not return calls overnight or on weekends, leading to frustration among staff. The DON directed nurses to contact the retired medical director if they did not receive a callback within 15 minutes. The retired medical director expressed discomfort in treating the resident over the phone since she was not his patient, highlighting the lack of communication and coordination in the facility's medical care provision.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by each other on two separate occasions. The first incident occurred on May 3, 2024, when a physical altercation between the two residents was reported. Although the incident was deemed accidental and unsubstantiated, a witness confirmed seeing one resident hit the other. The facility's response included separating the residents, assessing them for injuries, and placing them on 15-minute checks, but no injuries were noted. The second incident took place on July 19, 2024, involving the same two residents. This time, a staff witness reported that one resident kicked the other's chair, leading to a verbal exchange and physical retaliation. Again, the residents were separated and assessed for injuries, with no injuries found. However, the facility did not document whether this incident was substantiated, and the care plans for both residents were not updated to include interventions to prevent further altercations. Resident #70, who was cognitively intact, admitted to hitting Resident #28 on purpose during the first incident due to a confrontation. Resident #28, who had moderate cognitive impairments and a history of verbal aggression, did not remember the incidents. The facility's failure to update care plans and implement person-centered interventions after these incidents contributed to the deficiency, as the residents continued to have altercations without adequate preventive measures in place.
Deficiencies in ADL Assistance for Residents
Penalty
Summary
The facility failed to provide adequate assistance with activities of daily living (ADL) for two residents, specifically in the areas of showering and fingernail care. Resident #65, who has diagnoses including chronic obstructive pulmonary disease, Parkinson's disease, rheumatoid arthritis, and dementia, did not receive showers according to his preferences. Despite requiring substantial to maximal assistance with bathing, the resident's care plan did not document his shower preferences, and he received significantly fewer showers than scheduled over several months. Resident #180, diagnosed with Alzheimer's disease, dementia, hemiplegia, and other conditions, did not receive proper fingernail care. Observations revealed that her fingernails were long, discolored, and soiled, with a dark substance under several nails. Despite being dependent on staff for personal hygiene, the facility's records showed that nail care was not provided on multiple occasions throughout July 2024. Interviews with staff, including CNAs and LPNs, highlighted a lack of accountability and documentation regarding the provision of showers and nail care. The Director of Nursing acknowledged the issue, noting that a previous audit had identified similar deficiencies, but the problem persisted. The facility's policies required documentation of showers and nail care, but these were not consistently followed, leading to the deficiencies observed.
Failure to Provide Adequate Activities for Resident
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the needs and interests of a resident, identified as Resident #12, who was one of six residents reviewed for activities. Resident #12, a 75-year-old with multiple medical conditions including hemiplegia, aphasia, Parkinson's disease, Alzheimer's disease, and multiple sclerosis, was dependent on staff for all activities of daily living. His care plan indicated preferences for listening to music and participating in religious activities, yet observations revealed he was often left in his room with only the radio playing, which was not listed as a care-planned activity. The activity care plan for Resident #12, revised in May 2024, specified that he should receive one-to-one visits with activity staff two to three times per week and participate in group activities twice a week as desired and tolerated. However, documentation showed that these one-to-one visits were inconsistently provided, with only a few visits recorded each month and no documented refusals by the resident. Additionally, Resident #12 did not attend any group activities from mid-June to the end of July 2024, with staff noting he was unavailable rather than documenting any refusals. Interviews with staff, including the Activity Director and a Certified Nurse Aide, revealed a lack of adherence to the care plan. The Activity Director acknowledged that the activity department was not meeting the resident's activity goals and had assumed the resident's television was not working, which was later found to be incorrect. The Activity Assistant noted that Resident #12 was marked as unavailable for group activities due to being in bed, despite the care plan indicating he should be offered opportunities to observe and listen to group activities. The Nursing Home Administrator confirmed that the care plan should reflect the resident's needs and that documentation should accurately record visits or refusals.
Failure to Administer Pain Management Medication
Penalty
Summary
The facility failed to manage pain for a resident in accordance with professional standards of practice and the resident's care plan. The resident, who was cognitively intact and had a history of chronic kidney disease, PTSD, major depressive disorder, anxiety disorder, low back pain, and restless leg syndrome, reported not receiving a prescribed pain-relieving cream. Despite the medication administration record (MAR) indicating that the Biofreeze gel was administered as ordered, the resident stated she had not received it, which was corroborated by her alert and oriented status. The deficiency was further highlighted during staff interviews. An LPN admitted to not remembering if the medication was administered and acknowledged that the MAR was inaccurately marked as if the medication had been given. The Director of Nursing confirmed that medications should be administered as ordered and not signed off if not given. The DON expressed concern about the potential for other medications not being administered as documented, indicating a broader issue with medication administration practices.
Medication Administration Errors in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, with an observed error rate of 8% during a medication administration observation. This deficiency was identified through the observation of a licensed practical nurse (LPN) who made two errors out of 25 opportunities. The first error involved the administration of Lexapro to a resident. The physician's order was for two 5 mg tablets of Lexapro to be given once daily, but the LPN initially administered only one tablet. Upon realizing the mistake, the LPN corrected it by administering the second tablet. The second error involved the administration of levothyroxine sodium. The resident had a physician's order for 150 mcg of levothyroxine sodium to be administered in the morning on an empty stomach. However, the LPN administered the medication 89 minutes after the scheduled time and after the resident had already eaten breakfast. The Director of Nursing confirmed that levothyroxine sodium should be administered on an empty stomach and that medications should be given according to the physician's order.
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A resident with severe dementia, hallucinations, delusions, and chronic pain, who was independent with mobility and at risk for wandering, was struck in the face by another cognitively impaired resident known to exhibit verbal and physical aggression and to be highly protective of her room. An RN heard a commotion, saw the victim outside the aggressor’s room, and attempted to intervene but witnessed the aggressor hit the victim before reaching them, resulting in a lip laceration and bruise. The aggressor’s care plan noted use of a doorway stop sign or closed door and the need to redirect others away from her room, but she often refused these measures. At the time of the incident, only one CNA and one nurse were on the memory care unit due to an unfilled CNA call-in, and staff reported it was difficult to manage when two CNAs were not present. The facility investigation substantiated the event as abuse and identified that both residents may have had increased pain contributing to agitation before the altercation.
A resident with severe cognitive impairment and multiple chronic conditions intentionally slid from a wheelchair to sit on the floor and refused assistance to return to the chair. An LPN directed two CNAs to place a blanket under the resident and drag the resident across the floor, onto an elevator, and to another floor, rather than allowing the resident to remain seated on the floor as requested. The resident later reported trying to resist and stated dislike of the experience. Documentation by the LPN omitted how the resident was actually moved between floors, despite care plan goals for dignity and autonomy and a facility policy requiring residents be treated with dignity and respect and that their choices and preferences be honored.
Surveyors found that staff repeatedly failed to follow hand hygiene and Enhanced Barrier Precautions (EBP) requirements. CNAs and an LPN provided direct care, including incontinence care, use of a mechanical lift sling, and gastric tube feeding, without performing hand hygiene before or after care and without using required gowns for residents on EBP. One CNA handled a soiled lift sling, touched his hair and face, used a touchscreen to document care, and then assisted another resident without cleaning his hands. Another CNA entered an EBP room wearing only gloves, not a gown, and did not perform hand hygiene after removing gloves. An LPN handled a feeding tube and provided care to residents on EBP without hand hygiene or gown use. A resident’s representative reported seeing staff work with a feeding tube without gloves or a gown, while staff interviews and facility policy described correct practices that were not followed in practice.
A resident with severe cognitive impairment and multiple serious diagnoses had a physician-appointed health care proxy who reported that the facility did not inform her when the resident’s condition changed or when an antibiotic was started, and that her calls were not returned for days. Another representative for the same resident stated that calls went to a general voicemail and were rarely or very slowly returned. Grievance records documented repeated concerns about delayed communication, lack of notification about new medications, and difficulty reaching staff. Other residents’ representatives similarly reported that calls to check on residents or report suspected verbal abuse went to voicemail and were returned late or not at all, while staff acknowledged that calls often went to voicemail and that several calls from representatives were missed or delayed.
The facility failed to investigate an allegation of verbal abuse and threats between two cognitively impaired roommates after a family member, who was on the phone with one resident, reported hearing the other resident yelling loudly and making threats. The resident’s representative could not reach staff by phone and contacted EMS, which responded to the facility, yet no investigation or documentation of the altercation, alleged threats, or EMS involvement was found in either resident’s record. Staff acknowledged loud yelling and arguing and initiated a room change, but the RN did not fully inform the DON, the SSD—who was not present—dismissed the event as a simple argument, and the NHA did not treat or report it as abuse, contrary to facility policies requiring identification, investigation, and reporting of possible verbal or mental abuse by other residents.
Unsafe food handling and kitchen sanitation practices were observed in the dining room and main kitchen. Staff handled ready-to-eat foods with bare hands, failed to wash hands between tasks and after bathroom use, and touched food, dishes, and meal tickets while plating and serving meals. The facility also kept moldy croissants in dry storage, used a pencil to prop up a hood drip pan, and allowed a dietary aide with artificial nails and multiple bracelets to serve residents.
The facility failed to maintain and document safe food temperatures during meal service, resulting in cold foods being held and served within the temperature danger zone and incomplete temperature logs on multiple days. During a lunch service observation, various forms of chicken salad were held at 45–55°F, yet plates were assembled and sent out, and a resident reported that meals delivered to the room were always cold and often not eaten. Staff interviews showed inconsistent understanding of required hot and cold holding temperatures and confirmed that temperature logs were sometimes not completed as required.
Failure to Honor Residents’ Choice of Attending Physician: Three cognitively intact residents said they were not allowed to choose their own attending physician and were required to see the facility MD instead. EMR and admission agreement review showed no documentation that they were offered a choice of physician, despite one resident wanting to continue with a community PCP. The NHA stated residents could choose their attending physician, but also said the facility had only one physician available for residents to choose from.
Psychotropic Medication Documentation and PRN Behavior Monitoring Deficiencies Survey review found that several residents had psychotropic medications ordered without documented physician rationale, resident-specific target behaviors, or individualized non-pharmacological interventions. Generic behavior-monitoring orders were used instead of approaches tied to each resident’s history, interests, and identified behaviors, and one resident’s PRN antipsychotic was administered multiple times without documentation of attempted non-pharmacological interventions before use. The EMR also showed notes of stability or no unwanted behaviors for some residents, yet the records still lacked rationale supporting continued psychotropic treatment.
Failure to Address Suicidal Ideation and Individualized Psychosocial Needs: The facility did not adequately address suicidal statements, trauma-related needs, or individualized behavioral interventions for multiple residents. One resident with dementia, anxiety, and PTSD made a suicidal threat, but the record did not show ongoing safety monitoring or documented follow-up. Another resident with PTSD, depression, and a history of trauma and suicide attempts had ongoing depressive symptoms, but the care plan and orders did not reflect the PASRR-identified need for therapeutic support, psychiatric oversight, coping skills, or a safety plan. A third resident with autism and mood disturbance had inappropriate sexual behavior toward the DON, but the care plan was not updated with person-centered interventions specific to that behavior.
Failure to Prevent Resident-to-Resident Physical Abuse on Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. On the date of the incident, an RN heard a commotion in the hallway outside the alleged assailant’s room and observed that resident strike another resident, causing the victim’s lip to bleed. The RN had seen both residents near the medication cart a few minutes earlier without concern and attempted to intervene when she saw the victim standing outside the assailant’s room, but was unable to reach them before the strike occurred. The two residents were then separated, and frequent checks were initiated. The victim was a younger-than-65 resident with vascular dementia (severe, with agitation), Alzheimer’s disease, Lewy body disease, bipolar disorder, and chronic pain. Her MDS showed short- and long-term memory problems, hallucinations, delusions, and physical and verbal behaviors toward others, with moderately impaired cognition and impaired decision-making. She was independent with mobility and had a care plan for wandering and dementia that identified her as pleasantly confused and easily redirected, with interventions to identify wandering patterns, offer diversions, and assess for pain or toileting needs when agitated. Documentation on the day of the incident noted her involvement in a resident-to-resident altercation, a small laceration to the middle of her upper lip, and a small bruise below her lower lip. The assailant was an older resident with severe vascular dementia with agitation, memory deficit after intracranial hemorrhage, and recurrent depressive disorder. Her MDS documented short- and long-term memory problems, fluctuating disorganized thinking, and verbal behaviors directed toward others that could significantly intrude on others’ privacy or disrupt the environment. Her behavior/dementia care plan identified verbal aggression (yelling/screaming), physical aggression (hitting), refusal of care, withdrawal, tearfulness, and negative statements, and noted that she was protective of her room and became upset if others entered or tried to enter. The care plan included use of a velcro stop sign across her doorway or keeping her door closed, but also documented that she often declined having the door closed, requiring staff to redirect other residents away from her room. Staff statements indicated that at the time of the incident there was one CNA and one nurse on the memory care unit, that one CNA had called in and was not replaced, and that it was hard when there were not two CNAs on the unit. The facility’s investigation substantiated the incident as abuse and identified that both residents may have been experiencing increased pain leading up to the altercation, with pain, constipation, and urinary retention noted as contributing factors for the victim and hand contracture pain and refusal of interventions noted for the assailant.
Resident Dragged on Blanket Instead of Honoring Request to Sit on Floor
Penalty
Summary
The deficiency involves a failure to honor a resident’s right to dignity and self-determination when staff did not allow the resident to remain seated on the floor per his wishes and instead dragged him on a blanket between floors. Late at night, the resident, who lived on the second floor, was in his wheelchair on the first floor and intentionally slid out of his wheelchair to sit on the ground according to his own wishes. When staff offered assistance to help him back into his wheelchair, he refused. Despite this refusal, an LPN directed two CNAs to move the resident from the first floor back to the second floor. Following the resident’s refusal to get back into his wheelchair, the LPN instructed the CNAs to place a blanket underneath the resident so he could be dragged while lying on it. The CNAs and the LPN maneuvered the blanket under the resident by moving him from side to side. One CNA positioned herself behind the resident and placed her arms under his armpits, while the other CNA held the resident’s pants at his ankles. The LPN then pulled on the blanket with the resident on it. Together, the three staff members dragged the resident on the blanket across the floor and onto the elevator, transported him to the second floor, and then dragged him off the elevator onto the second floor hallway. Once on the second floor, the resident agreed to have two staff members assist him back into his wheelchair, and a two-person transfer was performed to lift him from the floor into the chair. The resident later reported that he remembered being pulled on the blanket, stated that he "tried to fight them like crazy," and said he did not like what had been done. The nursing progress note written by the LPN the following morning documented that the resident had remained on the first floor until late at night, refused to talk with staff, refused care, and declined snacks, fluids, and redirection, but the note did not document how he was actually relocated to the second floor. The resident’s records showed he had severe cognitive impairment with a BIMS score of 3/15, diagnoses including Parkinson’s disease, depression, unspecified intellectual disabilities, traumatic brain injury, seizures, and chronic kidney disease stage 3, and care plan goals that included being treated with dignity and autonomy. The facility’s dignity policy stated that residents are to be treated with dignity and respect at all times, that their choices and preferences are to be honored, and that demeaning practices are prohibited, which was not followed in this incident.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to hand hygiene and adherence to Enhanced Barrier Precautions (EBP) on all four units. The facility’s own policies require hand hygiene before and after direct patient care and the use of gowns and gloves during high-contact care activities for residents on EBP. CDC guidance cited in the report emphasizes that hand hygiene protects both healthcare personnel and patients, and that EBP requires targeted gown and glove use during high-contact resident care activities, particularly for residents with wounds, indwelling devices, or MDRO colonization or infection. Surveyors observed multiple instances where staff did not follow these requirements. An unidentified CNA exited a room of a resident on EBP without wearing a gown while providing care. On another occasion, a CNA exited a resident’s room carrying a soiled mechanical lift sling without gloves, failed to perform hand hygiene, touched his hair and face, used a touchscreen to document care, and then entered another resident’s room to answer a call light and assist with a request without performing hand hygiene before or after assisting that resident. Another CNA entered the room of a resident on EBP, donned only gloves without a gown, provided incontinence care, then left the room with soiled linens and trash properly disposed of, removed gloves, but did not perform hand hygiene before caring for another resident. Additional observations showed an LPN entering the room of a resident on EBP for gastric tube feeding, setting up and handling the feeding tube without performing hand hygiene beforehand and without wearing a gown. The same LPN later entered another EBP room, provided care, and left without performing hand hygiene. A resident’s representative reported seeing staff work with the resident’s feeding tube without gloves or a gown. In interviews, CNAs and nursing staff described correct hand hygiene and EBP practices, including washing hands for about 20 seconds and using gowns and gloves for residents on EBP, and the DON stated she expected staff to perform hand hygiene when entering and exiting rooms and to follow EBP procedures requiring gown and glove use. These stated practices conflicted with the observed failures in hand hygiene and EBP adherence documented by surveyors.
Failure to Notify Health Care Proxy and Return Calls Regarding Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to inform a resident’s physician-appointed health care proxy of changes in the resident’s condition and new treatments, and to return the proxy’s calls in a timely manner. Facility policy on Notification of Changes required informing the resident, consulting with the physician, and notifying the family member or legal representative when there was a change requiring such notification, and specified that when residents were incapable of making their own decisions, the representative would make necessary decisions. Resident #1 was under 65, admitted with diagnoses including paralysis and weakness following a stroke, respiratory failure, cognitive communication deficit, and encephalopathy, and was documented as severely cognitively impaired with a BIMS score of 0/15, indicating reliance on the health care proxy for decision-making. The health care proxy reported that the facility made it very difficult to contact the resident, stating that staff did not return calls for days and that she was not informed when the resident developed an infection and was started on an antibiotic until after the medication had already been initiated. She stated she had several questions about the medication and was not consulted on the medical decision prior to its start. Another representative reported that calls to the facility went to a general voicemail and that her messages were either not returned or took several days for a response. Grievance records showed repeated concerns from the resident’s representatives about delays in speaking with the resident, delays in return calls, and lack of notification about new medications and changes in condition. Additional interviews with other residents’ representatives supported a broader pattern of delayed or absent communication. One representative of another resident reported that his call to check on a newly admitted resident went to voicemail and was not returned for two days. Another resident’s representative and a secondary witness reported that when they attempted to report suspected verbal abuse, their calls to the facility and to the SSD went to voicemail and were never returned. Staff interviews confirmed that calls first went to the front desk and then to the nurses’ stations, that calls often went to voicemail when nurses were unable to answer, and that voicemail messages were expected to be returned within 24 hours. The NHA acknowledged that several calls from the resident’s representatives went to voicemail and that calls were often made during shift change when it was harder to reach the nurse on duty, but there was no documentation to support the claimed regular communication with the health care proxy.
Failure to Investigate Alleged Verbal Abuse Between Cognitively Impaired Roommates
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of verbal abuse and threats between two cognitively impaired residents after a family member reported overhearing the incident. Facility policy on abuse, neglect, exploitation, and misappropriation requires that all possible incidents of abuse, including verbal and mental abuse by other residents, be identified, investigated, and reported within required timeframes, with residents protected from further harm during investigations. The policy on identifying types of abuse specifies that yelling or hovering over a resident with intent to intimidate is an example of mental and verbal abuse. Despite these policies, the facility did not initiate or document an investigation into a reported verbal altercation that included alleged threats. One resident, under age 65, with dysphagia, left-sided hemiplegia, attention and concentration deficit, delusional disorder, and major depressive disorder, had moderate cognitive impairment and was dependent on staff for most ADLs. He reported that he and his roommate yelled back and forth at each other after the roommate told him to “shut the [expletive],” but he did not recall the specific words used and denied any physical contact. His guardian stated that he later reported being fearful of his roommate after the incident. Another representative, who was on the phone with him during the event, reported hearing the roommate yelling loudly and making threats toward him, then hearing a nurse enter to calm the situation. This representative attempted to call the facility to report the yelling and threatening behavior, was sent to voicemail without a return call, and subsequently contacted emergency services. The roommate, an older resident with dementia, cognitive communication deficit, depression, and insomnia, also had moderate cognitive impairment and required staff assistance for most ADLs. He did not recall the incident, and his representative only learned of it the following day and was told it involved yelling about loud phone use. A review of both residents’ medical records revealed no documentation of the verbal altercation, the alleged threats, or related concerns, and no investigation documents were produced when requested. Staff interviews confirmed there had been loud yelling and arguing, that EMS responded to the facility, and that a room change was initiated due to the incident, but the RN who responded did not report the EMS involvement to the DON. The SSD, who was not present during the incident, characterized it as just an argument and stated there were no threats, and the NHA stated the event was not reported as abuse because they believed no threats were made. No contemporaneous interviews with the residents were documented, and no inquiry was made by facility staff into why EMS had been called in relation to the altercation, resulting in a failure to investigate the allegation of verbal abuse as required by facility policy.
Unsafe Food Handling and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the main kitchen and dining areas. During meal service observations, staff repeatedly handled ready-to-eat foods with bare hands and did not perform hand hygiene when changing tasks, after touching dirty dishes, after using the bathroom, or before serving food. An LPN cut a resident’s patty melt and handed pieces to the resident with her bare hand without sanitizing her hands. A DA passed drinks by touching the rims of cups, and another DA tore a resident’s patty melt into smaller pieces with bare hands and handed food to the resident. During a later observation, kitchen staff continued to work without washing hands between tasks and while handling food, dishes, and meal tickets. A DA entered the kitchen from the dishroom and did not wash his hands before putting away snacks. A cook did not wash her hands after working at the sink, after touching dirty dishes, after exiting the bathroom in the kitchen, or before serving room trays. She was observed touching shrimp, corn bread, rice, squash, cheese, and frozen fries with bare hands while plating and preparing meals, and she also handled fryer baskets and food items without washing her hands. Another cook wiped her hands on her clothing, handled meal tickets, and touched ready-to-eat foods with bare hands while assembling plates and serving meals. The facility also failed to discard expired or spoiled food, maintain equipment in good repair, and prevent staff from wearing prohibited items while preparing or serving food. A plastic bag of croissants in dry storage contained bread-like food covered in dark green and black fuzz and remained on the bread rack on two separate observations. In the kitchen hood system above the grill, a half wooden pencil was being used to hold up the grease drip pan on two observations. In addition, a dietary aide taking meal orders, passing drinks, and serving meals had artificial nails approximately half an inch long and multiple fabric bracelets on her wrists while working with residents.
Failure to Maintain and Document Safe Food Temperatures During Meal Service
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner by not maintaining appropriate food temperatures during meal service and by not consistently documenting food temperatures as required. During a continuous observation of lunch meal service, chicken salad, including soft and bite-sized and pureed versions, was found on the steam table at temperatures of 55°F and 45°F, which were within the documented temperature danger zone and below the required cold-holding standard. Despite these temperatures, plates with wedge chicken salad and a Hawaiian roll were assembled and placed on the meal cart for service. A resident reported that meals delivered to his room were always cold, leading him not to eat them and to attempt to obtain food from outside the facility. Review of the facility’s April 2026 food temperature logs showed multiple instances where temperatures were not documented for breakfast, lunch, and dinner services on numerous dates. Staff interviews revealed inconsistent understanding and application of proper holding temperatures, with the cook and dietary manager providing varying temperature thresholds that did not align with the facility policy or the Colorado Retail Food Establishment Rules and Regulations. The cook acknowledged that the wedge chicken salad should not have been served at 55°F and attributed difficulty maintaining proper temperatures to a hot room with inadequate ventilation, while the dietary manager stated that cooks sometimes forgot to complete the temperature logs.
Failure to Honor Residents’ Choice of Attending Physician
Penalty
Summary
The facility failed to ensure three cognitively intact residents were allowed to choose their own attending physician. Resident #15, Resident #28, and Resident #30 each stated during a group interview that they did not have a choice in who their physician could be while in the facility and that they had to see the facility’s MD. Resident #15 said she had a primary care physician in town that she wanted to continue seeing, but she was told she could not see that physician. Resident #28 and Resident #30 each said they were required to see the facility’s MD instead of choosing their own physician. Record review for each of the three residents, including the admission agreement and EMR, showed no documentation that they were provided a choice of attending physician. Resident #15 had diagnoses including COPD, cirrhosis of the liver, and osteoarthritis, and her MDS showed she was cognitively intact with a BIMS score of 15. Resident #28 had diagnoses including type 2 diabetes mellitus, asthma, osteoarthritis, and TIA/cerebral infarction, and was also cognitively intact with a BIMS score of 15. Resident #30 had diagnoses including type 2 diabetes mellitus, wedge compression fracture of T11-T12 and L3, and hypertension, and his MDS likewise showed a BIMS score of 15. The NHA stated residents were able to choose their attending physician when admitted, but also said the facility had one physician residents could choose from and was not aware that these residents wanted different physicians.
Psychotropic Medication Documentation and PRN Behavior Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure four residents were free from unnecessary psychotropic medication use and chemical restraint concerns. Survey review found that the facility did not document a physician’s rationale for the continued use of psychotropic medications for three residents, did not document resident-specific care approaches with medication-specific target behaviors and person-centered interventions for those residents, and did not ensure one resident’s PRN antipsychotic use had corresponding documentation of identified behaviors and non-pharmacological interventions. For one resident with PTSD, anxiety, and depression, the record showed buspirone, Valium, duloxetine, and Lexapro orders with behavior-monitoring language, but the orders did not identify resident-specific non-pharmacological interventions for specific behaviors. The resident’s PASRR described a history of self-harm, suicidal thoughts, mood swings, loss of interest, and low energy, and recommended therapeutic interventions, coping skills, psychiatric oversight, increased socialization, and activities such as puzzles, games, and painting. The EMR review did not show documented behaviors during the review period, and it did not show a physician rationale to justify continued psychotropic use. For another resident with schizoaffective disorder, dementia, anxiety, and depression, the care plan and orders listed generic interventions and behavior targets such as screaming, hallucinations, kicking, and yelling, but the resident-specific behaviors and interests identified in the PASRR, including hearing the devil inside her head and being soothed by prayer and rosary use, were not incorporated into the behavior-monitoring orders or care plan. The record also lacked documentation of non-pharmacological interventions used for the resident’s behaviors and lacked a physician rationale for continued psychotropic use despite notes stating the resident was stable and not experiencing unwanted behaviors. A third resident with vascular dementia, anxiety, and PTSD had orders for Abilify, mirtazapine, sertraline, clonazepam, and behavior monitoring tied to verbal aggression, exit seeking, tearfulness, and hitting staff, but the orders remained generic and did not reflect the resident’s individualized approaches such as listening to 80’s rock music or watching a favorite program when crying or confused. The EMR again did not show a physician rationale for continued psychotropic use despite notes indicating pleasant mood and no unwanted behaviors. For the resident who died during the stay and had dementia and depression, the record showed Lexapro, Seroquel, and PRN injectable haloperidol ordered for behaviors such as swinging at staff and agitation. The PRN haloperidol order did not list a diagnosed specific condition, only behaviors, and the order for non-pharmacological interventions was not initiated until after the resident had already been receiving psychotropic medications. MAR and order administration notes showed multiple PRN haloperidol administrations, but several entries lacked documentation of attempted non-pharmacological interventions before the medication was given, and one note only documented encouragement to sit down without identifying the other ordered interventions or their effectiveness.
Failure to Address Suicidal Ideation and Individualized Psychosocial Needs
Penalty
Summary
The facility failed to ensure that residents with mental disorders, psychosocial adjustment difficulties, and trauma histories received appropriate treatment and services to support their mental and psychosocial well-being. For one resident with vascular dementia, anxiety, and PTSD, the record showed repeated depression screens indicating little interest, depressed mood, poor appetite, sleep problems, low energy, and feelings of worthlessness, along with notes describing chronic behaviors potentially causing harm, tearfulness, withdrawal, and anxiety. A behavior note documented that the resident stated she was going to kill herself, but the record did not show documented interventions to keep her safe afterward or ongoing monitoring for suicidal ideation. A second resident with PTSD, anxiety, depression, and a documented history of trauma, self-harm, suicidal thoughts, and numerous suicide attempts had a PASRR evaluation identifying the need for therapeutic interventions, psychiatric oversight, coping skills development, and a safety plan. The resident told staff she had previously seen a therapist at the facility, but that therapy had stopped and no new arrangements had been made. She also reported that staff had not asked about her PTSD triggers or what interventions would help her. The record showed depression screens with ongoing depressive symptoms, but no follow-up documentation after those screenings, and the care plan and physician orders did not reflect the resident’s suicidal history or the specialized services identified in the PASRR. The facility also failed to provide individualized care approaches for a resident with autistic disorder, dementia with mood disturbance, anxiety disorder, major depressive disorder, and cognitive communication deficit. The resident had a history of inappropriate sexual behaviors and was documented as having sexually inappropriate contact with the DON when he squeezed her breast during a dining activity. Although the resident was placed on 15-minute behavior monitoring for 24 hours, the care plan was not revised to reflect a person-centered intervention specific to that sexual behavior. Staff interviews showed that interventions were inconsistently understood and that the nursing staff did not know what person-centered interventions were in place for the resident’s behaviors.
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