Heights Care & Rehabilitation Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Denver, Colorado.
- Location
- 3131 S Federal Blvd, Denver, Colorado 80236
- CMS Provider Number
- 065191
- Inspections on file
- 27
- Latest survey
- April 6, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Heights Care & Rehabilitation Llc during CMS and state inspections, most recent first.
Staff failed to follow required food-handling and hand hygiene practices during a dinner meal service, repeatedly touching ready-to-eat items such as hot dog buns with bare hands after handling meal tickets, countertops, wet towels, trays, plates, utensils, and their clothing, and then assembling meatball sandwiches and other plates placed on trays and in meal carts for residents. Although staff later reported awareness that bread and buns should not be handled with bare hands and that gloves or utensils should be used for ready-to-eat foods, observations showed inconsistent handwashing and lack of glove use while preparing and serving these foods.
Two residents did not receive care according to physician orders and professional standards. One resident with a lower extremity venous/arterial ulcer and lymphedema had wound care performed by the ADON and an RN without use of ordered skin prep to the peri-wound area and without application of ABD pads, even though the existing dressing removed from the leg included heavily saturated ABD pads and the CPO specified Dakin’s, skin prep, silver sulfadiazine, adaptic, ABD, and Kerlix every shift. Another resident with chronic pain syndrome, cervical spinal stenosis, and alcoholic polyneuropathy, who was cognitively intact and independent with ADLs, had a standing order for morphine ER 30 mg TID but had multiple scheduled doses not administered when the facility ran out of the medication and did not have the ordered dose available; MAR review and staff interviews confirmed missed doses and lack of timely availability of the prescribed morphine.
Surveyors identified that the facility exceeded the acceptable medication error rate when two residents did not receive ordered medications and documentation was inaccurate. In one case, an LPN did not administer a prescribed topical diclofenac gel for chronic pain because it was not available on the cart, and the medication was not given despite being ordered three times daily. In another case, an LPN discovered an empty insulin lispro vial for a resident with type 1 DM, did not obtain replacement insulin or notify supervisory staff, and omitted the insulin dose while still documenting on the MAR that the insulin was given and recording an incorrect blood glucose value.
A resident with type 1 DM, who was cognitively intact and ordered insulin lispro 20 units SQ before meals with pre-administration blood glucose checks, did not receive the ordered morning insulin dose. After the resident reported having eaten breakfast, an LPN obtained a blood glucose of 205 mg/dl, discovered the insulin vial was empty, and then administered the resident’s other medications but did not obtain insulin from other facility sources, notify a supervisor, or call the pharmacy at that time. The LPN later documented on the MAR that the blood sugar was 125 mg/dl and that the insulin was given, despite it not being administered. A subsequent lunchtime blood glucose by an RN was 191 mg/dl, and documentation that the morning insulin dose was missed was entered only after the issue was raised to facility leadership.
A resident with paraplegia and a history of falls, who required maximal assistance with showering, was left alone in the shower room by a CNA while the call light was out of reach. The resident reported feeling scared and unable to call for help, and staff interviews revealed inconsistent understanding of supervision requirements for dependent residents.
Multiple residents were involved in verbal and physical altercations, including incidents in the smoking area and dining room, where staff failed to implement timely behavioral interventions, update care plans, or consistently document events and follow-up assessments. Staff interviews revealed gaps in awareness and supervision, and the facility did not ensure adequate protection from abuse or update care plans after incidents.
A resident with a history of aggressive behavior physically assaulted another resident in the smoking area, leading to a deficiency in resident safety. Despite being placed on one-to-one supervision due to his aggressive tendencies, the supervision was discontinued, resulting in the incident. The facility's failure to maintain consistent supervision, despite the known history of aggression, led to the physical abuse of another resident.
A resident with chronic conditions developed a stage 3 pressure ulcer on his left heel. Despite the wound care physician's recommendations to offload the pressure injury, elevate the legs, and float the heels, these interventions were not implemented in the care plan or documented in the physician's orders. Observations and staff interviews revealed a lack of awareness and documentation regarding the necessary interventions, leading to the worsening of the pressure injury.
The facility failed to maintain proper infection control practices during wound care for a resident with multiple stage 4 pressure ulcers. The wound care nurse used the same gauze and gloves for different wounds, leading to potential cross-contamination. The nurse admitted to not understanding the need for separate treatment for each wound, and the Director of Nursing confirmed the lapse in protocol.
Improper Bare-Hand Contact With Ready-to-Eat Foods During Meal Service
Penalty
Summary
The deficiency involves failure to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen, specifically related to improper handling of ready-to-eat foods and lack of appropriate glove use. The Colorado Retail Food Establishment Rules and Regulations require that food employees do not contact exposed ready-to-eat food with bare hands and instead use suitable utensils or single-use gloves, and that they wash their hands and exposed portions of their arms for at least 20 seconds in a properly equipped handwashing sink. These professional standards were cited as the reference for the expectations that were not met. During continuous observation of the dinner meal service, multiple instances were documented where dietary aides and a cook handled hot dog buns and assembled meatball sandwiches with bare hands, without performing hand hygiene between tasks. One dietary aide repeatedly picked up hot dog buns with bare hands after touching meal tickets, countertops, wet towels, plates, trays, and her clothing, and then assembled meatball sandwiches and other meal plates that were placed on trays or in meal carts for resident service. The cook also adjusted her clothing and wristwatch with bare hands and then handled buns, plates, bowls, and utensils without washing her hands before continuing food preparation and service. Additional observations showed that staff intermittently washed their hands but still handled ready-to-eat items such as hot dog buns with bare hands, and sometimes resumed serving meals after touching their clothes or other non-food surfaces without handwashing. Staff interviews confirmed that dietary staff understood they were not supposed to touch bread or buns with bare hands and that gloves or utensils should be used when handling ready-to-eat foods. The kitchen manager and a dietary aide both stated that staff should wash hands consistently between tasks and use tongs or gloves for handling ready-to-eat foods, and acknowledged that the staff observed should not have handled hot dog buns with bare hands.
Failure to Follow Wound Care and Pain Medication Orders
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with physician orders and professional standards of practice for two residents. For one resident with an open wound on the right lower leg, lymphedema, and unsteadiness on feet, the facility did not follow the prescribed wound care orders. The resident was cognitively intact and largely independent with ADLs, and had a documented venous/arterial ulcer on the lower leg. During an observed wound care session, the ADON and an RN performed wound care that did not fully comply with the physician’s written orders for the right lower extremity. During the wound care observation, the ADON removed existing dressings, including an Ace wrap, rolled gauze, and three ABD pads that were saturated with serosanguineous drainage. The ADON then cleansed the wound using gauze soaked in quarter-strength Dakin’s solution and dried it with dry gauze. Silver sulfadiazine was applied to an adaptic dressing and placed on the wound, followed by rolled gauze and tape. However, the ADON did not apply skin prep to the peri-wound area and did not place ABD pads over the adaptic and under the rolled gauze, despite the physician’s order specifying Dakin’s, skin prep, silver sulfadiazine, adaptic, ABD, and Kerlix every shift and as needed. The ADON later acknowledged she had not used the ABD pads as ordered. The second deficiency concerns a resident with chronic pain syndrome, cervical spinal stenosis, and alcoholic polyneuropathy who was cognitively intact and independent with ADLs, and had documented pain during the MDS assessment period. The resident had a standing order for morphine sulfate ER 30 mg by mouth three times daily for chronic pain. Review of the MAR showed the resident did not receive scheduled morphine doses on two days in January and missed an afternoon dose in March. The resident reported not receiving morphine for 24 hours because the facility ran out of the medication and did not order it, and stated this had occurred several times in the past when the facility ran out and did not reorder in time. Nursing documentation on one of the missed March doses indicated the morphine was “waiting on reorder,” but there was no documentation explaining the missed January doses. Staff interviews confirmed that the scheduled morphine dose was unavailable at the time of administration, that only a different strength was present in the Ekit without a corresponding order, and that the resident’s scheduled pain medication was not consistently administered as ordered.
Medication Administration and Documentation Errors Resulting in Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to maintain a medication error rate below 5%, with surveyors identifying a 7.41% error rate (two errors out of 27 opportunities) during medication administration observations. One error occurred when an LPN prepared to administer morning medications to a resident who had a physician’s order for diclofenac sodium 1% external gel to be applied topically to both upper extremities three times daily for chronic pain. The LPN reported that the diclofenac gel was not available in the medication cart, stated she would reorder it, and then administered the remaining medications without giving the diclofenac. The medication was not documented as given on the MAR and was instead coded as “other” for the morning and afternoon doses, and progress notes confirmed the medication was ordered. The second error involved another resident with a physician’s order for insulin lispro 20 units subcutaneously before meals for type 1 diabetes, with blood glucose to be checked and recorded prior to administration. An LPN checked the resident’s blood sugar, which was 205 mg/dl, and then attempted to prepare insulin lispro from a vial that was found to be empty. The LPN stated she would call the pharmacy for another vial but did not call the pharmacy, notify a supervisor, or check other areas of the facility for insulin at that time. The LPN proceeded to administer the resident’s other medications but did not administer the insulin lispro. Record review showed that for the resident ordered insulin lispro, the MAR documented a blood sugar of 125 mg/dl and indicated that the insulin was given on the date in question, despite the resident’s actual blood sugar being 205 mg/dl and the insulin not being administered as observed. Interviews confirmed that the LPN later stated she had not had time to give the insulin yet. The DON and regional clinical resource stated that nurses were expected to follow the rights of medication administration, not document medications as given if they were not administered, and that insulin and some pain medications could be obtained from the facility’s emergency kit when not available on the cart. These findings collectively demonstrate failures in medication availability, administration, and accurate documentation that resulted in the identified medication errors.
Failure to Administer Ordered Insulin and Inaccurate MAR Documentation
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when an ordered dose of insulin lispro was not administered as prescribed. Facility policy required staff to review the MAR, verify the medication against the MAR, and administer medications within 60 minutes of the scheduled time, as well as to observe the resident consuming the medication. Despite this, on the morning in question, the assigned LPN discovered that the insulin lispro vial for a resident was empty and did not obtain a replacement vial, notify a supervisor, or check other areas of the facility for insulin at that time. The resident involved was under 65 years of age, cognitively intact with a BIMS score of 14, and had diagnoses including type 1 diabetes mellitus, hypothyroidism, and asthma. The resident had a physician’s order for insulin lispro 20 units subcutaneously before meals, with blood glucose to be checked and recorded prior to administration. On the morning of the incident, the resident reported having already eaten breakfast. The LPN checked the resident’s blood sugar, which was 205 mg/dl, but later documented on the MAR that the blood sugar was 125 mg/dl and that the insulin lispro was given, even though the insulin was not administered. Observations showed that after finding the insulin vial empty, the LPN proceeded to give the resident’s other medications but omitted the insulin lispro dose. The LPN did not immediately contact the pharmacy, did not inform a supervisor, and did not seek insulin from other facility sources such as the emergency kit. Later that day, another nurse checked the resident’s blood sugar at lunchtime and obtained a reading of 191 mg/dl. A progress note documenting that the morning insulin dose had been missed and that the physician was notified was entered in the record only after the issue was brought to the facility’s attention by surveyors, and the note indicated no adverse reactions were observed.
Resident Left Unsupervised During Shower Despite Fall Risk
Penalty
Summary
A deficiency occurred when staff failed to provide adequate supervision to a resident with a history of falls and paraplegia during showering. The resident, who was cognitively intact but dependent on staff for toileting, transfers, and showering, was observed being left alone in the shower room by a CNA for several minutes while the CNA left to retrieve bath sheets. During this time, the resident remained seated on a shower chair with the door closed and the call light out of reach. The resident confirmed in an interview that staff often left her alone in the shower room with the door closed to retrieve forgotten items, and that the call light was not accessible to her during these times. She expressed feeling scared and uncomfortable due to her history of falls and inability to call for assistance if needed. The resident's care plan identified her as a fall risk and included interventions such as ensuring the call light was within reach and anticipating her needs. Staff interviews revealed inconsistent understanding of the resident's supervision needs. One CNA stated that dependent residents should not be left unsupervised during showers and that all supplies should be gathered beforehand. Another CNA admitted to leaving the resident alone and not ensuring the call light was accessible, stating she was unaware the resident could not be left alone. The assistant director of nursing and the regional clinical resource initially provided conflicting statements regarding the resident's fall risk and supervision requirements, but later agreed that the resident should not have been left unsupervised.
Failure to Prevent and Address Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect four residents from abuse, including verbal and physical abuse, as evidenced by multiple resident-to-resident altercations. In one incident, two residents engaged in a verbal and physical altercation in the supervised smoking area, where one resident pushed another, resulting in a fall, and attempted to slap him. The care plans for these residents did not reflect timely or adequate interventions to address their behavioral risks, and documentation of the incident was incomplete in the medical records. Additionally, the behavior care plan for one of the residents was not initiated until after a subsequent incident occurred. Another event involved a resident slapping another during an argument in the dining room, causing the victim to lose balance and fall, resulting in redness to the eye. The facility substantiated this as physical abuse, but the care plan for the victim was not updated with new personalized interventions to prevent further abuse. Furthermore, behavior monitoring records did not accurately reflect the occurrence of the incident, and there was a lack of interdisciplinary team documentation and follow-up in the medical record. A third incident occurred during a supervised smoking session, where a resident became agitated, overturned a smoking cart, verbally abused another resident, and then struck her on the hand. The care plan for the victim did not include new interventions after the altercation, and there was no nursing progress note documenting the incident or the RN assessment. Staff interviews revealed a lack of awareness of special interventions for residents with known behavioral issues, and supervision in the smoking area was inconsistent with facility policy. The facility's process for documenting and care planning after such incidents was found to be lacking, with no formal interdisciplinary documentation and incomplete updates to care plans.
Failure to Protect Resident from Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, which constitutes a deficiency in ensuring resident safety. The incident occurred when Resident #2, who had a history of aggressive behavior, physically assaulted Resident #1 in the smoking area. Resident #2 became upset when Resident #1 was looking at him, leading to Resident #2 hitting Resident #1 multiple times in the head. This altercation was part of a pattern of aggressive behavior exhibited by Resident #2, who had been involved in multiple verbal and physical altercations during his stay at the facility. Resident #2, who was over 65 years old, had diagnoses including moderate vascular dementia with mood disturbances, alcohol abuse, depression, and insomnia. His cognitive skills were moderately impaired, and he had a history of physical and verbal behaviors directed towards others. Despite being placed on one-to-one supervision due to his aggressive tendencies, this supervision was discontinued when he showed no behaviors, only to be reinstated after the incident with Resident #1. Resident #1, under 65 years old, had a history of traumatic brain injury and dementia, with moderately impaired cognitive skills and no history of aggressive behavior. The facility's policy on abuse prevention required the nursing home administrator to coordinate and implement measures to prevent abuse, including staff training and resident protection during investigations. However, the facility's failure to maintain consistent supervision of Resident #2, despite his known history of aggression, led to the physical abuse of Resident #1. The incident was reported to the police and emergency services, highlighting a lapse in the facility's adherence to its own policies and procedures designed to protect residents from abuse.
Failure to Implement Wound Care Interventions
Penalty
Summary
The facility failed to provide the necessary treatment and services to prevent pressure injuries from occurring and worsening for Resident #9. The resident, who was admitted with chronic obstructive pulmonary disease and type II diabetes mellitus with diabetic chronic kidney disease, developed a stage 3 pressure ulcer on his left heel. Despite the wound care physician's (WCP) recommendations to offload the pressure injury, elevate the resident's legs, and float his heels, these interventions were not implemented in the resident's comprehensive care plan or documented in the physician's orders. Observations revealed that the resident's heels were not floated or offloaded, and his feet were often directly on the mattress or floor, contributing to the worsening of the pressure injury. The facility's skin integrity care plan did not address the resident's actual skin breakdown or provide person-centered interventions to prevent the development and worsening of pressure injuries. The care plan interventions were not updated to include the WCP's recommendations, and the resident's medical record did not document any refusal or non-compliance with the recommended interventions. Interviews with staff, including a certified nurse aide (CNA) and a licensed practical nurse (LPN), indicated a lack of awareness and documentation regarding the resident's pressure injury and the necessary interventions. The director of nursing (DON) confirmed that the resident's stage 3 pressure wound was not addressed in the comprehensive care plan prior to the survey and that the WCP's recommendations were not documented or implemented. The WCP expressed disappointment that the recommended interventions were not in place, despite multiple recommendations to offload the pressure on the left heel and elevate the resident's legs. The updated care plan, created during the survey, still did not include the necessary treatments to offload the wound, elevate feet, and float heels as ordered by the WCP.
Infection Control Lapse During Wound Care
Penalty
Summary
The facility failed to maintain an infection prevention and control program while providing wound care to a resident with multiple stage 4 pressure ulcers. The wound care nurse (WCN) did not follow proper infection control practices, such as using the same piece of gauze to clean multiple wounds and not changing gloves between treating different wounds. This was observed during a wound care session for a resident with pressure ulcers on the right hip and right buttocks. The WCN used the same gauze and gloves for both wounds, which is against standard infection control practices. The WCN admitted to not understanding that each wound should be treated separately to avoid cross-contamination. The Director of Nursing (DON) confirmed that the WCN should have used different pieces of clean gauze and changed gloves between treating each wound. The resident involved was cognitively intact and required total assistance with bed mobility and transfers. The deficiency was identified through record review, observations, and interviews with the WCN and DON.
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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