Highline Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Denver, Colorado.
- Location
- 6060 E Iliff Ave, Denver, Colorado 80222
- CMS Provider Number
- 065256
- Inspections on file
- 20
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 2 (1 serious)
Citation history
Health deficiencies cited at Highline Post Acute during CMS and state inspections, most recent first.
A resident with HIV did not receive the prescribed antiretroviral medication, Biktarvy, due to a transcription error by an LPN, resulting in the administration of only one component of the therapy. The error went uncorrected by nursing staff, the pharmacist, and the medical director, and was only discovered after the resident was hospitalized for routine viral load testing, which revealed a high viral load and absence of the correct medication on the facility's records.
A deficiency was cited when a facility area was not kept free from accident hazards and supervision was inadequate to prevent accidents. The environment and oversight did not meet required standards to minimize accident risks.
A resident with multiple comorbidities and a history of falls experienced an unwitnessed fall in the courtyard. The facility did not conduct a root cause analysis or review and update the resident's fall care plan after the incident, as required by policy. The fall was not documented in the risk management system, and leadership was unaware of the event, resulting in missed opportunities to evaluate and adjust fall prevention interventions.
A resident with severe cognitive impairment and a history of elopement and exit-seeking behaviors was able to leave the facility undetected due to failures in care planning, inaccurate risk assessments, and lack of increased supervision. Despite frequent documentation of exit-seeking behaviors and difficulty with redirection, the care plan was not updated with individualized interventions, and staff did not consistently recognize or respond to the resident's risk. Delays in notification and investigation further contributed to the deficiency.
The facility did not have a written transfer agreement in place with a local hospital certified by Medicare or Medicaid, as confirmed by record review and staff interviews. Leadership was unable to provide documentation of an active agreement, despite recent attempts to secure one.
The facility's QAPI committee did not identify or address ongoing exit-seeking behaviors in a resident, resulting in a second elopement event. Despite frequent documentation of these behaviors, no new interventions were implemented, and staff did not discuss the changes during daily huddles. The resident was found outside the facility hours later, and unclear documentation contributed to the lack of timely intervention.
The facility did not provide a variety of activities to meet the needs and preferences of three residents, resulting in limited opportunities for socialization and engagement. Activity calendars were repetitive, lacked weekend and special interest activities, and did not include outings or animal-related events. Residents reported decreased participation and enjoyment, with some not being personally invited to activities as required by their care plans. Staff interviews revealed outdated assessments and inconsistent communication about available activities.
A resident was physically assaulted by a nonclinical employee at an LTC facility, resulting in severe injuries including brain bleeds and fractures. The incident, captured on video, began with an argument over money and escalated when the employee punched the resident, causing him to fall from his wheelchair. The resident was hospitalized in the trauma ICU. The employee, a long-time staff member with no prior issues, admitted to the assault and was terminated.
The facility failed to provide consistent access to functional phones for residents, leading to communication issues and feelings of isolation. Residents reported missing phones at nurse's stations, unrelayed messages, and lack of privacy when making calls. The removal of room phones without notice further isolated residents, and the library phone was not a viable alternative due to privacy concerns and limited access.
The facility failed to conduct annual performance reviews for five CNAs, as required by their policy. This oversight was confirmed by the DON and RDCS, who acknowledged that the evaluations were not completed. Consequently, the CNAs did not receive necessary in-service education based on these reviews.
The facility failed to accommodate resident food and drink preferences, with residents in a secured unit receiving only cranberry juice without choice, and a resident receiving incorrect meal items. Despite policies, staff did not ask for drink preferences, and residents reported not receiving ordered items. The DON and RDCS were unaware of these issues.
The facility failed to maintain sanitary conditions in food preparation and storage. Staff did not change gloves or perform hand hygiene between tasks, leading to potential cross-contamination. Food items were improperly stored, with many being unlabeled, undated, or past their use-by dates. Additionally, the facility did not maintain safe holding temperatures for both cold and hot food items, compromising food safety.
The facility failed to ensure that five CNAs received the required 12 hours of annual in-service training, as mandated by their policy. This deficiency was due to the absence of a staff development coordinator and ineffective monitoring of the computer-based training program, resulting in incomplete training for the CNAs.
The facility failed to provide necessary ADL assistance and incontinence care for two residents. One resident, with severe cognitive impairments, was not repositioned or offered snacks and drinks timely, and was inadequately assisted during meals. Another resident, with moderate cognitive impairments, was not checked or changed for over three hours despite being on a check and change program. Staff interviews revealed inconsistencies in care provision and documentation.
Two residents in a facility did not receive oxygen therapy as per physician's orders, with one receiving 3 LPM instead of 4 LPM and another receiving 3 LPM instead of 2 LPM. This led to issues such as difficulty breathing and incorrect oxygen saturation levels. Staff interviews revealed a lack of adherence to physician's orders, with nursing staff responsible for monitoring and adjusting oxygen flow rates.
The facility failed to properly store and label medications, with insulin vials lacking resident names and medications stored improperly by administration route. Additionally, medications were stored with food in an unlocked dormitory-style refrigerator, risking contamination and temperature fluctuations.
The facility failed to provide meals prepared according to residents' prescribed mechanically altered diets, as per IDDSI guidelines. Observations revealed that residents received food items not properly modified, such as improperly sized carrots and unblended rice. Staff interviews indicated a lack of training and understanding of diet textures, contributing to the deficiency.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a feeding tube, as required by their care plan and physician's orders. Observations showed no EBP signage on the resident's door, and an LPN provided care without wearing a gown. Interviews revealed a misunderstanding of EBP requirements among staff, despite clear guidelines from the infection preventionist and director of nursing.
A resident with type 2 diabetes did not receive insulin injections consistently at the prescribed times, as documented in the medication administration record. The facility's policy required timely administration and documentation, but the insulin was administered late on multiple occasions. Staff interviews revealed discrepancies in the understanding of the acceptable time window for medication administration, contributing to the deficiency.
A resident with limited mobility and multiple health conditions did not receive a restorative nursing program as recommended by the DOR. Despite a referral for specific ROM exercises, the program was not implemented due to a lack of communication and follow-through among staff. The resident expressed a desire to continue therapy to regain independence, but no restorative care was provided.
The facility failed to maintain emergency response carts and equipment in safe operating condition, with incomplete safety check logs and missing essential items like backboards, blood pressure cuffs, and stethoscopes. Staff interviews revealed that night shift nurses were responsible for checks but were inconsistent, and management did not audit the logs.
Failure to Administer Prescribed HIV Medication Due to Transcription Error
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of HIV received the physician-prescribed antiretroviral medication, Biktarvy, upon admission. Instead, the admitting nurse transcribed the order incorrectly, listing only one component of the medication, tenofovir alafenamide, rather than the full combination therapy required for effective HIV treatment. There was no documentation or recall as to why the order was changed, and neither the facility pharmacist nor the medical director reviewed or corrected the order prior to its implementation. As a result of this transcription error, the resident received only tenofovir alafenamide for several months, rather than the complete Biktarvy regimen. When the order for tenofovir expired, it was not renewed, and the resident subsequently received no HIV medication for a period of time. Throughout this period, the facility's nursing staff, pharmacist, and medical director failed to identify or address the omission, despite regular medication reviews and the resident's ongoing need for antiretroviral therapy as documented in the care plan and physician orders. The deficiency was discovered when the resident was sent to a hospital for routine HIV viral load testing, which revealed a significantly elevated viral load, indicating a lack of effective HIV treatment. The hospital physician noted that the resident's medication list from the facility did not include Biktarvy, and the resident was subsequently restarted on the correct medication. Interviews with facility staff confirmed that the resident was cooperative with care and did not refuse medications, and that the error was not identified until the hospital visit. The facility's failure to administer the prescribed medication as ordered resulted in a significant medication error and actual harm to the resident.
Removal Plan
- Resident #1's medication list was printed and reviewed with the facility physician for accuracy.
- The hospital's infectious disease office was contacted regarding follow-up appointment recommendations for lab monitoring.
- The DON or designee will prioritize reviewing current residents who are receiving clinically significant medications such as insulin, anticoagulants, cancer agents, antivirals, and medications for multiple sclerosis or Parkinson's, focusing on order accuracy.
- The DON/designee will review all remaining residents.
- The DON or designee reviewed all resident orders with a discontinuation date using the order listing report to ensure accuracy.
- Facility Medication policy was reviewed by the NHA, the DON, and the medical director.
- New admission orders will be reviewed against the discharge orders to ensure transcription accuracy. Any discrepancies identified will be clarified with the attending physician.
- The primary physician will review new admission orders in conjunction with the history and physicals to ensure accuracy.
- Consultant pharmacists will complete a review of new admissions for clinically significant risk. This review will include assessment of high-risk medications, potential interactions, contraindications, missing indications, and duplicate therapies. Any concerns identified will be communicated to the facility.
- The LPN who may not have transcribed the original order correctly was re-educated via phone by the assistant director of nursing (ADON). Education included the facility's policy regarding medication administration and reconciliation guidelines of noting who medications were verified with and any changes made during reconciliation.
- The staff development coordinator (SDC) or designee re-educated all licensed nurses on the facility's medication administration and reconciliation policy. Education included documenting who was verified for each medication, noting any changes made during reconciliation, completing a two-nurse verification of order accuracy, and clarifying when a long-term medication has a stop date.
- Any nurse who has not yet received the education will not work the floor until training is completed.
- Licensed nurses who have not worked have been terminated.
- Licensed nurses on a leave of absence will be educated upon their return and prior to working on the floor.
- Licensed nurses were unable to be reached by the SDC or designee and will not be scheduled to work until the required education is completed.
- The SDC/designee will educate agency licensed nurses on the facility's policy regarding medication administration and reconciliation guidelines. Education was uploaded to the agency portal.
- The agency platform requires the agency nurse to complete training before they can confirm the shift.
- The regional director of clinical services notified the pharmacy account representative of the error. A meeting has been scheduled with the pharmacy to review the error in detail and establish an ongoing plan for medication monitoring.
Failure to Maintain Accident-Free Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a specific area within the facility was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment was not maintained in a manner that would minimize the risk of accidents, and supervision protocols were insufficient to prevent such incidents from occurring. No additional details regarding the specific individuals involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Review and Update Fall Interventions After Resident Fall
Penalty
Summary
The facility failed to ensure adequate supervision and services to prevent accidents for one resident reviewed for falls. Specifically, after a resident experienced a fall in the main courtyard, there was no documentation that a root cause analysis was conducted by the nurse on duty or by the interdisciplinary care team (IDT). The facility's policy requires that after a fall, the IDT analyze the incident to identify specific accident hazards or risks and target interventions to reduce those risks, but this process was not followed in this case. The resident involved was over 65 years old with multiple diagnoses, including dementia, diabetes, COPD, and chronic kidney disease, and had a history of falls. The resident required varying levels of assistance for mobility and activities of daily living and used a manual wheelchair. Despite these risk factors, the resident's fall care plan had not been updated since the previous year, and there was no evidence that the care plan was reviewed or revised following the fall incident. Additionally, the weekly nurse summary note failed to document the fall, and there was no further progress note detailing the incident or any follow-up. Interviews with facility leadership revealed that the DON and regional clinical resource were unaware of the fall, as it had not been entered into the risk management system by the nurse on duty, who was an agency nurse. As a result, the required IDT meeting to determine the root cause and review the effectiveness of fall interventions did not occur. The lack of documentation and communication prevented the facility from implementing or modifying interventions to prevent future falls for this resident.
Failure to Prevent Elopement and Inadequate Supervision for Cognitively Impaired Resident
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with severe cognitive impairment and a known history of elopement and exit-seeking behaviors remained as free from accidents as possible. The resident, who had previously eloped from the facility, was assessed as being at risk for future elopement, but the care plan update did not document the prior elopement, did not identify specific behaviors that might precipitate another elopement, and did not provide individualized interventions to minimize risk factors such as independence with ambulation, verbalized desire to go home, and attempts to open doors. There was also no plan to increase the level of supervision for this resident. Despite ongoing documentation in the medication and treatment administration records indicating frequent exit-seeking behaviors and difficulty with redirection, the facility did not update the care plan or increase supervision. The quarterly elopement assessment was inaccurate, failing to account for all relevant risk factors, including medications and diagnoses that could increase restlessness or agitation, and did not reflect the resident's prior elopement. Staff interviews confirmed that the resident was known to wander, especially in the evenings and at night, and often pushed on doors and talked about going outside. On one occasion, the resident eloped from the facility during the night and was not discovered missing until hours later. There were delays in notifying facility management and law enforcement, and the facility's investigation did not identify root causes or consider lapses in the response. The care plan remained insufficient, lacking specific interventions or documentation of the resident's elopement history, and there was no evidence of a timely reassessment or adjustment of supervision following the incident.
Lack of Written Hospital Transfer Agreement
Penalty
Summary
The facility failed to maintain a written transfer agreement with at least one local hospital certified by Medicare or Medicaid, as required to ensure residents could be transferred and admitted in a timely manner when medically necessary. During a record review, facility leadership was unable to provide documentation of an active transfer agreement with one area hospital, despite having made recent requests to two hospitals for such agreements. Interviews with the NHA, DON, and nurse consultant confirmed that the facility could not locate the required agreement at the time of the survey.
Failure to Identify and Address Resident Elopement Risk Through QAPI
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program to identify and address compliance concerns, specifically related to resident safety and accident prevention. The QAPI committee did not recognize or act upon repeated exit-seeking behaviors exhibited by a resident, despite documentation in the medication and treatment administration records showing frequent incidents of such behaviors. The committee also did not develop or implement new interventions to address the resident's high risk for elopement, even after a previous elopement event. As a result, a resident was able to elope from the facility a second time, with staff unable to determine the exact time of departure due to delays in shift change reporting. The resident was eventually found approximately one mile from the facility several hours later. Staff interviews revealed that changes in the resident's behaviors were not discussed during daily huddles, and the documentation in the electronic medical record was unclear, contributing to the lack of appropriate intervention. The facility's failure to identify and address these risks created a situation where a serious adverse outcome was likely, rising to the level of immediate jeopardy.
Failure to Provide Activities Meeting Resident Needs and Preferences
Penalty
Summary
The facility failed to provide activities that met the needs and preferences of three residents, as evidenced by interviews and record reviews. Activity calendars for January and February showed repetitive weekly schedules, with limited activities on weekends and a lack of variety, such as animal-related activities or outings. Bingo was the most frequently offered activity, and outings or special interest activities were notably absent from the calendar. Residents reported a significant reduction in the variety and frequency of activities compared to previous years, and some activities previously enjoyed, such as jewelry making, art, music, and outings, were no longer available. One resident, who was cognitively intact and had a history of enjoying group activities, outings, and being around animals, stated that she now spent more time alone in her room due to the lack of engaging activities. She also reported that staff did not personally invite her to activities, despite her care plan indicating that she should be encouraged and escorted to participate. Another resident, also cognitively intact, expressed disappointment that outings and card games he enjoyed were no longer offered, and that weekend activities had diminished. His activity assessment and care plan did not reflect his preferences for outings or card games. A third resident, with moderate cognitive impairment, expressed a desire for more weekend activities. Her assessment and care plan documented her enjoyment of both group and independent activities, but interventions noted she declined group activities due to lack of interest in those offered. Staff interviews revealed inconsistencies in the communication and posting of activity and outing calendars, with the outings calendar not always being distributed or posted in accessible locations. The activities consultant indicated that quarterly participation assessments should be conducted to adjust activities as needed, but assessments for the residents in question were outdated or did not reflect current preferences. The activities assistant stated that daily activity sheets were distributed and staff attempted to remind residents of activities, but residents reported not being personally invited or encouraged to participate. These findings demonstrate a failure to individualize and update activity programming to meet the socialization and activity needs of the residents.
Resident Assaulted by Facility Employee
Penalty
Summary
The facility failed to protect a resident from physical abuse by a nonclinical employee, resulting in significant injuries. The incident occurred on the facility's outside smoking patio and was captured on video surveillance. The altercation began with an argument over money between the resident and the employee, which escalated when the employee physically assaulted the resident, causing the resident to fall out of his wheelchair. The resident sustained severe injuries, including brain bleeds, nasal bone fractures, and facial contusions, requiring hospitalization in the trauma ICU. The facility's investigation revealed that the employee, a housekeeper, had been involved in an argument with the resident, during which the resident allegedly used a racial slur. This provoked the employee to repeatedly punch the resident, as confirmed by a witness and video evidence. The resident initially did not report the incident to the facility staff but informed his family, who then notified the facility. Upon assessment by a licensed practical nurse, the resident was found with multiple facial injuries and was later convinced by his representative to seek hospital treatment. The facility had no prior indication that the employee would engage in such behavior, as he was a long-time employee with no disciplinary issues and was well-liked by residents. The employee admitted to the assault when questioned and was immediately suspended and later terminated. The facility's policy on abuse prevention was not effectively implemented in this instance, leading to the resident's harm.
Removal Plan
- Immediate suspension/ removal from facility property of the staff assailant during the investigation.
- Notify the resident's family and physician. Notify the police, adult protective and the State oversight office and initiate an investigation.
- Staff education on resources for the employee assistance program; stress management and management of resident behavior.
- Interview resident witnesses.
- Contract a mental health provider to provide counseling services to the three resident witnesses of the incident.
- Complete audit of all staff for a completed background check. Request missing background checks.
- Interview all residents and resident representatives of residents who were not interviewable to determine if any had a similar experience of being abused (emotionally or physically) by a staff.
- Complete skin evaluations on residents who were not interviewable to assess for any potential injuries of unknown origin.
- Provide training to all staff on abuse identification, prevention and reporting; how to recognize resident triggers; and how to address resident in the moment of distress.
- Ensure that all newly hired staff receive training on abuse and neglect identification, prevention and reporting prior to having resident interaction.
- Conduct ongoing interviews with 10 randomly selected residents on staff treatment.
- Conduct ongoing interviews with 10 randomly selected staff on staff treatment and other related concerns.
- Submit the Quality improvement plan to the quality assurance quality improvement (QAPI) committee for review and monitoring.
Inadequate Phone Access and Privacy for Residents
Penalty
Summary
The facility failed to ensure that residents had consistent access to functional phones for communication, as required by their policy. Observations and interviews revealed that phones were not consistently available or operational for residents to use from their rooms or other private areas. Residents reported that the phones at the nurse's stations were often missing, and messages left for them were not relayed. Additionally, the facility had removed phone lines from residents' rooms without prior notice, leaving residents feeling isolated from their families. Interviews with residents and the resident council highlighted the lack of privacy and accessibility for phone use. Residents had to stand at the nurse's station to make calls, which compromised their privacy. Bedridden residents faced additional challenges as they could not access the nurse's station to make phone calls. The library, which had a landline phone, was not a viable alternative due to its lack of privacy and frequent use by the facility administration for meetings, limiting residents' access. Staff interviews confirmed the presence of phones at each nurse's station, but there were issues with the phones being charged and available. The facility's system involved calls being transferred from the reception desk to the appropriate unit, but messages were not consistently passed on to residents. The social services director acknowledged receiving grievances about unreturned messages and difficulties in reaching residents through the cordless phones. Despite these measures, residents continued to feel they lacked adequate access and privacy for phone communication.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to conduct annual performance reviews for five certified nurse aides (CNAs), which is a requirement according to their policy and procedure. The policy, revised in September 2020, mandates that each employee's job performance be reviewed and evaluated at least annually. This evaluation is crucial for determining potential training needs, promotions, transfers, demotions, terminations, wage increases, and improving the quality of work performance. However, the facility was unable to provide the required annual performance evaluations for the CNAs hired between 2014 and 2022, indicating a lapse in adherence to their own policy. Interviews with the Director of Nursing (DON) and the Regional Director of Clinical Services (RDCS) confirmed that the annual performance reviews had not been completed as required. The DON, who had recently assumed her position, acknowledged the oversight, and the RDCS admitted that the evaluations were not conducted. This lack of performance reviews also meant that the CNAs did not receive the necessary in-service education based on the outcomes of these reviews, further compounding the deficiency.
Failure to Accommodate Resident Food and Drink Preferences
Penalty
Summary
The facility failed to provide food and drinks that accommodate resident allergies, intolerances, and preferences, specifically in one of the two dining rooms and for one resident reviewed for preferences. Observations revealed that residents in the secured unit were not offered drinks of choice during meal times. Instead, all residents received a pre-poured glass of cranberry juice on their meal trays without any other drink options being offered. Staff interviews indicated that while residents' preferences were supposed to be considered, in practice, the staff did not ask residents for their drink preferences during meal service. Additionally, the facility failed to ensure that a resident received the meal items they ordered. The resident, who had moderate cognitive impairments and was on a therapeutic diet, reported frequently receiving incorrect food items. On one occasion, the resident ordered mashed potatoes but received rice instead, without being informed of the substitution. Staff interviews confirmed the discrepancy, but no alternative was offered to the resident. A group interview with other residents revealed that they could select menu items, but often did not receive what they ordered. The kitchen staff reportedly served the same food items to all residents, regardless of individual orders. The Director of Nursing and the Regional Director of Clinical Services were unaware of these issues, despite previous education provided to CNAs about offering alternative menu items and ensuring care plans reflected residents' preferences.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure that food was prepared, distributed, and served under sanitary conditions in the kitchen. Observations revealed that dietary aides and the nutritional services director (NSD) did not change gloves or perform hand hygiene after touching non-food items such as tongs, meal tickets, and equipment handles before handling ready-to-eat foods. This improper glove use led to potential cross-contamination of food items during meal preparation and service. Additionally, the facility did not store food items correctly in refrigerators and dry storage areas. Unlabeled and undated food items were found in various refrigerators, including opened bags of lettuce, shredded cheese, tortillas, and other perishable items. Some food items were past their use-by dates, and there were missing temperature logs for certain days. The absence of thermometers in some freezers further compromised the ability to monitor and maintain safe food storage temperatures. The facility also failed to maintain safe holding temperatures for food items. Observations showed that cold food items such as sliced tomatoes, cucumbers, and tzatziki sauce were stored at temperatures above the safe limit of 41 degrees Fahrenheit. Similarly, hot food items like sliced gyro meat were served at temperatures below the required 135 degrees Fahrenheit. Despite being informed of the correct temperature requirements, staff did not reassess the temperatures of these items before serving them to residents.
Deficiency in CNA Training Compliance
Penalty
Summary
The facility failed to ensure that five certified nurse aides (CNAs) received the required 12 hours of annual in-service training necessary for maintaining their competence. This deficiency was identified through a review of records and interviews, which revealed that CNAs #1, #2, #5, #6, and #7 did not complete the mandated training. The facility's policy, revised in December 2016, mandates that all nurse aide personnel participate in regularly scheduled in-service training classes, which must include at least 12 hours per employment year. These trainings are intended to address areas of weakness identified in performance reviews, the special needs of residents, and include training in dementia management and abuse prevention. Interviews with facility staff, including the nursing home administrator (NHA) and the regional director of clinical services (RDCS), highlighted the absence of a staff development coordinator (SDC) for a period, which contributed to the lack of training oversight. The NHA mentioned that a floor nurse was recently promoted to the SDC position to manage training tracking. The RDCS acknowledged that the computer-based training program used by the facility was not effectively monitored, resulting in incomplete training for the CNAs. Additionally, there was no tracking system in place to ensure staff training was completed, which led to the deficiency.
Failure to Provide Timely ADL Assistance and Incontinence Care
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living (ADLs), specifically for two residents. Resident #23, who had severe cognitive impairments and was totally dependent on staff for care, did not receive timely repositioning, toileting, or incontinence care. Observations revealed that Resident #23 was left unattended for extended periods, not offered snacks or drinks when other residents were, and was not properly assisted during meal times, resulting in food and drink spilling onto her clothing. Resident #23's care plans indicated she required assistance with ADLs, frequent repositioning, and encouragement to drink fluids. However, during observations, she was not repositioned or checked for incontinence for over three hours. The CNA task schedule showed incomplete documentation of repositioning tasks, and interviews with staff confirmed that Resident #23 needed assistance with toileting and repositioning, which was not consistently provided. Resident #46, who had moderate cognitive impairments and was frequently incontinent, also did not receive timely incontinence care. Observations showed that Resident #46 was not checked or changed for over three hours, despite being on a check and change program. Interviews with staff revealed inconsistencies in the understanding and implementation of the check and change program, with some staff unsure of the documentation process. This lack of consistent care and attention to the residents' needs contributed to the facility's failure to meet the required standards for ADL assistance.
Failure to Administer Correct Oxygen Therapy
Penalty
Summary
The facility failed to provide necessary respiratory care and services consistent with professional standards of practice and the comprehensive person-centered care plan for two residents reviewed for respiratory care. Specifically, the facility did not ensure that these residents received oxygen therapy in accordance with their physician's orders. Resident #19, who had a history of chronic obstructive pulmonary disease (COPD) and other health issues, was observed receiving 3 liters per minute (LPM) of oxygen via nasal cannula, despite a physician's order for 4 LPM. This discrepancy was noted over several days, and the resident's oxygen saturation levels dropped below the recommended threshold during a respiratory treatment. Similarly, Resident #24, who also had COPD and other respiratory conditions, was observed receiving 3 LPM of oxygen, contrary to the physician's order for 2 LPM. This resident experienced difficulty breathing during meal times, which was exacerbated by the incorrect oxygen flow rate. The resident was unable to verify the oxygen flow rate due to the placement of the oxygen concentrator, and the nursing staff were responsible for setting the flow rate. Interviews with staff revealed a lack of adherence to physician's orders for oxygen therapy. Certified nurse aides and licensed practical nurses acknowledged the incorrect oxygen flow rates and the responsibility of nursing staff to monitor and adjust them according to physician's orders. The director of nursing emphasized the importance of following physician's orders to prevent medical complications, highlighting a systemic issue in ensuring proper oxygen therapy administration.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, as observed in two medication carts and one medication storage room. Specifically, a vial of glargine insulin was found without a resident's name on it, labeled as house stock, which was against the facility's policy that each resident should have their own labeled vial or pen for insulin. Additionally, medications were not stored according to their route of administration, as evidenced by Lantus insulin being stored next to Latanoprost eye drops, which could lead to potential contamination or infection. Furthermore, the medication storage room contained a refrigerator that was unlocked and housed both medications and food items, such as Boost supplement drinks, alongside controlled medications like Lorazepam and injectable pens like Trulicity. The refrigerator was a dormitory style with ice buildup, which could cause temperature fluctuations, potentially compromising the medications stored within. The facility's policy clearly stated that medications should be stored separately from food and in a secure manner, which was not adhered to in this instance.
Failure to Provide Mechanically Altered Diets as Prescribed
Penalty
Summary
The facility failed to ensure that residents received food and fluids prepared in a form designed to meet their individual dietary needs, as prescribed by their diet orders. Specifically, the facility did not adhere to the International Dysphagia Diet Standardization Initiative (IDDSI) guidelines for mechanically altered diets, which include puree, level five minced and moist, and level six soft and bite-sized textures. During meal service observations, several discrepancies were noted, such as serving food items that were not properly modified according to the residents' prescribed diet textures. For instance, Resident #86, who was prescribed a level six soft and bite-sized diet, was served roast beef, rice, and carrots that were not cut to the appropriate size, and the rice lacked the necessary gravy to meet the IDDSI recommendations. Similarly, Resident #23, who required a puree diet, received rice that was not fully blended and smooth, containing visible lumps. Additionally, Resident #81, on a level five minced and moist diet, was served carrots that were not chopped to the required four-millimeter size, and during another meal, received a sandwich with meat in strips and potatoes with skin, contrary to the IDDSI guidelines. Interviews with staff revealed a lack of adequate training and understanding of the mechanically altered diet textures. The nutritional services director admitted to not having recent training and acknowledged that the kitchen staff were not fully knowledgeable about the different diet textures. The consulting registered dietitian also noted errors in food preparation, such as serving potato skins on french fries and toasting buns for residents on soft and bite-sized diets. These findings indicate a systemic issue in the facility's ability to provide meals that meet the specific dietary needs of residents with dysphagia or other swallowing difficulties.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection control program, specifically in the implementation of Enhanced Barrier Precautions (EBP) for a resident with a feeding tube. The resident, under 65 years old, was admitted with diagnoses including dysphagia and severe protein-calorie malnutrition, and was documented to require EBP due to the presence of an indwelling device. Observations revealed that there was no sign indicating the need for EBP on the resident's door, contrary to the care plan and physician's orders. Additionally, an LPN was observed providing care to the resident without wearing a gown, which is a requirement under EBP for high-contact care activities. Interviews with staff, including the LPN, the infection preventionist (IP), and the director of nursing (DON), highlighted a lack of adherence to EBP protocols. The LPN incorrectly believed that EBP was not necessary for feeding tubes, while the IP and DON confirmed that EBP, including the use of gowns and gloves, was required for residents with indwelling lines and feeding tubes. The deficiency was further evidenced by the absence of EBP signage and the failure to follow proper PPE protocols during care activities, as outlined in the facility's policy and CDC guidelines.
Inconsistent Insulin Administration for Resident
Penalty
Summary
The facility failed to ensure that a resident received insulin medication in accordance with professional standards of practice. The resident, who was under 65 years old and had multiple diagnoses including type 2 diabetes, reported receiving insulin injections at inconsistent times. The resident was unsure of the exact administration time due to the variability in the timing of the injections, which were supposed to be administered in the evening as per the physician's orders. A review of the medication administration record revealed that the insulin was not administered at the prescribed time on several occasions. Specifically, the insulin was administered late on five different days, with delays ranging from 30 minutes to nearly five hours past the scheduled time. This inconsistency in medication administration was not in line with the facility's policy, which required medications to be administered safely and timely, and any deviations to be documented and communicated to the physician. Interviews with staff, including an LPN and the DON, highlighted discrepancies in the understanding of the acceptable time window for medication administration. The LPN stated that medications could be administered within an hour of the scheduled time, while the DON indicated a 30-minute window. The DON suggested that the late documentation might have been the issue rather than late administration, but acknowledged that the records indicated the insulin was given late. The lack of consistent adherence to the administration schedule and documentation requirements contributed to the deficiency identified by the surveyors.
Failure to Implement Restorative Nursing Program for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with limited mobility to maintain or improve their range of motion (ROM). The resident, who was over 65 years old and had multiple diagnoses including COPD, type 2 diabetes, and chronic respiratory failure, was dependent on staff for personal hygiene and required moderate assistance with mobility. Despite a referral for a restorative nursing program by the Director of Rehabilitation (DOR) on 6/13/24, which included specific ROM exercises and strengthening activities, the program was not implemented. The resident expressed a desire to continue therapy to regain independence, but no restorative nursing program was in place. Interviews with staff revealed a lack of communication and follow-through regarding the implementation of the restorative nursing program. The DOR confirmed the referral but noted the absence of documentation in the resident's electronic medical record (EMR) and was unaware of why the program had not been initiated. A restorative nurse aide (RNA) acknowledged seeing the referral but had not been instructed to start the program. The Director of Nursing (DON) admitted responsibility for the restorative nursing program and recognized that the resident's care plan should have been updated to include the service.
Failure to Maintain Emergency Response Equipment
Penalty
Summary
The facility failed to maintain emergency response carts and equipment in safe operating condition across five different locations within the facility. Observations revealed that the crash carts were not regularly checked to ensure they were in proper working condition. Specifically, the safety check logs for the crash carts were incomplete, with numerous dates missing checks. Additionally, several crash carts were missing essential equipment such as backboards, blood pressure cuffs, and stethoscopes. The facility's policy required that crash carts be checked every 24 hours and after each use, but this was not consistently followed. Interviews with staff highlighted a lack of adherence to the facility's policy regarding the maintenance of crash carts. The Unit Manager and Director of Nursing both acknowledged that it was the responsibility of the night shift nurses to complete the safety check logs, but this was not consistently done due to the inconsistency of the night shift nurses, many of whom were agency staff unfamiliar with the process. Furthermore, nursing management did not audit the safety logs, contributing to the oversight. The facility also lacked a defibrillator, which is critical for responding to cardiac emergencies.
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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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