Life Care Center Of Colorado Springs
Inspection history, citations, penalties and survey trends for this long-term care facility in Colorado Springs, Colorado.
- Location
- 2490 International Cir, Colorado Springs, Colorado 80910
- CMS Provider Number
- 065356
- Inspections on file
- 20
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Life Care Center Of Colorado Springs during CMS and state inspections, most recent first.
A high fall‑risk resident with traumatic brain injury, seizures, dementia, impaired mobility, and impaired vision experienced multiple falls, including one with head and facial lacerations requiring hospital treatment, while care‑planned fall‑prevention measures and supervision were not consistently implemented. The care plan called for the bed to be kept in the lowest position, floor mats at the bedside, the call light and personal urinal within reach, and close supervision, but surveyors observed the bed not in the lowest position, no floor mats in place, and the urinal out of reach. The resident was also observed beginning to fall forward from a wheelchair while an RN at the nearby nurses’ station was not watching him until prompted, and he was left unattended in the shower room despite being identified as a high fall risk. Documentation of several falls lacked clear root cause analysis or review of the effectiveness of existing interventions, demonstrating a pattern of inconsistent implementation of person‑centered fall‑prevention strategies and supervision.
Staff failed to follow Enhanced Barrier Precautions (EBP) and hand hygiene requirements during care of multiple residents. In several instances, CNAs and an LPN provided wound care, incontinence care, and linen changes to residents on EBP using only gloves and no gowns, despite posted EBP signage and available PPE. During one wound dressing change, an LPN did not change gloves between removing a soiled dressing and preparing a new one. In another case, an RN administered tube feeding to a resident with a feeding tube while wearing gloves and a mask but no gown, and initially believed the resident was not on EBP. These events occurred despite facility policy and CDC-based expectations for gown and glove use during high-contact care activities and proper hand hygiene.
Surveyors identified a deficiency when expired OTC medications, including CoQ10, calcium, and acetaminophen, were found on a medication cart, despite facility policy requiring house stock medications to be stored in original containers with visible expiration dates and discarded when expired. An RN reported being trained to date OTC bottles when opened and discard them three months later, while an LPN demonstrated uncertainty about whether to follow a post-opening timeframe or the manufacturer’s expiration date and did not know where to find the facility’s policy. The DON stated staff were expected to follow manufacturer expiration dates, acknowledged that nurses were informally trained by other bedside staff, and confirmed there was no specific facility training on medication expiration dates, while also stating that expired medications should not be administered because they could make a resident very sick.
A resident on hospice with hypertensive heart disease, heart failure, palliative care, and protein-calorie malnutrition did not have a current hospice plan of care or hospice visit documentation readily accessible in the EMR or physical chart. The hospice care plan on file was outdated, and there were no hospice visit notes for days when an RN and an LPN reported that hospice staff had seen the resident. Staff described an informal process where hospice CNAs and RNs checked in verbally, with no formal sign-in system or structured method for documenting or tracking hospice visits and services, and the DON acknowledged poor communication from the hospice provider while recognizing the facility’s responsibility for ensuring appropriate hospice services.
A resident with moderate cognitive impairment and a history of wandering was not properly supervised during an off-site medical appointment, leading to the individual leaving the clinic unsupervised and being missing for several hours. Despite documented wandering behaviors and cognitive deficits, staff did not reassess elopement risk or implement a care plan, and miscommunication among staff resulted in no escort being provided.
The facility failed to provide a resident with speech difficulties due to a stroke with an appropriate communication tool, leading to ineffective communication of her needs. Staff were unaware or did not use the communication board, and the care plan lacked specific instructions.
The facility failed to assist a resident with applying her compression stockings, necessary for treating her bilateral lower leg edema. Despite the resident's cognitive intactness and ability to dress herself, she required assistance with the stockings, which staff did not consistently provide. Observations and interviews revealed the resident's feet were often swollen, and she was seen without the stockings, indicating non-compliance with physician's orders and facility policy.
Failure to Consistently Implement Fall-Prevention Interventions and Supervision for a High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure a high fall‑risk resident received adequate, person‑centered supervision and that fall‑prevention interventions identified in the care plan were consistently implemented. The resident was an older adult with traumatic subdural hemorrhage, seizures, dementia, generalized weakness, impaired mobility, impaired vision, cognitive communication deficit, and a history of multiple falls. The 1/14/26 MDS showed the resident was cognitively intact by BIMS but had fluctuating difficulty focusing attention and had already experienced multiple falls, including one with injury, since admission. The fall care plan, revised on 12/10/25 and 1/23/26, identified the resident as at risk for falls due to impaired mobility, history of falls, impaired vision, seizures, and psychotropic medication use, and called for specific interventions such as keeping the bed in the lowest position at all times, placing floor mats at the bedside, ensuring the call light and personal urinal were within reach, and moving the resident to a room across from the nurses’ station. Surveyor observations showed that these care‑planned interventions were not consistently in place. On 2/24/26, the resident was observed in his wheelchair in his room, leaning forward toward the floor and beginning to fall forward with his legs buckling, while an RN sat at the nurses’ station across the hall but was not watching him until prompted. The RN then had to physically assist the resident back to a safe sitting position and instructed him to use his call light. On 2/26/26, the resident was observed sleeping in bed with the bed not in the lowest position, no floor mats at the bedside, and his personal urinal not within reach, despite the care plan requiring all three interventions to prevent falls. These observations demonstrated that the facility did not consistently provide the level of supervision and environmental controls it had identified as necessary for this resident. The record review documented a pattern of repeated falls, many unwitnessed, with incomplete or inconsistent post‑fall analysis and follow‑through. The resident sustained multiple falls in the bathroom, from bed, from a low bed, during attempts to walk with a friend, and while attempting to transfer or reach for objects without assistance. On 11/22/25, he was found on the bathroom floor with root cause attributed to gait imbalance and an intervention to offer frequent toileting. On 11/24/25 and 11/26/25, he fell while attempting to walk with a friend and while trying to retrieve his cell phone, but the progress notes did not document a root cause analysis or review of the effectiveness of existing interventions or need for new ones. On 12/1/25 and 12/6/25, he was found on the floor after rolling or falling from bed, with one fall linked to toileting urgency and possible UTI, but again without consistent documentation of reassessment of interventions. Further falls continued despite the resident’s high‑risk status and care‑planned interventions. On 12/9/25, he had two falls: one witnessed as he attempted to get out of bed unassisted, and a later unwitnessed fall in which he was found on the floor bleeding from lacerations to his forehead and jaw after attempting to empty a urinal without using his call light, resulting in transfer to the hospital for treatment. On 12/10/25, he reported sliding from bed and getting himself back in, and on 12/16/25 he fell in the shower room after sliding from the shower chair while reaching to turn off the water; the CNA had left him unattended in the shower room for a few minutes, even though the DON later stated that a resident with a high fall‑risk diagnosis should not be left alone there. On 12/31/25, he fell while trying to get into bed when he could not find his call light, which had fallen and become wrapped around the wheelchair wheel, and on 1/19/26 he fell in the bathroom while transferring from the toilet to his wheelchair without assistance when the wheelchair was not locked. Staff interviews confirmed that the resident was very impulsive, had been falling frequently, and required close supervision, yet the documented lapses in supervision, inconsistent implementation of care‑planned interventions, and incomplete root cause analyses after several falls led surveyors to conclude that the facility failed to provide adequate supervision and consistently implement person‑centered fall‑prevention measures for this resident.
Failure to Implement Enhanced Barrier Precautions and Hand Hygiene Practices
Penalty
Summary
The deficiency involves the facility’s failure to implement and maintain an effective infection prevention and control program, specifically related to Enhanced Barrier Precautions (EBP) and hand hygiene. Facility policy, consistent with CDC guidance, required targeted gown and glove use during high-contact resident care activities for residents with MDROs, wounds, or indwelling medical devices, and required staff to follow IPCP standards including hand hygiene and appropriate PPE use. Despite posted EBP signage and availability of PPE, staff did not consistently don required gowns or perform appropriate hand hygiene during resident care. For one resident with MDRO in the urine and an EBP sign posted outside the room, two CNAs entered to provide incontinence and perineal care without donning gowns, using only gloves as PPE. One CNA later confirmed she provided incontinence and perineal care using only gloves. These actions occurred despite the presence of an EBP sign and a bin of isolation gowns outside the room, and despite facility policy requiring gown and glove use for high-contact care activities under EBP. For another resident on EBP with a posted sign specifying that gloves and a gown must be worn for activities such as wound care, incontinence care, and linen changes, an LPN and a CNA performed coccyx wound care, incontinence care, and a linen change without wearing gowns. The LPN removed a soiled wound dressing and prepared a new dressing without changing gloves between tasks, contrary to hand hygiene expectations. Both staff acknowledged the importance of hand hygiene and PPE but reported not having received education or training on EBP requirements. In a third case, an RN provided tube feeding to a resident with a feeding tube while wearing gloves and a mask but no gown, and initially stated the resident was not on EBP. The IP later stated she had only just become aware of the resident’s feeding tube and had not yet entered EBP orders, despite the process requiring EBP determination at admission for residents with indwelling devices. These observations across three units demonstrate failures to ensure appropriate PPE use for residents on or meeting criteria for EBP and failures in hand hygiene practices during wound care, in direct conflict with CDC guidance and the facility’s own IPCP policy.
Expired OTC Medications Found on Medication Cart
Penalty
Summary
The deficiency involves the facility’s failure to ensure that over-the-counter (OTC) medications were stored and discarded in accordance with manufacturer expiration dates and facility policy. The facility’s House Stock Items policy required house stock medications to be stored in the original manufacturer’s container with the medication name, strength, expiration date, and lot number clearly visible. During an observation of a medication cart on the 300 east hall with an LPN, surveyors found multiple OTC medications with manufacturer expiration dates that had already passed, including CoQ10 100 mg, Calcium 500 mg, and Acetaminophen 500 mg. These medications remained on the cart despite being expired according to the dates printed on the manufacturer’s containers. Staff interviews revealed inconsistent understanding and training regarding OTC medication expiration and storage. An RN reported she had been trained to write the open date on OTC medications and to discard them three months after that date. The LPN observed with the cart stated she was unsure whether OTC medications expired 30 days after opening or followed the manufacturer’s expiration date, did not know where to find the facility’s OTC storage and expiration policy, and was unsure why staff were writing open dates on OTC bottles, though she acknowledged that medications should be discarded if the manufacturer’s expiration date had passed. The DON stated that nursing staff were expected to reference the manufacturer’s expiration date on OTC medications, acknowledged that nurses were trained informally by other bedside staff, and confirmed the facility did not provide specific training on medication expiration dates for either pharmacy-dispensed or OTC medications. The DON stated that expired medications should not be administered because they could make a resident very sick.
Failure to Maintain Current Hospice Care Plans and Documentation
Penalty
Summary
The facility failed to meet hospice care requirements for a resident receiving hospice services by not maintaining readily accessible, current hospice documentation and by not clearly delineating care responsibilities between the facility and the hospice provider. The hospice agreement required both parties to keep complete, detailed, and readily accessible clinical records, organized to facilitate retrieval. For a resident over age 65 with hypertensive heart disease with heart failure, palliative care, and protein-calorie malnutrition, the electronic medical record contained a hospice plan of care that was only current through a certification period ending in mid-November 2025, with no updated hospice plan of care for the subsequent certification period beginning in January 2026. The resident’s hospice care plan in the facility record, initiated in March 2024 and revised in July 2024, included an intervention to work cooperatively with the hospice team, but there was no current hospice care plan from the hospice team in the record. Surveyors’ review of the resident’s electronic and physical charts did not show clinical documentation from routine hospice visits, including no visit notes from hospice staff on specific days when facility nurses reported hospice staff had been present. An RN stated that neither the physical chart nor the EMR contained the most recent hospice care plan and acknowledged that hospice notes were not updated or in chronological order. The RN also reported there was no system for hospice staff to sign in or for the facility to ensure required weekly hospice visits were completed, and that hospice CNAs typically came on certain days to assist with bathing without a formal system for charting or reporting the care provided. An LPN confirmed seeing hospice staff on particular days and relied on their informal check-ins rather than reviewing the chart, which lacked corresponding visit notes. The DON acknowledged that communication from the hospice company was poor and affirmed that the facility was ultimately responsible for ensuring hospice services were provided appropriately, yet the records did not demonstrate that hospice services and care planning requirements were being met for this resident.
Failure to Provide Adequate Supervision Resulting in Resident Elopement
Penalty
Summary
A deficiency occurred when a resident with moderate cognitive impairment, aphasia, encephalopathy, and a history of wandering was not provided with adequate supervision during an off-site medical appointment. The resident was scheduled for transportation to a neurology clinic and required an escort due to his cognitive and behavioral status. Despite multiple progress notes documenting the resident's wandering and confusion, the facility failed to identify him as an elopement risk prior to the incident, and no care plan addressing elopement was in place at the time of the event. On the day of the incident, the resident was transported to his appointment by an outside medical transportation company and escorted into the clinic. After the appointment concluded, the resident was discharged from the clinic and left the premises unsupervised. The transportation driver, scheduled to return later, was unable to locate the resident and notified the facility. Facility staff initiated a search, and the resident was eventually found several hours later, walking miles away from the clinic. Interviews and documentation revealed that there was confusion and miscommunication among facility staff regarding who was responsible for escorting the resident, with some staff believing the resident's representative would attend, while others were aware that the representative could not be present and had requested a staff escort. The facility's elopement risk assessments did not accurately reflect the resident's cognitive impairments and history of wandering, as documented in progress notes and diagnoses. Staff interviews confirmed that the resident had exhibited wandering behaviors and required frequent redirection, yet these observations did not prompt a reassessment of elopement risk or the implementation of appropriate interventions. The lack of a clear process for ensuring supervision during off-site appointments and the failure to update the resident's care plan contributed directly to the resident's unsupervised elopement.
Failure to Provide Appropriate Communication Tool for Resident
Penalty
Summary
The facility failed to provide a resident who had difficulties with speech due to a stroke with an appropriate communication tool to ensure effective communication of her needs. The resident, who was cognitively intact and required assistance for daily activities, was observed struggling to communicate with staff using gestures. Staff members were unable to understand her needs, and there was no clear communication tool available in her room. The care plan indicated the use of alternative communication tools but did not specify what those tools were, leading to confusion among staff members. Interviews with staff revealed that some were unaware of the existence of a communication board, while others knew about it but did not use it. The communication board was not readily accessible, and there was no clear indication of its location. The speech therapist had not assessed the resident for the use of a communication board, and the social services assistant was also unaware of its existence. Despite the unit care coordinator's intention to update the care plan, it was not done before the end of the survey.
Failure to Assist Resident with Compression Stockings
Penalty
Summary
The facility failed to ensure Resident #55 received treatment and care in accordance with professional standards of practice. Specifically, the facility did not assist the resident with applying her compression stockings, which were necessary to treat her bilateral lower leg edema. Despite the resident's cognitive intactness and her ability to dress herself, she required assistance with the compression stockings, which staff failed to provide consistently. Observations and interviews revealed that the resident's feet were swollen, and she was often seen without the compression stockings, indicating a lack of adherence to the physician's orders and the facility's policy on anti-embolism stocking application. The resident reported that staff did not help her put on her compression stockings, which she could not manage on her own due to the difficulty of pulling them up. On multiple occasions, the resident was observed with swollen feet and without the compression stockings. Staff members, including a CNA and an LPN, were either unaware of the resident's need for assistance or felt uncomfortable applying the stockings due to the swelling. The unit care coordinator incorrectly believed the resident was supposed to apply the stockings herself, despite the resident's repeated requests for help. A review of the resident's medical records showed a physician's order for compression stockings, but this order was not correctly entered into the system, leading to a lack of documentation and follow-through by the staff. The DON acknowledged the error and the absence of documentation indicating the resident's refusal to wear the stockings. The care plan was not updated to reflect the physician's order, contributing to the oversight in providing the necessary care for the resident's edema.
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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