Life Care Center Of Longmont
Inspection history, citations, penalties and survey trends for this long-term care facility in Longmont, Colorado.
- Location
- 2451 Pratt St, Longmont, Colorado 80501
- CMS Provider Number
- 065282
- Inspections on file
- 20
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 16
Citation history
Health deficiencies cited at Life Care Center Of Longmont during CMS and state inspections, most recent first.
A resident with Alzheimer’s disease, dementia with behavioral disturbance, and severe cognitive impairment was physically restrained during incontinence care when a CNA placed a hand over the resident’s mouth and held the resident’s arms while the resident was yelling and striking out. Staff statements described the resident as combative during care, and the resident’s representative said the event would have been frightening. The care plan addressed confusion, anxiety, and yelling, but did not include interventions for physically aggressive behavior during care.
Insufficient nursing staffing resulted in delayed call light response and missed showers. Residents reported waiting over an hour for help with toileting, transfers, and other needs, and several said showers were not provided as scheduled or were cancelled when staff ran out of time. Observations showed a resident’s call light left unanswered for 25 minutes and another resident waiting for assistance to get out of bed because a nurse could not be obtained. Staff acknowledged that call-offs and high care needs made it difficult to meet residents’ needs on all shifts.
A facility failed to ensure meals were consistently palatable and served at an appetizing temperature. Residents reported cold, bland, hard, or missing food items, including eggs, pancakes, hamburgers, cereal milk, and coffee creamer, and said the menu was repetitive and trays were sometimes forgotten. Surveyors also found a test tray with bland, pasty, and doughy items, and record review showed trays sitting for an extended period with food temperatures dropping before delivery.
Medication carts and storage rooms contained multiple labeling and storage errors, including an opened nitroglycerin bottle without a resident name, an undated Wixela inhaler, undated insulin glargine pens, and tuberculin vials without open dates. Staff also found expired or improperly stored items, including docusate past its expiration date, lidocaine patches for a discharged resident, and other items left in carts despite being personal items or having storage instructions that were not followed.
Failure to Protect Residents from Abuse: A resident with dementia and aggressive behaviors physically abused another resident after entering her room and striking her chest when she tried to help him. In separate incidents, the same resident sexually abused two cognitively impaired residents by placing his hand inside one resident’s pants while she slept and touching another resident’s breast over her clothing in a common area. The report documents prior inappropriate sexual and grabbing behaviors by the assailant and resident-to-resident incidents that occurred despite those known behaviors.
Failure to Report Alleged Physical Abuse: A cognitively intact resident with multiple medical diagnoses reported that another resident entered her room and hit her in the chest after she tried to help him. Staff documented the incident, noted soreness, and placed the other resident on 1:1 supervision, but the facility’s IDT decided it was not reportable because they did not believe there was allegation or intent. The NHA later stated the incident should have been reported to the State Survey Agency.
A facility failed to ensure two residents received scheduled showers needed for ADL support and personal hygiene. One resident with an ankle fracture and another resident with a humerus fracture, heart disease, UTI, and DM both had documented bathing preferences and required assistance, but shower records showed missed or delayed showers with no documented refusals or explanation. Staff and the DON acknowledged the residents should have received regular showers, yet the records did not show that the scheduled bathing occurred as planned.
Failure to Enter and Follow Post-Orthopedic Dressing Orders: A resident with a right ankle fracture returned from an orthopedic visit with instructions for dressing changes, but the orders were not entered into the EMR and the dressing was not changed as directed. The resident reported the dressing remained unchanged until she alerted staff, and the wound care order was not initiated until later during the survey.
A resident with Parkinson’s disease, chronic respiratory failure, MI, AFib, and anticoagulant use was transferred with confusion between a Sara Steady and a Hoyer lift, despite staff records not matching her transfer needs. She reported that a CNA used the sit-to-stand incorrectly, causing pain and bruising across her back and side, and nursing later changed her to a Hoyer lift. The record also showed therapy was not timely notified to review the transfer concern after the bruising occurred.
Delayed Pain Medication Administration: A resident with severe post-surgical knee pain and orders for PRN hydromorphone had repeated pain ratings up to 10/10, but the first dose was not given until many hours after the pain began escalating. The record also lacked timely documentation for Tylenol, and the DON stated the ordered opioid was available and should have been administered when requested.
The facility failed to complete annual performance reviews for three of five CNAs and did not identify their training needs. Record review showed the CNAs’ last evaluations were overdue, and the DON said the SDC tracked employee evaluations while the NHA said all-staff training was done during the annual skills fair.
Medication administration errors exceeded the allowed rate, with surveyors finding a 10.34% error rate. An RN left a resident’s oxycodone at the bedside and did not directly observe the resident take it, and an LPN incorrectly selected propranolol instead of Seroquel, documented Seroquel as given, and later administered only 25 mg of Seroquel instead of the ordered 37.5 mg dose.
An LPN prepared propranolol 20 mg instead of the ordered Seroquel for a resident with dementia and severe cognitive impairment, then documented Seroquel as given on the MAR. The error was identified before the medication was administered, and the DON stated the resident could have had an adverse reaction if propranolol had been given instead of the prescribed medication.
A resident with severe cognitive impairment, Alzheimer's disease, and dementia with psychotic disturbance was admitted to hospice, but the care plan did not include a hospice plan with a delineation of care. Staff gave conflicting accounts about who was responsible for creating the hospice care plan, and the DON acknowledged the resident did not have one.
Survey Results Binder Missing Required Findings: The facility failed to make the most recent survey findings and the last three years of complaint findings fully available for review in the lobby binder. The binder contained older survey findings, but it did not include the most recent recertification survey or the required complaint findings. The NHA stated the most recent survey and complaint findings should have been in the binder and believed they were already there.
A resident with a history of falls and multiple medical conditions experienced a fall during the night, but the facility failed to promptly notify the resident's power of attorney as required by policy. The representative was only informed after the resident became unresponsive and was transferred to the hospital, where a large subdural hematoma was discovered. Staff interviews confirmed the expectation for immediate notification, but documentation and actions showed a delay.
A resident's dignity was compromised when staff failed to timely empty urine from her external catheter canister, leading her to sometimes empty it herself due to embarrassment. Despite facility policy requiring catheter care during the night shift, staff interviews revealed inconsistencies in following this procedure. The resident's representative had filed a grievance requesting the canister be emptied every morning, underscoring the facility's failure to maintain the resident's dignity.
A resident reported excessive wait times for call light responses, ranging from 30 to 50 minutes, with a specific instance of a 48-minute wait. Despite complaints, the facility did not provide a resident handbook or explain the grievance process, and the DON's limited investigation found no issues. The facility failed to assess the root causes of the delays or interview residents, leading to unresolved grievances.
A resident did not receive timely medical appointments with specialists as ordered by the physician, including a dermatologist, urologist, and infectious disease specialist. Despite orders being documented, the facility failed to arrange these appointments, leading the resident's family to intervene. The DON acknowledged the oversight and was working on scheduling the appointments.
Physical restraint used during resident care
Penalty
Summary
The facility failed to ensure a resident was free from physical restraint when a CNA placed one hand over the resident’s mouth and the other hand over the resident’s arms during incontinence care. The resident had diagnoses of Alzheimer’s disease and dementia with behavioral disturbance, a history of behavioral symptoms, and severe cognitive impairment with a BIMS score of 4 out of 15. The resident also required substantial to maximal assistance with toileting hygiene and bathing. According to the facility investigation and staff statements, the resident was yelling and striking out during care when the CNA entered the room to assist another CNA. One CNA reported that the second CNA placed a hand over the resident’s mouth for about two minutes while the resident tried to move and strike out, then grabbed the resident’s hands, held them against the resident’s chest, and pushed the resident back onto the bed. Another CNA reported that the resident was combative and that the CNA held the resident’s hands so the resident would not hit her. The resident’s representative stated the resident would have been fearful if she could recall the incident and that covering her mouth would have been frightening. The resident’s care plan identified confusion, anxiety related to dementia, yelling, and hunger-related behaviors, but it did not include interventions for physically aggressive behavior during care. The resident’s record also documented ongoing behaviors such as yelling, rejection of care, and anxiety. The facility investigation concluded it could not substantiate or unsubstantiated abuse, but the record and interviews documented that the resident was physically restrained during care.
Insufficient Nursing Staff Led to Delayed Call Light Response and Missed Showers
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet residents’ needs for timely assistance with showers and call lights. The staffing policy stated the facility maintains adequate staff on each shift to meet residents’ needs and uses the facility assessment to determine staffing levels. The facility assessment listed an average daily census of 116 residents, a bed capacity of 187 residents, and desired daily staffing of 15 nurses and 28 CNAs, but the schedule review showed multiple dates when staffing fell below those levels for nurses and CNAs. Residents described repeated delays in care and services. One resident said staffing, especially on nights, was an issue and reported waiting over an hour for a call light to be answered and sometimes receiving no shower for a week or more. Other residents reported waiting over an hour to use the restroom, missing timely assistance with transfers, and being unable to get to bed until late because staff were occupied with other residents. Several residents stated that showers were not provided as scheduled, that they sometimes had to initiate the shower themselves, and that call light response times often depended on staffing levels. Observations confirmed delayed response to call lights. During one continuous observation, a resident’s call light was not answered for 25 minutes while staff walked past the room or did not stop to check on the resident. During another observation, a resident who needed help getting out of bed waited while a CNA said she was waiting on a nurse to assist; after repeated returns to the room, the CNA ultimately told the resident she would have to complete care in bed because another staff member could not be obtained. Grievances from the prior months also documented call light delays of up to several hours and showers being cancelled or not completed because of staffing concerns. Staff interviews acknowledged that the facility often needed more help on all shifts, that call-offs affected coverage, and that some showers could not be completed because there was not enough staff.
Food Served Cold, Bland, and Inconsistently Prepared
Penalty
Summary
The facility failed to ensure residents consistently received food that was palatable in taste, texture, and temperature. The facility policy stated that food should be prepared by methods that conserve nutritive value, flavor, and appearance, and that food and drink should be palatable, attractive, and served at a safe and appetizing temperature. During a group interview, residents reported that the kitchen frequently ran out of items such as ice cream and Greek yogurt, that substitute items were usually offered, and that the quality of food was inconsistent. They also said over-easy eggs were often overcooked, scorched, and hard, and that only one frying pan was available for preparing fried eggs in the upstairs dining room. Multiple residents described meals that were cold, dry, hard, missing items, or otherwise unappetizing. One resident said scrambled eggs were cold and breakfast was not served in a timely manner despite a sign requesting not to be awakened before 7:30 a.m. Another resident said food was sometimes served cold, while another reported pancakes were hard and dry, hamburgers were cold, and milk was often missing with cereal. Additional residents reported repetitive menus, cold food, forgotten trays, incorrect meal items, and lunches that did not arrive. One resident said she received coffee without creamer, oatmeal was not provided, and cereal was served without milk because staff said there was no milk that day. Surveyors also observed a regular diet test tray after lunch service and found the spinach lacked flavor, the mashed potatoes had a pasty consistency and bland taste, the meatloaf was bland, and the cornbread was doughy and bland. Record review showed a prior concern about cold food, including a dietary audit documenting trays sitting for 30 minutes before the last tray was delivered and stew temperature dropping from 175 degrees F to 130 degrees F. Staff interviews indicated food temperatures were monitored and meals could be remade if residents complained, but residents continued to report cold and unappetizing food, and one resident described a pot pie that did not resemble a pot pie and appeared as broken pieces of chicken and vegetables.
Medication Labeling and Storage Deficiencies
Penalty
Summary
Medications and biologicals were not consistently labeled or stored according to accepted professional principles in three medication carts and two medication storage rooms. During observation of the second floor west medication cart, an opened bottle of sublingual nitroglycerine had no resident name on it, a used Wixela inhaler for a resident was not labeled with the date it was opened, and an opened bottle of docusate sodium remained in use past its expiration date. In the second floor west medication storage room, an opened bottle of tuberculin purified protein was also found without an open date. Additional medication storage problems were observed in other areas. In the third floor east medication cart, a box of 5% lidocaine patches remained with medications for a resident who had already been discharged. In the first floor east medication cart, three opened insulin glargine pens for three residents were undated, a half-used bottle of normal saline was labeled only with an open date, an opened water bottle had a staff member's name written on it, and an opened bottle of chocolate syrup was partially full and stored in the cart despite instructions to refrigerate after opening. In the first floor medication storage room, an unopened RSV test remained with an expired physician order, and an opened tuberculin purified protein vial was present with an expiration date. During interviews, nursing staff acknowledged several of these issues. An RN stated the nitroglycerine bottle should have been labeled with the resident's name, thought the inhaler could be used until empty, and did not know how long the tuberculin vial was good after opening. An LPN stated the discharged resident's lidocaine patches should have been removed from the cart after discharge and said insulin pens must be used within 30 days of opening. The DON later stated that nitroglycerin vials were for individual resident use and should be labeled with the resident's name, that insulin pens, Wixela inhalers, and tuberculin vials should be labeled with the open date and discarded according to manufacturer instructions, and that medications for a discharged resident should be removed from the cart within 24 hours.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect residents from abuse in multiple incidents involving resident-to-resident contact. The report states that three residents were affected: one resident was physically abused by another resident, and two residents were sexually abused by the same resident. The facility’s own investigation and record review documented that these events occurred and that the residents involved had significant cognitive or behavioral impairments. Resident #31, who was cognitively intact with a BIMS score of 14 out of 15, was involved in an incident with Resident #39, who had dementia, severe impairment in daily decision-making, and a history of physical and verbal behaviors toward others. Staff reported that Resident #39 was in Resident #31’s room or doorway, grabbed her leg, and asked for help. Resident #31 stated that when she bent down to help him, he hit her chest, causing pain. The investigation documented that Resident #39 was removed from the area and later placed on one-to-one supervision. Resident #31’s care plan was not updated after the incident to reflect her tendency to help others even when they might not want help. Resident #71, who had severe cognitive impairment with a BIMS score of 2 out of 15 and required partial to moderate assistance with all ADLs, was sexually abused by Resident #149. Staff observed Resident #149 sitting next to Resident #71 while she was asleep on a couch in the common area and placing his hand down inside her pants. Resident #71 slept through the occurrence and later did not remember the incident because of cognitive impairment. The investigation documented that Resident #149 had a history of grabbing others, public indecency, inappropriate sexual comments to women, and repeated entry into female residents’ rooms before the incident occurred. Resident #96, who had dementia, encephalopathy, morbid obesity, acute respiratory failure, and a BIMS score of 4 out of 15, was also sexually abused by Resident #149. Staff witnessed Resident #149 reach down and touch Resident #96’s breast over her clothing while she was sitting in a wheelchair near the nurses’ station. The report documents that Resident #149 had a known pattern of hypersexual and inappropriate behavior toward women, including prior sexual comments and masturbation in common areas. The facility investigation substantiated the abuse involving Resident #96 and documented that the resident was cognitively impaired and did not recall the incident.
Failure to Report Alleged Physical Abuse
Penalty
Summary
The facility failed to report an alleged physical abuse incident involving a resident to the State Survey and Certification Agency in accordance with state law. The resident involved was cognitively intact, with diagnoses including multiple subsegmental thrombotic pulmonary emboli without acute cor pulmonale, malnutrition, hyperlipidemia, and hyperthyroidism. The resident stated that a male resident entered her room, she tried to help him, and he hit her in the chest, causing pain. Record review showed that staff were notified after a CNA found the male resident inside the resident’s room and the resident reported that he had hit her chest. Another CNA reported seeing the male resident in front of the room, grabbing the resident’s leg while asking for help finding his buddy, and staff removed him from the room. A skin and pain assessment were completed, the resident said the area where she had been hit was sore, and one-to-one supervision was provided for the male resident. The facility’s investigation documented that the interdisciplinary team did not feel the incident was reportable because they did not feel there was an allegation or intent. During interviews, staff gave differing descriptions of the event, including that the resident reported being punched in the chest and was holding her chest when she described the incident. The social services assistant, unit manager, DON, and NHA all discussed the event and the facility’s response. The NHA stated the facility was uncertain about reporting because of the resident’s interview, but later acknowledged that the male resident had willfully hit the resident and that the incident should have been reported to the State Survey Agency.
Missed Scheduled Showers for Two Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to complete activities of daily living received the necessary assistance to maintain personal hygiene, specifically by not providing scheduled showers for two residents. The facility policy stated residents would receive assistance as needed with ADLs and that residents unable to carry out ADLs would receive services to maintain good grooming and personal hygiene. Surveyors reviewed bathing records, care plans, progress notes, and interviewed the residents and staff. One resident, admitted with a right ankle fracture, muscle weakness, and a history of falls, was cognitively intact and required partial to moderate assistance with bathing and showering. She reported that the shower schedule was inconsistent, that she had to seek staff out to request showers, and that she did not receive showers on scheduled days. Records showed a preference for Wednesday and Saturday evening showers, but documentation did not show showers on two scheduled March dates, and there was no documentation explaining why the showers were missed or showing refusals. Staff interviews indicated showers were expected to be completed for dependent residents and that missed showers should be documented and communicated, but no such documentation was found for this resident. A second resident, admitted with a left humerus fracture, heart disease, UTI, and diabetes, had moderate cognitive impairment and required substantial assistance with hygiene and bathing. During interview, the resident’s hair was disheveled and she stated she had not been getting showers as scheduled and had not had one in at least a week. Her care plan and bathing preference indicated twice-weekly showers, but the shower record showed a nine-day gap between documented showers, with no documentation of refusals. The DON stated the resident should have received two showers per week and could not explain the gap or the discrepancy in the shower record.
Failure to Enter and Follow Post-Orthopedic Dressing Orders
Penalty
Summary
The facility failed to ensure Resident #46 received treatment and care in accordance with physician orders after an orthopedic follow-up appointment. Resident #46 was admitted with a displaced trimalleolar fracture of the right lower leg, muscle weakness, and a history of falling. The resident was cognitively intact and required assistance with several activities of daily living. After the orthopedic visit, the cast and sutures were removed, and the orthopedic note stated the resident could shower over the incision but not submerge it under water, with dressing changes to be completed daily or every other day. The resident reported that the dressing on the right ankle was not changed until the morning of 3/9/26 after she brought it to staff attention. Review of the medical record showed no physician orders for the dressing changes were entered after the 3/4/26 orthopedic appointment, and there was no documentation that the ankle dressing had been changed as ordered. A wound care order for cleansing and application of a dry dressing with ACE wrap every other day was not initiated until 3/11/26 at 2:25 p.m., during the survey.
Inaccurate transfer status and delayed therapy review after bruising during transfer
Penalty
Summary
The facility failed to ensure Resident #33 received adequate supervision during transfers and failed to keep her transfer status accurate and current in staff-directed records. Resident #33 was over age 65, admitted with Parkinson’s disease, chronic respiratory failure, myocardial infarction, and atrial fibrillation, and her MDS showed she was cognitively intact, required substantial to maximal assistance with ADLs, was dependent on staff for transfers, and was taking an anticoagulant. Her care plan, revised on 1/13/26, directed maximum assistance of two people using a Sara Steady, while the Kardex dated 3/10/26 identified her as a two-person maximum assist with a Hoyer lift. Staff interviews showed confusion about whether she required a Sara Steady or a Hoyer lift, and CNA #6 stated the Kardex should reflect the resident’s transfer needs. Resident #33 reported that staff used a sit-to-stand lift incorrectly during a transfer and that the sling/belt was not placed correctly. She stated the transfer caused pain, and she yelled for the CNA to stop, but the CNA continued lifting her from the wheelchair. The resident later had a large bruise on her back and bruising on her side and breast area. Nursing documentation noted bruising across her back and left side, and one nurse changed her transfers from a Sara Steady to a Hoyer lift with instructions to pad under her shirt with pillows during Hoyer transfers. Staff interviews also reflected that the resident had bruising related to a sling and that the incident may have involved improper lift use. The record also showed that therapy was not timely involved after the bruising and transfer concern. Social services documented that the SSD would review transfer concerns with the therapy team, but the EMR did not show documentation that therapy was notified to review the resident’s transfer concerns. The director of rehabilitation stated the resident had not been on the therapy caseload since 2/4/26, before the bruising occurred, and that staff had concerns about the resident’s transfer status. Interviews with nursing and therapy staff showed differing views about whether therapy had assessed the resident for the appropriate lift and whether the resident should have been using a sit-to-stand or a Hoyer lift.
Delayed Pain Medication Administration
Penalty
Summary
Provide safe, appropriate pain management for a resident who required such services. Resident #147 was admitted after explantation of a knee joint prosthesis and infection/inflammatory reaction involving the left knee prosthesis, with diagnoses including seizure disorder and neuropathy. The resident had severe left knee pain documented on the MDS note, and the pain care plan initiated on 3/5/26 identified that the resident expressed pain and included evaluation of pain interventions and administration of pain medication as ordered. The March 2026 physician orders included numeric pain assessments every four hours for three days and hydromorphone HCL 2 mg by mouth every four hours as needed for pain. The resident stated that after arriving at the facility, pain increased to 8/10 at 10:00 p.m. and later to 10/10 at 5:00 a.m., but the first dose of hydromorphone was not administered until 11:30 a.m. the next day. The record showed hydromorphone was not given until 19.5 hours after the resident began rating pain at a 7 level, and Tylenol was not documented until later, with no physician orders for Tylenol documented until 3/10/26. The DON stated the resident should have had pain medication available on admission, that the automated medication dispensing system contained the ordered hydromorphone, and that the nurse should have administered it when requested.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete annual performance reviews for three of five CNAs, specifically CNA #2, CNA #15, and CNA #16, and therefore did not determine potential training needs for those staff members. The facility’s Performance Evaluation policy stated that annual performance reviews are given to all associates, and that ongoing performance feedback is encouraged throughout employment. Record review showed CNA #2’s last employee evaluation was on 7/14/23, CNA #15’s last employee evaluation was on 6/5/24, and CNA #16’s last employee evaluation was on 7/14/23. During interviews, the DON stated that the staffing development coordinator tracked employee evaluations, and the NHA stated that all-staff training was done during the annual skills fair; the NHA also stated the SDC could not be interviewed because the SDC was in the hospital.
Medication Administration Errors Exceeded Allowed Rate
Penalty
Summary
The facility failed to ensure the medication error rate remained below 5%, with surveyors identifying a 10.34% error rate based on 3 errors out of 29 opportunities for error. During observation of medication administration, an RN prepared oxycodone for a resident with an order for 5 mg every 3 hours for pain, placed the tablet in a cup on the bedside table, left the room, and later asked the resident if she had taken the medication rather than directly observing ingestion. The resident did not have an order or assessment allowing unsupervised self-administration. Surveyors also observed an LPN preparing medications for another resident with an order for Seroquel 37.5 mg twice daily for dementia with behaviors. The LPN incorrectly identified propranolol as Seroquel, placed the propranolol into the medication cup, and documented the Seroquel as given on the MAR. In a separate observation, the same LPN correctly identified Seroquel but administered only 25 mg instead of the ordered 37.5 mg dose. Interviews confirmed the incorrect medication selection, the incorrect dose, and that the resident could have received an additional dose later because the Seroquel had been charted as administered.
Wrong Medication Prepared and Documented for a Resident
Penalty
Summary
The facility failed to ensure Resident #34 was free from a significant medication error when the wrong medication was prepared for administration. Resident #34 had diagnoses including Alzheimer's disease, dementia, major depressive disorder, and anxiety disorder, and the resident's MDS showed severe cognitive impairment with a BIMS score of 4 out of 15. The physician's orders included Seroquel 37.5 mg twice daily for dementia with behaviors and propranolol HCL 20 mg, one tablet by mouth twice daily, with instructions to hold for heart rate less than 55 beats per minute. During medication preparation, an LPN removed a medication from the cart labeled propranolol 20 mg, stated it was Seroquel, placed the propranolol tablet into the medication cup, and documented Seroquel as given on the MAR. The medication cup containing propranolol was taken to the resident, but the dose was not administered because the error was identified before administration. The LPN stated the resident was not due for propranolol until later that evening and acknowledged that documenting Seroquel as given would have meant the resident could have received propranolol twice within a few hours. The DON stated the resident could have had an adverse reaction from receiving propranolol instead of the prescribed medication.
Missing hospice care plan for a resident admitted to hospice
Penalty
Summary
The facility failed to ensure hospice services met professional standards and principles for one resident who was receiving hospice care. Resident #62, who had diagnoses including senile degeneration of the brain, Alzheimer's disease, and dementia with psychotic disturbance, had severe cognitive impairment with a BIMS score of 3 and needed supervision or touching assistance with most activities of daily living. The resident was admitted to hospice with a diagnosis of senile degeneration of the brain, and the MDS indicated she was receiving hospice care. Record review showed the resident's comprehensive care plan, reviewed after hospice admission, did not include a hospice care plan with a delineation of care. Staff interviews reflected confusion about who was responsible for creating the hospice care plan: one LPN said there was no hospice communication book and everything was uploaded into the EMR, the SSA said he was not responsible for creating the hospice care plan and thought nursing or the unit manager was responsible, and another LPN said she did not initiate hospice care plans and that the MDS nurse did. The DON stated hospice care plans should be initiated at the time of hospice admission and should include a delineation of care, and acknowledged that Resident #62 did not have a hospice care plan.
Survey Results Binder Missing Required Findings
Penalty
Summary
The facility failed to ensure residents, family members, and legal representatives had full access to review the results of the most recent survey findings, including survey results, certifications, complaint investigations, and plans of correction in effect for the past three years. On observation, the survey results binder in the front lobby contained findings from surveys dated 9/28/22, 11/12/20, and 9/26/19, but it did not include the facility’s most recent recertification survey from 1/23/24 or the last three years of complaint findings. During interview, the NHA stated that the most recent survey and the last three years of complaint findings should have been in the binder and said she had thought they were already there.
Failure to Notify Resident's Representative After Significant Change in Condition
Penalty
Summary
The facility failed to notify a resident's designated representative of a significant change in the resident's condition, specifically following a fall. According to the facility's policy, staff are required to immediately inform the resident, consult with the resident's physician, and notify the resident's representative when there is an accident or significant change in status. In this case, the resident, who had a history of falls and multiple medical conditions including stroke, acute respiratory failure, and osteoarthritis, experienced a fall during the night. The nurse's progress note documented the fall, the resident's condition, and that the physician was notified, but there was no documentation that the resident's representative was informed at that time. The resident's representative later reported not being notified of the fall until the resident was transferred to the hospital after becoming unresponsive, approximately eight hours after the incident. The representative expressed frustration and distress over not being informed promptly, especially as she was the resident's power of attorney and had previously communicated her expectation to be notified at any time, including during the night. Hospital records indicated the resident had a large subdural hematoma and was placed on hospice care, passing away four days later. Interviews with staff, including LPNs, RNs, and the DON, confirmed that the facility's protocol was to notify the resident's representative immediately after a fall, regardless of the time, unless otherwise care planned. However, in this instance, the notification was delayed until after the resident's condition had significantly deteriorated and he was transferred to the hospital. The DON acknowledged the delay and lack of awareness regarding the representative's wishes for immediate notification.
Failure to Maintain Resident Dignity in Catheter Care
Penalty
Summary
The facility failed to maintain the dignity of a resident by not emptying urine from her external catheter canister in a timely manner. The resident, who was cognitively intact and required assistance with transfers and bed mobility, reported that staff did not consistently empty the urine canister in the morning, leading her to sometimes empty it herself due to embarrassment. Observations confirmed that the canister was partially filled and visible in the resident's room, and the resident's representative corroborated that the canister often contained urine during visits. The facility's policy required catheter care during the night shift and specified that the canister should be emptied when it was three-quarters full. However, interviews with staff revealed inconsistencies in following this policy. A registered nurse claimed that the canister was emptied every morning, while the director of nursing was unsure of the frequency and acknowledged that the canister should be emptied before reaching a certain capacity. A grievance had been filed by the resident's representative, requesting that the canister be emptied and rinsed every morning, highlighting the facility's failure to adhere to its own procedures and maintain the resident's dignity.
Failure to Address Long Call Light Wait Times
Penalty
Summary
The facility failed to promptly address grievances related to resident care, specifically concerning long call light wait times. Resident #1, who was cognitively intact and required significant assistance due to conditions such as cellulitis and post-polio syndrome, reported waiting 30 to 50 minutes for call light responses. The resident's representative also noted a 48-minute wait for assistance during a visit. Despite these complaints, the facility did not provide a resident handbook or explain the grievance process to Resident #1, hindering their ability to formally address these issues. The facility's response to the grievances was inadequate, as evidenced by the director of nursing's (DON) interview. The DON acknowledged reviewing complaints from a resident council meeting but found no concerns after speaking with staff and conducting limited observations. The facility did not conduct a comprehensive assessment to identify the root causes of the long wait times, nor did they interview residents to gauge the extent of the issue. This lack of a systematic approach to addressing grievances contributed to the ongoing problem of delayed call light responses.
Failure to Arrange Timely Medical Appointments
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for a resident. The resident, who was cognitively intact and required assistance with transfers and bed mobility, had been waiting for medical appointments with a dermatologist and a urologist as ordered by the physician. Additionally, there was a delay in arranging an appointment with an infectious disease specialist for the resident's chronic cellulitis. Despite the physician's orders for these referrals being documented in May 2024, there was no evidence in the electronic medical record that the appointments had been made. Interviews with the resident and their representatives revealed that the family had to intervene by contacting the primary physician to request a referral for the infectious disease specialist, as the facility had not taken action. The Director of Nursing (DON) stated that the unit managers were responsible for processing referrals and scheduling appointments, but the unit manager was unaware of the referrals for this resident. The DON acknowledged that the appointments should have been made by this time and was working on scheduling them on the day of the interview.
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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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