Life Care Center Of Pueblo
Inspection history, citations, penalties and survey trends for this long-term care facility in Pueblo, Colorado.
- Location
- 2118 Chatalet Ln, Pueblo, Colorado 81005
- CMS Provider Number
- 065269
- Inspections on file
- 20
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Life Care Center Of Pueblo during CMS and state inspections, most recent first.
A resident on anticoagulant therapy with a history of falls and fragile skin was pushed in a wheelchair without foot pedals by a social services staff member, during which the resident’s foot dropped and the leg struck the wheelchair. The resident reported pain, and later a large hematoma was found on the lower leg, requiring ER evaluation, imaging, splinting, and repeated pain management. Documentation showed the hematoma enlarged over time and necessitated a second ER visit. During the survey, multiple other residents were observed being transported by CNAs, the IP, and housekeeping staff in wheelchairs without proper use of foot pedals, with feet dragging on the floor or positioned unsafely, despite staff acknowledging they knew pedals were needed to prevent injury. These actions and inactions demonstrated a pattern of unsafe wheelchair transport practices that led to the cited deficiency.
Surveyors identified multiple infection control failures involving hand hygiene, handling of drinkware and silverware, and mask use during a COVID-19 outbreak. CNAs refilled water pitchers and passed meal trays between residents without performing hand hygiene, including after directly handling a resident’s straw and assisting with dressing and food setup. Staff handled utensils by the tines and cutting surfaces, and cups by the rims, and used a knife that had just cut food to stir a resident’s coffee. During the same period, staff pulled masks down while in close contact with residents, wore masks below the mouth while assisting with meals, and did not perform hand hygiene after touching the outside of their masks, contrary to facility policy and CDC-based expectations.
A facility failed to treat residents with dignity and respect, as evidenced by incidents involving a CNA refusing to assist a non-weight-bearing resident, a bath aide neglecting care requests, and an LPN dismissing a resident's chest pain. Despite complaints, the issues persisted, leaving residents feeling humiliated and degraded.
A resident with a history of constipation experienced physical abuse when an RN continued a painful digital stool removal procedure despite the resident's pleas to stop. The incident was not documented in the resident's medical record, and the facility's investigation was inadequate. The resident's distress was corroborated by interviews with the resident, her roommate, and a CNA, but the facility ultimately unsubstantiated the claim of sexual abuse.
A resident reported being forcibly administered a suppository by an RN, leading to an inadequate investigation by the facility. The resident's account was supported by her roommate, but the facility failed to interview all relevant staff and did not explore the possibility of physical abuse. The investigation was compromised by a CNA conducting interviews instead of a qualified individual, and the facility unsubstantiated the abuse claim based on emergency department findings.
A resident was discharged AMA without proper documentation or coordination, leaving the representative to manage the discharge independently. The facility failed to provide discharge instructions, medications, or notify the physician, resulting in the resident missing essential medications for nearly two weeks.
A facility failed to follow and document bowel management protocols for a resident with a history of constipation and other medical conditions. The resident did not receive necessary laxatives or enemas after four days without a bowel movement, and the nurse did not document the administration of medications or procedures performed. Interviews confirmed the lack of documentation and adherence to standing orders.
The facility failed to complete annual performance reviews and provide regular in-service education based on the outcome of these reviews for five CNAs. The DON was unaware that performance reviews needed to include a regular in-service plan.
The facility failed to develop comprehensive care plans for two residents, neglecting to include dementia care plans and update fall care plan interventions. One resident had multiple unwitnessed falls without updates to the care plan, while another resident's care plan lacked a specific focus on dementia care despite their diagnosis. Staff interviews revealed inconsistencies in understanding and implementing care plan interventions.
The facility failed to ensure that inhalers were dated when opened, as observed in two of three medication carts. Both an RN and an LPN were unaware that the inhalers lacked open dates, which is necessary to ensure medication safety. The DON confirmed the importance of dating medications to ensure resident safety.
Failure to Use Wheelchair Foot Pedals Resulting in Hematoma and Ongoing Transport Hazards
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision to prevent accidents, specifically related to wheelchair transport without foot pedals. One resident on anticoagulant therapy, with diagnoses including atrial fibrillation, history of falling, unsteadiness on feet, and fragile skin, used a wheelchair for mobility and had a care plan goal to minimize abnormal bleeding and bruising. Despite this, the resident was transported in a wheelchair without foot pedals by the social services director (SSD) when being taken to an activity in the dining room. During this transport, the resident’s foot dropped and her left leg hit the wheelchair. The SSD stopped, visually checked the leg, and did not see any marks, while the resident reported that her leg hurt but stated she still wanted to play bingo. The SSD then continued to assist the resident into the dining room and informed the nurse about the incident. Later that day, the resident complained of pain in the lower left leg and was given PRN pain medication. Subsequently, a large hematoma measuring approximately 8 inches by 4 inches was identified on the left calf, and the physician was notified, resulting in orders to hold the resident’s anticoagulant and to elevate and ice the leg. The resident was sent to the emergency room, where imaging showed soft tissue swelling without fracture, and she was treated and returned to the facility. The resident’s records documented ongoing severe pain, a progressively enlarging hematoma, and repeated assessments and treatments, including a splint and additional pain medications. The hematoma was later documented as 10 inches by 6 inches, and the resident required a second transfer to the emergency room for further evaluation. The DON acknowledged that foot pedals were likely not in use at the time of the initial incident and that no root cause analysis was conducted. In addition to this resident’s case, surveyor observations on multiple occasions showed other residents being transported by various staff (including CNAs, the infection preventionist, and housekeeping staff) in wheelchairs without proper use of foot pedals, with residents’ feet dragging on the floor or positioned unsafely between or off the pedals, demonstrating a broader pattern of unsafe wheelchair transport practices contributing to the deficiency. Staff interviews confirmed that they understood foot pedals were needed to prevent residents from bumping or dragging their feet or potentially falling, and that they had received education on this topic after a prior incident where a resident bumped a foot during wheelchair transport. Despite this knowledge, the observed practice during the survey period showed continued nonuse or improper use of wheelchair foot pedals when residents were being pushed, including residents lifting their feet to avoid dragging due to missing or flipped-up pedals. This pattern of actions and inactions—transporting a resident on anticoagulants without foot pedals leading to a significant hematoma and ongoing observations of similar unsafe transport for other residents—formed the basis of the cited deficiency for failure to maintain an environment free from accident hazards and to provide adequate supervision to prevent accidents.
Inadequate Infection Control During Meal Service and COVID-19 Outbreak
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to hand hygiene, handling of drinkware and silverware, and proper mask use during a COVID-19 outbreak. Surveyors observed that one CNA went from room to room collecting and refilling residents’ water pitchers without performing hand hygiene between rooms or after handling a resident’s straw. Another CNA assisted a resident with dressing, handled multiple residents’ meal trays, and then delivered and set up room trays for other residents without performing hand hygiene between residents or after direct contact with a resident and their food. Surveyors also observed improper handling of residents’ drinkware and silverware. One CNA pulled down the outside of his mask with his bare hand to speak with a resident, then used the same unwashed hand to hold the resident’s straw while encouraging her to drink, and continued refilling other residents’ water pitchers without hand hygiene. Another CNA unwrapped a resident’s silverware and held the fork and knife by the tines and cutting surface, grabbed the resident’s coffee mug by the rim to hand it to her, later grabbed the mug by the rim again to add sugar, and used the handle of the same knife that had been used to cut food to stir the resident’s coffee. During a period when the facility was in COVID-19 outbreak status, staff were also observed not donning face masks appropriately. One CNA repeatedly pulled his mask down by grabbing the outside of it while in close proximity to a resident’s face and did not perform hand hygiene after touching the mask, and his mask did not cover his mouth and nose while he was close to the resident. Another CNA wore a surgical mask pulled down below his mouth while assisting residents to their seats in the dining room and while sitting next to and assisting a resident with eating. These practices occurred despite facility policies and staff interviews confirming that hand hygiene should be performed before and after handling masks, that masks should cover both nose and mouth during an outbreak, and that staff should avoid touching areas of cups and utensils that contact residents’ mouths.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as evidenced by multiple incidents involving three residents. One resident, who was non-weight bearing due to a broken ankle, reported that a CNA was rude and refused to assist him with transfers to and from the toilet, leaving him feeling humiliated. The resident also experienced further disrespect when the CNA laughed at him and made derogatory comments in the dining room. Despite reporting these incidents to the nursing home administrator, the resident continued to feel bullied and disrespected by the CNA. Another resident reported that a bath aide refused to provide requested care, such as applying lotion and compression stockings after a shower, citing a lack of time. This resident also experienced delays in receiving meals and was told by staff that they did not have time to fulfill her requests for hot coffee, which made her feel unimportant and degraded. The resident expressed that complaints in the past had not led to any improvements, and she felt that staff gossiped about residents who complained. A third resident reported that an LPN did not treat her with respect and dignity, particularly when she experienced chest pain and felt that the LPN did not believe or care for her. This resident tried to avoid the LPN when she was on duty. The social service assistant acknowledged the resident's ability to communicate her needs and stated that staff were expected to treat residents with respect.
Failure to Protect Resident from Physical Abuse During Medical Procedure
Penalty
Summary
The facility failed to protect a resident from physical abuse, as evidenced by an incident involving a registered nurse (RN) and a resident with a history of constipation. The resident, who was cognitively intact and receiving renal dialysis, requested assistance for constipation and was subjected to a painful procedure by RN #1. Despite the resident's cries and requests to stop, RN #1 continued to digitally remove stool from the resident's rectum, causing mental anguish and emotional distress. The incident was not documented in the resident's electronic medical record, and the facility's investigation into the matter was inadequate. Interviews with the resident, her roommate, and a certified nurse aide (CNA) corroborated the resident's account of the event, indicating that RN #1 did not heed the resident's pleas to stop the procedure. The facility's director of nursing (DON) acknowledged that RN #1 should have stopped the procedure when the resident requested it and should have documented the event in the medical record. The resident's representative reported the incident to the dialysis center social worker, who then notified adult protective services. The facility's nursing home administrator (NHA) was informed of the allegation and initiated an investigation, but the facility ultimately unsubstantiated the claim of sexual abuse. The emergency department visit following the incident noted mild redness in the resident's rectum but no overt trauma. The lack of proper documentation and response to the resident's distress highlights a significant deficiency in the facility's handling of the situation.
Inadequate Investigation of Alleged Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of abuse involving a resident who reported being held down and forcibly administered a suppository by a registered nurse (RN). The resident, who was cognitively intact and had a history of constipation, reported the incident to her representative, stating that she was crying out for the nurse to stop but was ignored. The resident's roommate corroborated the account, stating that the resident had repeatedly yelled for the RN to stop and appeared to be in distress. The facility's investigation into the incident was inadequate, as it did not include interviews with all staff members present during the incident. Only one additional staff member working at the time was interviewed, and the investigation failed to explore the possibility of physical abuse despite the resident's claims of being hurt and asking the nurse to stop. The facility also did not ask other residents if they had experienced care that felt forceful, focusing instead on questions about sexual inappropriateness and safety. The investigation was further compromised by the involvement of a certified nurse aide (CNA) in conducting interviews, rather than a qualified social worker or management team member. The director of nursing (DON) recused herself from the investigation due to a conflict of interest, as the RN involved was her sister, but did not ensure that a qualified individual conducted the necessary interviews. The facility ultimately unsubstantiated the sexual abuse allegation based on the emergency department's findings, which noted no trauma, but failed to address the potential for physical abuse.
Failure to Implement Effective Discharge Plan
Penalty
Summary
The facility failed to develop and implement an effective discharge plan for a resident who was discharged against medical advice (AMA). The resident, who was cognitively intact and required a Hoyer lift for transfers due to a recent left leg below the knee amputation, was discharged without proper documentation or coordination with the interdisciplinary team (IDT). The facility's policy required documentation of decision-making capacity, risks, and discharge instructions, but these were not provided. The resident's electronic medical record (EMR) lacked documentation of discharge goals, reasons for the AMA discharge, and notification of the resident's physician or medical director. The resident's representative, who was a certified nurse aide and emergency medical technician, reported that the facility did not assist in the discharge planning process. The representative stated that the facility forced her to sign AMA paperwork and did not provide discharge instructions, medications, or a list of current medications. As a result, the resident went nearly two weeks without essential medications. The facility also failed to notify adult protective services (APS) about the AMA discharge, which was standard practice. Interviews with facility staff revealed that the director of nursing (DON) and the social services director (SSD) acknowledged the lack of proper discharge documentation and coordination. The SSD, who was newly employed, noted that the social worker should have led the discharge planning process and offered necessary services and referrals. The medical director confirmed that a physician's discharge order should have been obtained, and the attending physician should have been involved in the AMA discharge process. The dialysis center social worker also indicated that the facility did not provide a safe discharge, leaving the resident's representative to manage the discharge independently.
Failure to Document and Follow Bowel Management Protocols
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 reviewed for quality of care. Specifically, the facility did not follow the physician's standing orders for bowel management for the resident, who had a history of constipation and other medical conditions such as gastro-esophageal reflux disease, diabetes mellitus type 2, and end-stage renal disease. The resident's representative expressed concern about the resident's bowel regimen due to a family history of bowel obstruction. The facility did not document the administration of bowel medications, nursing medication reassessment, abdominal and peri-rectal assessments, or the digital fecal disimpaction procedure for the resident. The medication administration record showed that the resident did not receive any as-needed laxatives, softeners, or enemas after going four days without a bowel movement. The electronic medical record lacked documentation of the registered nurse's assessment of the resident's bowel status or the procedures performed. Interviews with staff revealed that the registered nurse did not document the administration of milk of magnesia, Miralax, or a suppository, despite performing these actions. The nurse also failed to document the abdominal and rectal assessments, digital stool removal, and fecal disimpaction. The director of nursing confirmed that all medications and treatments should be documented in the medical administration record when given.
Failure to Complete Annual Performance Reviews and Provide In-Service Education
Penalty
Summary
The facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for five of five staff reviewed. Specifically, CNA #1, CNA #2, CNA #3, CNA #4, and CNA #5 did not have an annual performance review completed, nor did they have an in-service education plan based on the outcome of the review. During an interview, the DON stated she was not aware that performance reviews needed to include a regular in-service plan based on the outcome of these reviews.
Failure to Develop Comprehensive Care Plans for Residents with Dementia
Penalty
Summary
The facility failed to develop a comprehensive care plan for two residents, specifically neglecting to include dementia care plans and update fall care plan interventions. Resident #63, who was moderately cognitively impaired and at risk for falls, had multiple unwitnessed falls in 2024. Despite these incidents, the care plan was not updated with new interventions, and the existing interventions were not effectively communicated to the staff. Interviews with staff revealed inconsistencies in the understanding and implementation of the care plan interventions for Resident #63. Resident #6, diagnosed with dementia and neurocognitive disorder with Lewy bodies, had a care plan that included interventions for psychotropic medication but lacked a specific focus on dementia care. The care plan did not address the resident's cognitive decline or behaviors related to dementia. Staff interviews confirmed the absence of a dementia-specific focus in the care plan, despite the resident's diagnosis and needs. The facility's policies on incident management and dementia care were not followed, as evidenced by the lack of updates to the care plans and the failure to develop person-centered interventions. The Director of Nursing and other staff acknowledged the deficiencies in the care plans, indicating a systemic issue in the facility's approach to care planning and communication among staff.
Failure to Date Opened Inhalers
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled and stored in accordance with accepted professional standards for two of three medication carts. Specifically, the facility did not date inhalers when they were opened, which is necessary to ensure the safety and efficacy of the medication. During an observation of the H hall medication cart with a registered nurse (RN), a Trelegy inhaler was found without an open date. The RN admitted to not knowing the inhaler was expired and acknowledged that it should have been dated to ensure safety. Similarly, an observation of the G hall medication cart with a licensed practical nurse (LPN) revealed an open Incruse inhaler and Wixela inhaler, both of which were not dated when opened. The LPN also admitted to being unaware that the inhalers lacked an open date and emphasized the importance of dating them to ensure safe administration to residents. The director of nursing (DON) confirmed in an interview that it is crucial for all medications to be dated when opened and discarded when expired to ensure resident safety. The failure to date the inhalers when opened was a clear deviation from the manufacturer's guidelines, which specify the time frame within which the inhalers should be discarded after opening. This oversight in labeling and storage practices led to the deficiency identified by the surveyors.
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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