Mcintosh Care And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Longmont, Colorado.
- Location
- 1800 Stroh Pl, Longmont, Colorado 80501
- CMS Provider Number
- 065226
- Inspections on file
- 22
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 10
Citation history
Health deficiencies cited at Mcintosh Care And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with stroke history, AFib, and Eliquis use was transported in a van for a swallow study when her wheelchair was not fully secured. During the trip, the wheelchair shifted and her head struck the van interior, resulting in an ED transfer and a CT-confirmed subdural hematoma with ICU monitoring.
Failure to Honor Resident Shower Preferences: Multiple residents with documented bathing preferences did not receive showers consistently according to their care plans and POC records. One resident with dementia repeatedly refused showers, while other residents with MS, morbid obesity, and vascular dementia reported or were documented as missing showers and bed baths despite stated preferences. Records showed missed bathing opportunities, inconsistent documentation of refusals, and no clear evidence that alternate times or bed baths were consistently offered when showers were not completed.
A facility failed to maintain a clean, comfortable, and homelike environment when multiple resident rooms lacked clean hand towels and washcloths on repeated observations. Residents reported having to ask for linens, often not receiving them, and sometimes using paper towels or dirty towels instead. Staff said clean towels and washcloths should be provided daily, but the linen closet was observed with limited supply and rooms remained without linens.
Loose medications were found at the bottom of a medication cart drawer, including fluoxetine, losartan, methocarbamol, potassium chloride, and a multivitamin. An LPN said a loose pill could be mistaken for the wrong medication and lead to a medication error, and the DON stated that nurses were responsible for keeping the cart clean during the shift and retrieving any pill that popped into the drawer.
Meal choices were not consistently honored after the resident aide role ended. Residents reported they were not regularly given menus or asked for orders, and several said they kept receiving foods they had already identified as dislikes or allergies, including pork, milk, pasta, salad, and red sauce items. Observations confirmed meals were served that did not match the meal tickets, and resident council feedback showed ongoing concerns about inconsistent meal ordering.
Environmental Deficiencies in Laundry and Soiled Utility Areas: Surveyors observed the laundry area and three soiled utility rooms with missing and cracked floor tiles, torn and peeling sheetrock, dust buildup, debris, chipped paint, a hole in the wall, a loose heater cover, and missing wall tiles. The housekeeping supervisor said no work orders had been placed before the survey, and the maintenance supervisor acknowledged the issues and said the flooring was ordered to be replaced.
A resident with MS, GERD, bipolar disorder, muscle weakness, and chronic pain had a MOST form indicating no CPR, but the CPO and care plan still listed CPR. Surveyors also observed a green dot by the room door indicating full code, and the DON confirmed the resident had stated a wish for no CPR.
Dishwashing Room Not Maintained in Good Repair: Surveyors found the facility’s dishwashing room was not maintained in accordance with food service safety standards. Observations included chipped paint, debris and lint on vent covers, a partially unpainted wall, dusty ceiling pipes, torn floor laminate, a separated baseboard, and dirt and debris on the floor. The NHA said he was not aware of the issues, and the RD said she had not submitted any work orders.
A resident reported that a CNA was rough and impatient during incontinence care, making her feel terrible and helpless. Despite a behavior care plan addressing potential mood issues, the resident's concerns about the CNA's treatment were not adequately addressed. The facility's investigation found the neglect allegation unsubstantiated, but the resident's report of rough treatment remained a significant concern.
Unsafe wheelchair transport led to resident head injury
Penalty
Summary
The facility failed to ensure safe transportation and adequate supervision for one resident who was being transported in the facility van for a swallow study. The resident had a history of cerebral infarction (stroke), acute respiratory failure, atrial fibrillation, pacemaker, osteoarthritis, obesity, hypertension, and acute kidney failure, and was receiving Eliquis for atrial fibrillation and a recent stroke. The resident’s MDS indicated no cognitive impairment with a BIMS score of 14 out of 15 and set-up assistance needed with transfers. During transport, the resident’s wheelchair was not properly secured in the van. The facility investigation documented that the resident was assisted into the transportation bus and, while en route, the wheelchair shifted and the resident’s head made contact with the interior of the van. The driver reported that he secured the resident in the wheelchair, locked the brakes, and secured the back of the wheelchair and the seatbelt and shoulder strap, but did not place the front straps on the wheelchair even though he knew that was part of the procedure. He later stated that after hearing a noise and the resident scream, he found her still in the wheelchair and reported that she said she hit the back of her head on the window. The resident was taken to the ED and hospital records documented a traumatic subdural hematoma, with a CT scan showing a 3 mm bleed. Because the resident was on Eliquis, she was admitted to the ICU for monitoring and started on Keppra for seizure prophylaxis. The facility investigation and staff interviews confirmed the incident occurred during transportation when the wheelchair was not fully secured, and the DON and NHA stated the resident initially declined the ER and insisted on going to the swallow study appointment before later being transferred for evaluation.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to honor resident choice and self-determination by not consistently providing showers according to residents’ preferences and care plans for four residents. The deficiency involved Resident #17, Resident #29, Resident #41, and Resident #77, all of whom had documented bathing preferences in their care plans and point-of-care (POC) records. The facility policy stated residents would be provided showers as requested or according to the facility schedule and based on resident safety. Resident #17, who had unspecified dementia and a BIMS score of 8, preferred showers in her room on Monday and Thursday evenings. Her POC bathing documentation from 2/19/26 through 3/16/26 showed she refused all showers, with reasons such as being too cold, not wanting one, having a full schedule, hot water being out, or it being too late. The record did not show that she received showers or bed baths on other days, and there was no documentation that staff tried different times or other interventions. Resident #29, who had MS, weakness, and a BIMS score of 15, said she was not receiving showers as often as she should and stated she was not regularly asked. She reported that she developed scabs on her scalp if she did not use her shampoo regularly and said she would not refuse showers. Her care plan and POC showed a preference for showers on Monday, Wednesday, and Friday evenings, but records documented only four showers out of nine opportunities. One POC entry showed a shower was provided on 3/4/26, while a CNA shower/bath form for that same day documented refusal. Resident #41, who had morbid obesity and was cognitively intact with a BIMS score of 15, preferred showers twice weekly. She told the surveyor she did not receive showers and was not offered bed baths when she did not feel well enough to get out of bed, and that not showering made her feel forgotten and disgusting. Her POC showed a preference for Wednesday and Sunday evening showers, but she received only one shower out of seven opportunities. A progress note documented she switched her shower to the next day, but there was no documentation that a shower or bed bath was offered or provided that day. Resident #77, who had vascular dementia, need for assistance with personal care, and a BIMS score of 4, had a care plan stating she preferred showers on Tuesdays and Thursdays and a bed bath on Saturday evenings, while the POC listed Tuesday and Friday day-shift showers. Records showed she received one shower out of nine opportunities and missed four bed bath opportunities, for a total of 13 missed bathing opportunities. CNA shower/bath forms documented refusals on multiple dates, including entries with no reason documented and one form lacking a nurse signature. Staff interviews indicated CNAs were responsible for showers, residents who refused should be re-approached multiple times, nurses should be notified, and bed baths should be offered, but the records for these residents did not show consistent bathing according to their stated preferences.
Missing Clean Towels and Washcloths in Resident Rooms
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for resident rooms on two of four units because clean linen hand towels and washcloths were not available in resident rooms on a daily basis. During an initial tour, resident rooms 306, 318, 406, 407, 410, and 412 did not have linen towels or washcloths in the rooms, and the same rooms were again observed without linen towels or washcloths on a subsequent tour the next day. The facility had one linen closet used for all units, and when it was observed, it contained only two hand towels, 20 washcloths, and 30 white bath towels. Resident interviews confirmed that clean towels and washcloths were often not available. One resident said she rarely had linen towels or washcloths and would be more likely to wash herself up if they were available. Another resident said she had to ask for clean towels and washcloths and most times did not receive them, which was frustrating. Other residents reported using paper towels because dirty towels were not picked up and replaced, or said they were not offered linen washcloths or towels in the evening to wash their face or hands. Staff interviews indicated that towels and washcloths should be passed out daily, that all shifts were responsible for providing them, and that dirty linen should be removed and replaced daily and as needed.
Loose Medications Found in Medication Cart Drawer
Penalty
Summary
The facility failed to ensure that drugs and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards for one of the two medication carts. During observation of the 300 north medication cart with an LPN, surveyors found 40 loose medications at the bottom of the medication cart drawer. The loose medications included fluoxetine, losartan, methocarbamol, potassium chloride, and a multivitamin, and the LPN was able to identify some of the pills in the drawer. The facility’s Medication Storage policy stated that medication carts should be kept clean and organized and that dropped, loose, refused, or unused medications should not be placed in the trash, red biohazard/sharps containers, or taped back into prescription cards. In interview, the LPN stated that a loose medication could be picked up and mistaken for the wrong medication, which could result in a medication error. The DON stated that the nurse assigned to the medication cart was responsible for cleaning it during the shift and that if a pill popped out into the drawer, it should be retrieved.
Meal Choices Not Consistently Honored
Penalty
Summary
The facility failed to ensure meals were served according to resident preferences on three of four units because residents were not consistently provided menus or given the opportunity to choose their meals. The facility policy stated that food preferences, allergies, intolerances, and cultural, ethnic, and religious requests should be noted and honored, and that nursing staff or designees were responsible for obtaining meal orders and documenting them on tray tickets. During observation of the service line, residents were served meals that did not match the dislikes listed on their meal tickets, including pasta served to a resident who disliked pasta, salad served to a resident who disliked salad, and pasta in red sauce served to a resident who disliked lasagna, marinara, and rose sauce. Resident interviews showed that several residents were not receiving consistent meal choice opportunities after the resident assistant position was eliminated. One resident said she never knew what she was going to receive and that staff did not consistently come around to take orders. Another resident reported that dislikes and allergies such as pork, fish, and thyme continued to be served because she was given the regular menu and that pork items were frequently placed on her breakfast tray despite telling CNAs she did not like pork. A third resident said CNAs did not come around daily to take orders and that she often received the main menu item even when it contained foods she would not choose. Another resident said she did not eat a lunch of pasta with red sauce because it looked too much like lasagna, which she had told staff she did not like. A resident group interview reflected the same pattern. Residents stated that meal order taking had not been consistent since the resident assistant position ended, that they did not always know what they would be served, and that some had to obtain menus themselves from the nurses' station to fill out. One resident reported being served sandwiches repeatedly because of allergies and feeling stuck with those choices, while another said he continued to receive milk every morning even after telling CNAs he did not drink milk. Record review showed resident council and food council concerns about meal tickets and meal choice, and a dietary performance improvement plan identified that meal orders were not being taken regularly. Staff interviews confirmed that CNAs were expected to take over meal order duties after the resident aide position ended, but the regional dietary resource acknowledged the facility was still in transition and that staff should provide meal descriptions, ask about alternatives, and communicate dislikes to dietary staff.
Environmental Deficiencies in Laundry and Soiled Utility Areas
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public because the laundry area and three soiled utility rooms had multiple environmental concerns. On 3/17/26, surveyors observed the soiled utility room in the laundry area with multiple layers of floor linoleum tile cut out and eight tiles missing, dirt and debris along the base tiles behind the entrance door, torn sheetrock along the walls, areas of torn sheetrock without texture or paint, dust built up behind the dryer near the vent pipe, peeling sheetrock outside the dirty utility room, missing cover-base tiles for approximately three feet, torn linoleum near the stand-alone washer, a three-by-three-inch hole in the wall by the washer, chipped paint outside the dirty utility room, and a missing transition strip with five chipped floor tiles. On 3/19/26, the same concerns remained except the hole had been repaired. Surveyors also observed additional damage in the north and south soiled utility rooms. The north soiled utility room had sheetrock damage above the hopper and three cracked floor tiles under the hopper and four cracked floor tiles under the bins. The south soiled utility room had a loose metal heater cover and nine missing wall tiles at the door. The housekeeping supervisor said she had not placed any work orders to have anything corrected before the survey and stated it was the responsibility of staff to place work orders for items to be fixed or replaced. The maintenance supervisor said the flooring was ordered to be replaced, would start in the more visible areas, and acknowledged that the issues were a problem and a safety concern if a staff member tripped and fell.
Advance Directive Records Did Not Match Code Status
Penalty
Summary
The facility failed to maintain accurate medical records for advance directives for one resident. Resident #29, who was admitted with diagnoses including multiple sclerosis, GERD, bipolar disorder, muscle weakness, and chronic pain, had a BIMS score of 15 out of 15 and was cognitively intact. The resident's MOST form, signed by the resident and the NP, indicated no CPR with selective treatment, including IV antibiotics and fluids, do not intubate, and avoid intensive care. However, the computerized physician order showed the resident's code status as CPR, and the care plan review document also listed the resident's advance directive as CPR. Surveyor observations and interviews showed the inconsistency remained in multiple locations. A green dot was observed next to the resident's door name tag, which staff identified as indicating full code status. The DON stated the advance directive forms should match the CPO and that when a resident's advance directive changed, the nurse receiving the new order was expected to discontinue the old order and initiate the new order in the CPO. The DON also confirmed the resident had told her she wanted no CPR, and said the order was changed in the EMR.
Dishwashing Room Not Maintained in Good Repair
Penalty
Summary
The facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety because its one dishwashing room was not maintained and repaired in a timely manner. During the environmental tour, surveyors observed chipped paint on the wall at the entrance to the room, an air vent exterior metal cover with black debris and lint, one wall that was not completely painted, and an exhaust vent over the dishwashing machine with areas of black debris. The ceiling pipes were dusty, and there was torn floor laminate approximately four feet long at the juncture of the floor and wall under the sink near the dishwashing machine. Surveyors also observed the baseboard separated from the wall almost the entire length of the wall under the sink, and the left corner of the room at the entrance door was dirty with debris scattered on the floor. During the environmental review with the surveyor, the NHA observed these concerns and stated he was not aware of them. The RD also observed the concerns and stated she had not put in any work orders for them. The facility policy stated housekeeping and maintenance services were to be provided as necessary to maintain a sanitary, orderly, and comfortable environment, and staff were to report unresolved environmental concerns to the NHA.
Resident Care Lacked Dignity and Respect
Penalty
Summary
The facility failed to ensure that a resident's care was provided in a dignified and respectful manner by a certified nurse aide (CNA). The resident, who was over 65 years old and had diagnoses including epilepsy, bipolar disorder, low back pain, and muscle weakness, was cognitively intact and required assistance with various activities of daily living. During an interview, the resident reported that the CNA was rough during incontinence care, hurried her through tasks, and was impatient due to the resident's inability to move quickly because of her wheelchair use. The resident expressed feeling terrible and helpless due to the CNA's treatment, which she described as rude. The facility's records indicated that a behavior care plan was in place for the resident, addressing potential mood and behavior problems related to her bipolar disorder. However, the care plan did not specifically address the resident's concerns about the CNA's rough handling. The facility's investigation into the incident revealed that the resident had previously reported feeling safe and having no issues with the CNAs, including the one in question. Despite this, the resident later reiterated her concerns about the CNA's rough and rude behavior. Interviews with staff, including the CNA involved, revealed differing perspectives on the incident. The CNA claimed that the resident was not following orders and was in a mood on the day of the concern. The Director of Nursing (DON) and other staff members were informed of the resident's complaint, and the CNA was temporarily reassigned. The facility's investigation found the allegation of neglect to be unsubstantiated, but the resident's report of rough treatment by the CNA was a significant concern that was not adequately addressed in the care plan or during the initial investigation.
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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