Parker Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Parker, Colorado.
- Location
- 9398 Crown Crest Blvd, Parker, Colorado 80138
- CMS Provider Number
- 065405
- Inspections on file
- 24
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 19
Citation history
Health deficiencies cited at Parker Post Acute during CMS and state inspections, most recent first.
Failure to Reassess Pain During Repositioning: A resident with sepsis, CHF, pneumonia, and a pressure injury reported severe pain during repositioning and incontinent care, but CNA and RN staff continued the care after he cried out and asked them to stop. The resident was known to have pain with movement, had scheduled oxycodone and PRN acetaminophen orders, and the care plan lacked documented pain interventions and monitoring details. Staff later acknowledged they should have stopped care and reassessed pain when the resident began moaning and reporting pain.
Staff failed to follow infection control practices during resident care, including not wearing required gowns and other PPE for residents on EBP and contact precautions, and not performing hand hygiene during wound care after glove contamination. An LPN contaminated gloves while dressing a wound, multiple staff entered a room for a resident with shingles without the required PPE, laundry was sorted without proper protective equipment, and a contaminated nasal cannula that had been on the floor was placed back on a resident.
Failure to honor resident choice and keep call light within reach: A cognitively intact resident requested to resume use of her electric wheelchair for greater mobility and independence, but the facility did not complete a safety reassessment after the request. Another resident with dementia, hearing loss, and mobility needs was repeatedly observed in bed with her call light on the floor and out of reach, and staff did not consistently ensure it was accessible.
Failure to report and investigate potential sexual abuse between two residents: staff found a resident with dementia naked in another resident’s room, but the incident was not reported to the State Agency and no formal investigation was documented. The residents were known to have a romantic relationship, yet the facility had no written evaluation of consent for either resident, and the DON, NHA, and SSD confirmed the lack of required documentation and reporting.
Failure to maintain a resident’s hearing device. A resident with significant hearing loss and impaired communication relied on a pocket talker after her hearing aid stopped working, but staff did not keep the device charged and it was often unavailable for use. Observations found the device and hearing aid stored in a bedside drawer while the resident could not hear staff unless they spoke very close to her. Interviews confirmed the pocket talker was her most effective communication method, that it only held a short charge, and that the issue was not documented in the EMR.
A resident with a hx of falls, gait/mobility impairment, and severe cognitive impairment had a care plan calling for the bed to remain in the lowest position, but staff repeatedly observed the bed left in the highest position. The resident had previously fallen during a shower when a hospice CNA could not catch the fall and the resident hit the back of his head. RN and ADON interviews confirmed the fall interventions were not being followed as written.
A resident with COPD, asthma, chronic respiratory failure with hypoxia, and OSA was found receiving oxygen above the physician-ordered 1 LPM. Staff observed the resident on 2.5 to 4 LPM via portable tank and concentrator, and a CNA changed the flow rate without verifying the order with the nurse. RN staff also failed to confirm the correct setting, and the resident stated 4 LPM seemed too much for her condition.
A resident with dementia and severe cognitive impairment was involved in a romantic relationship with another resident, but the EMR did not show that the facility assessed whether she could consent to a sexual relationship. Staff gave mixed opinions about her decision-making ability, with some saying she could consent and the DON stating she could not due to her cognitive status. The resident was found naked in the other resident’s bedroom, and the care plan documented the relationship, but there was no written consent evaluation for either resident.
A resident with multiple complex medical conditions was discharged without a documented assessment or arrangement for home oxygen therapy and timely home health services for intravenous antibiotics. The care plans and discharge summary indicated ongoing needs, but the facility did not confirm or document referrals for necessary equipment or services, resulting in a delay of home health care and missed medication doses.
Two residents in a LTC facility experienced multiple falls due to inadequate supervision and ineffective fall interventions. Despite being identified as high fall risks, the facility failed to consistently update care plans with new interventions or identify the root causes of the falls. This resulted in repeated falls and injuries, with one resident requiring hospital treatment twice.
A resident with severe cognitive impairments and multiple diagnoses, including low back pain and dementia, experienced excruciating pain that was not addressed by the facility for three and a half hours. The facility's pain management policy required the use of the PAINAD scale for non-verbal residents, but a numerical pain scale was used instead. Staff interviews revealed a lack of timely response and monitoring, leading to a failure in effective pain management.
The facility failed to implement baseline care plans within 48 hours of admission for two residents, omitting critical information such as dialysis schedules and wound care needs. The DON noted that admitting nurses were responsible for initiating care plans, but staff relied on admitting orders instead.
A resident with malignant bladder cancer missed several oncology and chemotherapy appointments due to the facility's failure to arrange transportation. Despite the facility's policy to assist with transportation, the resident's appointments were not documented in the electronic medical record, and staff were unaware of the missed appointments. A change in scheduling staff and lack of communication contributed to the oversight.
Failure to Reassess Pain During Repositioning
Penalty
Summary
The facility failed to provide effective pain management for a resident who reported significant pain during repositioning and incontinent care. Resident #64 was admitted with sepsis, acute respiratory failure, CHF, pneumonia, and a pressure-induced deep tissue injury of the left ankle. The resident was cognitively intact, required substantial assistance with care, and told staff that he had pain when moved or repositioned, rating it as 8 out of 10 when care was provided. During observation, CNA #5 and RN #5 repositioned and provided incontinent care while the resident repeatedly cried out that it hurt and asked the staff to stop. The resident moaned loudly and stated, “You don't know how bad it hurts,” but the staff continued the care instead of stopping to reassess his pain. RN #5 told the resident she would check for pain medication after care was finished, and then administered Tylenol 650 mg after the care was completed. The staff did not assess the resident’s pain level or location during the episode of acute pain. Record review showed the resident had orders for scheduled oxycodone 5 mg four times daily for pain and acetaminophen as needed, but the care plan did not include documented pain interventions, non-pharmacological measures, monitoring for medication effectiveness, or monitoring for opioid side effects. Interviews confirmed that RN #5 and CNA #5 routinely completed care first and reported pain afterward, and RN #5 stated she should have stopped care when the resident began moaning and saying he was in pain. The DON stated staff were expected to assess pain using verbal and nonverbal indicators, and the NHA stated that a complaint of pain should be treated as a new symptom every time.
Infection Control Failures With PPE, Hand Hygiene, Laundry, and Oxygen Tubing
Penalty
Summary
The facility failed to maintain and follow its infection prevention and control program during multiple resident care activities on all three floors. Staff did not consistently use the required PPE for residents on enhanced barrier precautions (EBP) or contact precautions, did not perform hand hygiene at key points during wound care, did not handle contaminated laundry in the manner described by facility policy, and did not manage oxygen tubing in a sanitary way. The report identifies these failures through direct observations and staff interviews involving residents with wounds, indwelling devices, and shingles. During EBP-related observations, an RN administered IV medication to a resident with a chest port without wearing a gown even though the door sign indicated gloves and a gown were required for resident care activities. Two CNAs assisted a resident with a mechanical lift transfer while wearing gloves but no gown. Another RN and CNA repositioned a resident with a left ankle wound while the resident was on EBP, and the CNA later stated she did not know the difference between contact precautions and EBP and had not been told the resident was on EBP. The DON stated that residents with wounds or indwelling devices were required to be on EBP and that gown and gloves were expected for high-contact direct care activities. Hand hygiene and contamination control also failed during wound care for a resident with a left heel wound. An LPN removed the old dressing, changed gloves without performing hand hygiene, touched a clipboard outside the room, returned to the room, and then reached into her scrub pocket for an ink pen before applying the new dressing. The LPN stated she did not realize her gloves had been contaminated and acknowledged the need for hand hygiene and glove changes between possible contamination points. The report also describes contact precaution failures for a resident with shingles: staff entered the room without PPE, including a scheduler, a CNA, a speech therapist, and another CNA who entered with a breakfast tray while wearing gloves but no gown or mask. Staff interviews showed differing understanding of the precautions, while RN and ADON interviews confirmed the resident remained on contact precautions. Additional infection control failures were observed in the laundry room and with respiratory equipment. Laundry staff sorted soiled laundry without wearing PPE except when handling sugar bags or biohazard bags, despite policy requiring gloves and other protective equipment when handling soiled laundry. The laundry worker described sorting items that sometimes contained fecal matter or urine and said she was caught off guard when contaminated laundry came down without PPE. Finally, an activities assistant untangled a resident’s nasal cannula after it had been on the floor several times and placed it back on the resident, then sought help from a CNA. The CNA later quickly reapplied the cannula, and both the CNA and DON/IP stated that a contaminated cannula should be replaced.
Failure to Honor Resident Choice and Keep Call Light Within Reach
Penalty
Summary
The facility failed to honor resident choice for a cognitively intact resident who requested to resume use of her electric wheelchair. The resident, who had diagnoses including hemiplegia and hemiparesis following cerebral infarction, muscle weakness, depression, chronic pain syndrome, and muscle contracture, had been using a manual wheelchair after a prior incident in which she ran into a wall with her power wheelchair and fractured her foot. During a care conference, she again expressed interest in using her electric wheelchair for improved mobility and independence, but the record did not show that the facility reassessed whether it was safe for her to use it after the request was made. Documentation showed the resident’s request was discussed in care conference summaries and a psychiatric evaluation note, which stated the request was relayed to social services. The director of rehabilitation acknowledged being present when the resident expressed her desire to use the electric wheelchair, but said the facility was waiting for the resident’s sister to purchase a smaller electric wheelchair. The director of rehabilitation also stated that no safety assessment was completed when the resident requested to use her power wheelchair again. The facility also failed to keep another resident’s call light within reach. That resident had diagnoses including chronic kidney disease, dementia, right shoulder pain, muscle weakness, overactive bladder, and unspecified hearing loss, and required partial/moderate assistance with toileting, showers, and transfers. On multiple observations over several days, the resident was lying in bed with the call light on the floor under the bed and out of reach, and staff entered the room without ensuring it was accessible. The resident stated she usually yelled out for help because she did not know where her call light was and preferred not to yell when she needed assistance.
Failure to Report and Investigate Potential Sexual Abuse Between Two Residents
Penalty
Summary
The facility failed to investigate and report an alleged violation of potential abuse to the State Survey and Certification Agency for two residents. The report states that the facility did not timely report an incident involving possible sexual abuse between a resident with dementia and another resident, and it also did not document a formal investigation into what occurred. Facility policy required alleged violations involving abuse to be reported immediately, but not later than two hours after the allegation if abuse was involved, and to the state survey agency and adult protective services. Resident #56 had diagnoses including dementia with behavioral disturbance and cognitive communication deficit, and a prior MDS documented severe cognitive impairment with a BIMS score of 6. Resident #102 had Parkinson's disease with dyskinesia, auditory hallucinations, visual hallucinations, and moderate cognitive impairment with a BIMS score of 10. The record documented that Resident #56 was found naked in Resident #102's bedroom after dinner, and staff intervened by speaking to her, helping her get dressed, and moving her to the living room. The DON was aware of the incident. Interviews showed staff knew the residents had a romantic relationship, but the facility had no documentation of an investigation, no written evaluation of consent for either resident, and no documentation that the incident was reported to the State Agency. The DON stated the facility did not have documentation of an investigation or consent evaluation and did not think Resident #56 could consent due to her cognitive status. The NHA confirmed the incident was not reported to the State Agency and that the facility did not conduct a formal investigation. The SSD said she spoke with the residents and the representative, but this was not documented, and the resident's representative said he had not been informed of the incident.
Failure to Maintain Charged Hearing Device
Penalty
Summary
The facility failed to ensure proper treatment and assistive devices were available to maintain hearing abilities for one resident with documented hearing impairment. The resident, who had diagnoses including COPD with exacerbation, type 1 diabetes mellitus, bipolar disorder, a history of TIA/CVA without residual deficit, and cognitive communication deficit, had a BIMS score of 14 out of 15 and required assistance with some ADLs. Her care plan identified impaired communication due to hearing loss and documented that she was hard of hearing, declined hearing aids, and used a pocket talker for most communication. Observations showed the resident seated in her wheelchair without her hearing aid or pocket audio device and not responding to greetings until staff moved directly in front of her. During the observation, the pocket audio device and hearing aid were found in her bedside drawer. The resident stated her hearing aid had stopped working months earlier and that the pocket audio device often was not charged, only held a charge for about one hour, and was frequently forgotten by staff. She also said she felt helpless without hearing and was cut off from the world, and that she stopped using the device because it was usually not charged. Record review showed the resident’s ancillary services note documented bilateral hearing loss ranging from moderately-severe to profound and recommended rechargeable devices to reduce frequent battery changes. The EMR did not contain documentation about her hearing impairment issues, broken hearing aids, or charging problems with the pocket talker. Staff interviews confirmed the device was the resident’s most effective communication method, that she could not hear without it, and that the device did not hold a charge. The social services director stated she was unaware of the charging problems and that the resident had not been seen by audiology in 2025.
Failure to Follow Fall Interventions for a Resident at Risk for Falls
Penalty
Summary
The facility failed to ensure an environment free of accident hazards for Resident #46 by not implementing fall interventions as written in the care plan. Resident #46, who was over age 65, had diagnoses including history of falling, unspecified abnormalities of gait and mobility, and palliative care. The 3/2/26 MDS showed severe cognitive impairment with a BIMS score of 3 out of 15 and that the resident required substantial to maximal assistance with functional abilities. The care plan, initiated 5/27/25, identified the resident as at risk for falls due to deconditioning and included interventions such as keeping the call light within reach, keeping the bed in the lowest position, and keeping needed items within reach. Record review showed the resident had a fall on 6/3/25 while a hospice CNA was assisting with a shower; the CNA was unable to catch the fall and the resident hit the back of his head in the shower. During multiple observations on 3/9/26, 3/10/26, 3/11/26, and 3/12/26, the resident was seen resting in bed with the bed approximately three feet in the air. RN #6 observed the bed in the highest position and lowered it, stating the CNA did not leave the bed in the lowest position as the care plan required. The ADON stated the resident had specific fall interventions in the care plan and was not aware the bed had been left in the highest position.
Failure to Follow Ordered Oxygen Flow Rate
Penalty
Summary
The facility failed to provide respiratory care consistent with the resident’s physician’s order for continuous oxygen therapy. Resident #21 had diagnoses including COPD, moderate persistent asthma, chronic respiratory failure with hypoxia, major depressive disorder, and obstructive sleep apnea. The resident’s care plan identified altered respiratory status related to COPD, chronic respiratory failure, and asthma, and the March 2026 physician’s order directed continuous 1 LPM oxygen via nasal cannula to maintain oxygen saturation at or above 90%. During observations, Resident #21 was found receiving oxygen at settings above the ordered amount. On 3/10/26, CNA #3 transferred the resident’s nasal cannula from the room concentrator to a portable tank and set it at 4 LPM after the resident asked to reduce it to 2 LPM; the CNA complied without verifying the order with a nurse. On 3/11/26, the resident was observed with the portable oxygen tank set at 2.5 LPM. On 3/12/26, the resident was observed in bed with the concentrator set at 4 LPM, and RN #4 and CNA #4 confirmed the setting. The resident stated she used oxygen continuously and believed 4 LPM was probably too much for her condition. Record review showed the resident had been consistently receiving 2 LPM of oxygen in the electronic medical record, but the physician’s order remained 1 LPM. Staff interviews confirmed CNA #4 did not know the ordered liter flow and did not report the incorrect setting, and RN #4 stated she did not verify the concentrator setting at the start of her shift. The DON stated oxygen was a form of medication and that staff were required to follow oxygen orders.
Failure to Assess Consent for Romantic Relationship
Penalty
Summary
The facility failed to ensure that Resident #56, a resident with dementia and cognitive communication deficit, received appropriate treatment and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Resident #56’s records showed severe cognitive impairment on the most recent MDS, with a BIMS score of 6 out of 15, and she required one-person assistance as needed for transfers, bathing, and toileting. Her care plans addressed dementia-related cognitive impairment and behavioral concerns, including interventions for routine, communication, and behavior management. The record also showed that Resident #56 and Resident #102 were involved in a romantic relationship. A nursing progress note documented that Resident #56 was found naked in Resident #102’s bedroom after dinner, after which staff assisted her to dress and she spent the rest of the evening in the living room. The comprehensive care plan reflected the relationship between the two residents, but the electronic medical record did not contain documentation that the facility assessed Resident #56 to determine whether she could consent to a sexual relationship. Staff interviews showed differing opinions about Resident #56’s ability to consent. A CNA and an LPN stated they believed she could make her own decisions and consent to a relationship, although the LPN also stated the resident was sometimes confused and had recently been unable to follow instructions. The DON stated she did not think Resident #56 could consent because of her cognitive status, while the SSD said there was no written documentation that consent had been evaluated for either resident. The facility also had an incident involving the residents that was referenced in a related deficiency for failure to timely report a potential sexual abuse incident to the State Agency.
Failure to Assess and Arrange Discharge Services for Oxygen and Home Health
Penalty
Summary
The facility failed to properly assess, arrange, and document discharge services for a resident who required ongoing oxygen therapy and intravenous antibiotics after discharge. The resident, who had a history of endocarditis, enterocolitis, sepsis, emphysema, COPD, heart failure, and pulmonary hypertension, was admitted with no oxygen therapy but began using supplemental oxygen during the stay. The care plans for pneumonia and respiratory issues included oxygen therapy, but there was no documented plan of care or discharge needs assessment for home oxygen services. Upon discharge, the resident's summary indicated a continued need for 2 LPM of oxygen via nasal cannula and ongoing intravenous antibiotics. However, the electronic medical record did not contain any physician's orders or referrals for home oxygen equipment or confirmation of home health services to provide antibiotic therapy after discharge. The home health provider did not begin services until four days after the resident left the facility, resulting in missed doses of antibiotics and a lack of oxygen therapy at home during that period. Interviews with facility staff revealed that the social services assistant sent a referral for home health services to the resident's insurance provider but did not confirm receipt or authorization. The DON was unable to locate a discharge needs assessment for oxygen or documentation of a referral for home oxygen. The NHA acknowledged that the resident was discharged before confirmation that a home health provider had accepted the referral, and the physician was not notified that services were not arranged prior to discharge. The facility's discharge planning policy required identification and documentation of discharge needs, involvement of the interdisciplinary team, and confirmation of post-discharge services, all of which were not met in this case.
Inadequate Fall Prevention and Supervision in LTC Facility
Penalty
Summary
The facility failed to ensure adequate supervision and effective fall interventions for two residents, leading to multiple falls and injuries. Resident #7, diagnosed with unspecified dementia, a history of falling, and muscle wasting, experienced 17 falls between June 2024 and March 2025. Despite the implementation of some interventions, such as fall mats and keeping the bed in a low position, the facility did not consistently update the care plan with new interventions after each fall. The facility also failed to identify the root cause of the falls, resulting in two incidents that required hospital transportation for treatment of injuries. Resident #4, with diagnoses including left-sided hemiplegia, muscle weakness, and a history of falling, experienced 12 falls between November 2024 and February 2025. The facility's interventions, such as ensuring the call light was within reach and frequent room checks, were insufficient to prevent further falls. The resident reported that she often had to wait too long for staff assistance, leading her to attempt transfers on her own, which contributed to her falls. The facility's policy required the interdisciplinary team to assess and evaluate fall risks and implement a plan of care for high-risk residents. However, the facility did not effectively implement or update fall interventions following each incident, nor did it adequately identify the root causes of the falls. This lack of effective intervention and supervision resulted in repeated falls and injuries for both residents.
Failure in Pain Management for Cognitively Impaired Resident
Penalty
Summary
The facility failed to provide effective pain management for a resident with severe cognitive impairments and multiple diagnoses, including low back pain and dementia. The resident was on a scheduled pain regimen that included Tylenol and Aspercreme, but on a specific date, the resident began complaining of excruciating pain in multiple areas of her body. Despite the resident's severe pain, the facility did not address her complaints for three and a half hours, during which time the resident was administered Valium for hallucinations and anxiety. The facility's pain management policy required an interdisciplinary team to assess and manage resident pain, using tools like the PAINAD for residents unable to communicate verbally. However, the care plan for the resident did not specify pain goals or acceptable levels of pain, and the facility used a numerical pain scale instead of the PAINAD, which was more appropriate given the resident's cognitive impairments. The facility's records showed inconsistencies in the administration of pain medications and a lack of timely response to the resident's pain complaints. Interviews with staff revealed that the resident was typically quiet and did not usually complain of pain, which may have contributed to the delay in addressing her pain. The DON acknowledged that follow-up after administering pain medication should occur within one to two hours, or every 30 minutes for residents in excruciating pain. However, the facility's electronic medical record did not show regular monitoring of the resident's pain after her initial complaint, indicating a failure to adhere to the facility's pain management policy.
Failure to Implement Baseline Care Plans for New Residents
Penalty
Summary
The facility failed to develop and implement a baseline care plan within 48 hours of admission for two residents, which is a requirement according to their policy. Resident #6, who was admitted with end-stage renal disease, a stage 3 pressure ulcer, and required maximum assistance for transfers, did not have pertinent medical information included in their baseline care plan. The care plan omitted details about the resident's dialysis schedule, wound care needs, and assistance required for activities of daily living, such as toileting and meal setup. Similarly, Resident #2, who had cognitive communication deficits, type 2 diabetes, and chronic kidney disease, also had an incomplete baseline care plan. Although the resident's chronic kidney disease and insulin use were documented, the care plan failed to include information related to the resident's dialysis care. The Director of Nursing indicated that the admitting nurse was responsible for initiating the baseline care plan, which was then audited for accuracy. However, the staff did not utilize the baseline care plan for new resident information, relying instead on admitting orders.
Failure to Arrange Transportation for Cancer Care Appointments
Penalty
Summary
The facility failed to ensure that a resident received necessary transportation services, resulting in missed medical appointments. The resident, who was over 65 years old and diagnosed with malignant bladder cancer, required regular oncology and chemotherapy infusion appointments. Despite the facility's policy to assist with transportation arrangements, the resident missed several critical appointments due to the facility's failure to arrange transportation. Interviews and record reviews revealed that the facility's scheduling process was flawed. The resident's care manager reported that transportation was confirmed for appointments, but the resident still missed them. There was no documentation in the resident's electronic medical record to indicate that the appointments were attended, and no progress notes were made regarding the missed appointments. Additionally, the facility staff, including registered nurses and schedulers, were unaware of the missed appointments, indicating a lack of communication and documentation. The facility experienced a change in scheduling staff during the period when the appointments were missed, which may have contributed to the oversight. The interim scheduler claimed to have arranged transportation but could not provide evidence of scheduling or billing for the missed appointments. The nursing home administrator was unaware of the missed appointments until informed during the investigation, highlighting a breakdown in the facility's internal communication and processes.
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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