Rio Grande Rehabilitation And Healthcare Center
Inspection history, citations, penalties and survey trends for this long-term care facility in La Jara, Colorado.
- Location
- 39 Calle Miller, La Jara, Colorado 81140
- CMS Provider Number
- 065399
- Inspections on file
- 19
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 17 (1 serious)
Citation history
Health deficiencies cited at Rio Grande Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
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.
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.
A CNA failed to change gloves or perform hand hygiene during incontinence care, including when handling a resident’s vanity drawer and barrier cream, while another CNA returned supplies while still gloved. Staff also did not disinfect shared vital signs equipment between residents, and a CNA-medication aide did not disinfect a shared glucometer with the proper wipe contact time or after removing soiled gloves. Interviews showed inconsistent understanding of the correct infection control practices.
Failure to Provide Medicare NOMNC and Appeal Notice: Two residents did not receive required notice when Medicare Part A skilled services were ending. One cognitively intact resident signed the NOMNC on the same day services ended, with no documentation of the required advance notice, and another resident’s representative received only verbal notice, with no written NOMNC, cost information, or appeal rights documentation.
Improper Use and Monitoring of Wanderguards: The facility used wanderguards for two residents without documenting that the devices were the least restrictive approach, without documenting representative notification of risks and benefits, and without documenting ongoing re-evaluation for continued need. One resident had dementia with behavioral disturbance and only one documented exit-seeking episode, while the other resident had severe cognitive impairment and wandering behaviors but no documented attempts to leave during observation. Staff described general redirection and other routine interventions, but the records did not show resident-specific efforts to reduce the restraint use.
A resident receiving warfarin for a prosthetic heart valve did not have PT/INR monitoring completed as ordered every four weeks. Records showed the lab was obtained regularly before, but one monthly INR was missed while the DON said the issue occurred during a transition to a new charge nurse and she did not follow up on the lab draws. The pharmacist stated INR monitoring should occur at least monthly for warfarin management.
Failure to Supervise and Individualize Fall Prevention for a Resident with Repeated Falls: A resident with dementia, anxiety, PTSD, weakness, and impaired decision-making had multiple falls and repeated attempts to stand from her wheelchair, but the record did not show consistent review of fall causes, updated care plan interventions, or reliable implementation of individualized measures. Therapy and pharmacy identified several fall-related concerns, including medication effects and possible vision issues, yet staff observations showed the resident was often left without close supervision or redirection when she tried to rise in the common area.
Failure to Monitor Dialysis Fistula: A resident with ESRD, DM2, and dependence on renal dialysis had both a right chest dialysis port and a left arm AV fistula, but the EMR did not show routine assessment or documentation of the fistula site. Although staff recognized the resident’s dialysis access devices and the DON stated the fistula should be monitored for bruit and thrill, there was no physician order for fistula monitoring and no documentation that nursing staff were assessing it routinely.
A resident with multiple diagnoses, including TBI, quadriplegia, dementia, anxiety, and insomnia, was receiving several psychoactive and pain medications. The pharmacist recommended reducing oxycodone because pain scores were consistently zero, obtaining A1c or monthly blood sugar checks due to risperidone use, and decreasing Lexapro after mirtazapine was started. The physician marked disagreement with these recommendations but did not document a rationale in the chart or on the MRR form, and the DON did not know the reason for the decisions.
A resident with severe cognitive impairment and multiple chronic conditions was started on Macrobid for suspected UTI after urinary symptoms and a positive urine dip. When the urine C&S later returned negative for UTI, the antibiotic was continued for several more doses before the MD was contacted to stop it, showing a failure in the facility’s antibiotic stewardship monitoring and discontinuation process.
A resident with quadriplegia and an indwelling Foley catheter experienced a significant decrease in urine output that was not communicated to nursing staff or the physician, and no assessment for urinary retention or catheter obstruction was performed. Staff failed to monitor urine characteristics or conduct necessary nursing assessments, and there was confusion among CNAs regarding reporting protocols. The resident was later found unresponsive and transferred to the hospital, where severe complications including sepsis and acute kidney injury were identified.
A resident with cognitive impairment and mobility needs was pushed to the floor by another resident with severe cognitive impairment and schizophrenia, resulting in a femur fracture that required surgery. Both individuals had behavioral care plans, but no recent history of physical aggression was documented. Staff were present at the time, but the incident occurred as the two passed near an exit, indicating a failure to prevent resident-to-resident abuse.
Two residents did not receive wound care and weekly skin assessments as required by facility policy and physician orders. One resident with multiple chronic conditions developed a perianal abscess requiring surgery after the facility failed to document skin assessments or address hemorrhoid care. Another resident with quadriplegia and stage 3 pressure wounds did not have wound care orders entered or treatments provided, resulting in significant skin breakdown. Staff interviews confirmed lapses in order entry, documentation, and follow-through on wound care responsibilities.
A resident with dementia and depressive episodes, who required supervision and had memory problems, was told by staff to return to her room or was taken to her room as a response to her behaviors, despite the care plan not including this intervention. Nursing notes documented that the resident was asked to eat lunch in her room due to disruptive behavior and was told she had to go to her room if not nice. Staff interviews confirmed that residents were sometimes removed from activities or sent to their rooms for behavioral issues, contrary to facility policy and resident rights.
A resident diagnosed with dementia did not receive the necessary treatment and services to address their condition, resulting in a deficiency related to inadequate dementia care.
The facility failed to complete annual performance reviews and provide regular in-service education based on the outcomes for four CNAs. The nursing home administrator admitted she could not locate the performance reviews and was unaware of the requirement for an in-service plan based on the reviews.
The facility failed to ensure that three residents were free from unnecessary psychotropic medications by not implementing effective individualized behavior monitoring and not ensuring consents were in place prior to administration. Documentation did not indicate what non-pharmacological interventions were tried or what medication they were associated with, and consents for certain medications were missing.
The facility failed to incorporate PASRR level II recommendations for a resident with bipolar disorder, including psychiatric consultation and individual therapy. The resident's request to see a rheumatologist was not addressed, and an inaccurate diagnosis of Huntington's disease was not corrected. Staff interviews revealed a lack of communication and follow-through on the PASRR recommendations.
The facility failed to ensure proper treatment and assistive devices for two residents, resulting in one resident not receiving an eye exam and another not obtaining necessary hearing aids. Staff interviews revealed a lack of awareness and coordination regarding the residents' needs, leading to prolonged periods without essential services.
The facility failed to ensure a resident had an order for a medication (Icy Hot) found at his bedside. The resident, who had diagnoses including autistic disorder, dementia, and fibromyalgia, was observed with Icy Hot at his bedside on two consecutive days. Both a registered nurse and the DON confirmed that the resident did not have an order for the medication nor an assessment for self-administration.
The facility failed to assist a resident in obtaining routine or emergency dental services as needed. Despite the resident reporting tooth pain and requesting an initial dental consult upon admission, there was no documentation of dental care being provided. Interviews with staff revealed a lack of clarity and responsibility in scheduling dental appointments, resulting in the resident not receiving necessary dental care.
The facility failed to ensure a resident over the age of 65 was offered the secondary pneumococcal immunization as per CDC guidelines. The MDS coordinator was unaware of the requirement to offer the vaccine annually, and the DON acknowledged the need to follow CDC guidelines.
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 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.
Infection Control Failures During Resident Care and Shared Equipment Use
Penalty
Summary
The facility failed to maintain infection control practices during incontinence care for a resident on enhanced barrier precautions. A CNA responded to the resident’s call light, returned with another CNA and a hoyer lift, and both staff donned gowns and gloves. While cleaning the resident’s buttocks, the CNA walked away from the resident without changing gloves and opened the resident’s vanity drawer to remove cleansing spray and wipes. The resident’s son entered the room, opened the same drawer with bare hands, and removed barrier cream. The CNA then took the cream from the son, opened the container, used her gloved hand to scoop cream from the container, and applied it to the resident’s bottom without changing gloves or performing hand hygiene. After the care was completed, the second CNA returned the barrier cream to the drawer while still gloved. Both staff removed PPE and performed hand hygiene with soap and water before leaving the room. The facility also failed to disinfect shared vital signs equipment between residents. During observation, a CNA measured one resident’s blood pressure in a common area, placed the cuff back into the vital signs cart, and then pushed the cart to another hallway and entered another resident’s room to obtain a blood pressure without disinfecting the equipment between residents. No disinfecting wipes were observed in the vital signs cart during the observation. Staff interviews showed differing practices and uncertainty about the proper wipes and dwell time used for disinfecting the equipment. The facility further failed to disinfect a shared glucometer appropriately between residents. A CNA-medication aide measured a resident’s blood glucose, then wiped the glucometer for about ten seconds with a Microdot minute wipe and placed the device in a basket while the surface was not wet or shiny. The aide did not remove soiled gloves and put on clean gloves before disinfecting the glucometer, and the device was not kept wet for the required dwell time. Interviews showed the glucometer was shared among multiple residents on the hallways, and staff gave inconsistent descriptions of the wipes used and the required contact time.
Failure to Provide Timely Medicare Skilled Service Termination Notices
Penalty
Summary
The facility failed to ensure that two residents were properly notified when Medicare Part A covered skilled services were ending and, in one case, failed to provide the resident’s representative with written notice and appeal information. Resident #35 had diagnoses including chronic respiratory failure with hypoxia, COPD, schizophrenia, dementia, and anxiety, and the 4/13/26 MDS showed the resident was cognitively intact with a BIMS score of 13 out of 15. Record review showed the resident was discharged from Medicare Part A skilled therapy services on 12/12/25, and the NOMNC was signed on the same day the services ended, with no documentation that the resident received at least two days’ notice before the end of skilled services. Resident #41 had diagnoses including schizophrenia, COPD, dementia with anxiety, and heart disease, and the 3/14/26 MDS indicated severe impairment in cognitive skills for daily decision making. Record review showed Medicare Part A skilled therapy services ended on 11/28/25, and the NOMNC documented verbal notification to the resident’s representative on 11/25/25. However, there was no documentation that the representative received the written NOMNC letter, the estimated cost of continuing services out of pocket, the reason skilled services were ending, or the information needed to appeal the decision.
Improper Use and Monitoring of Wanderguards
Penalty
Summary
The facility failed to ensure two residents were free from the use of physical restraints when it used wanderguards without documenting that the devices were the least restrictive approach, without documenting resident representative notification of the risks and benefits, and without documenting ongoing re-evaluation for continued need. The report states that the facility also failed to develop and implement interventions to reduce the restraint use for both residents. Resident #3 had diagnoses including COPD, asthma, muscle weakness, and dementia with behavioral disturbance. Her MDS showed moderate cognitive impairment, and the assessment documented that she did not wander, although she used a wander/elopement alarm daily. During observation, she moved between her room and common areas and played games, but she did not display attempts to exit-seek. The record showed one documented episode on 10/12/25 when she pushed open the front door and stated she was leaving, followed by another episode later that evening when she opened the front door and stated she wanted to leave with a family member who was not present. A wanderguard was placed on her ankle the next day. The record did not show documentation that her representative was informed of the risks and benefits or that consent was obtained, and it did not show documentation that less restrictive measures were offered or tried before the wanderguard was used. Resident #3’s chart also did not show ongoing documentation supporting continued use of the wanderguard. Several later notes described wandering, frustration, hallucinations, or statements about wanting to leave, but they did not document actual attempts to leave the facility. The report states there was no documentation that the resident was re-evaluated between late November 2025 and April 2026 to determine whether the wanderguard remained appropriate and necessary. Staff interviews indicated that employees identified elopement risk by the presence of a wanderguard and used general redirection, snacks, toileting, or activities, but the DON acknowledged that Resident #3 had not tried to leave during her time at the facility and said she would be a good candidate for removal. Resident #7 had dementia, muscle weakness, cardiac murmur, and edema, and her MDS showed severe impairment in daily decision-making with a daily wander/elopement alarm. During observation, she wore a wanderguard but did not attempt to exit-seek; she was seen sleeping, walking to her room, and being redirected back to the common area. Her record described wandering into other residents’ rooms, rummaging through drawers, and wandering at night, but the notes did not document attempts to leave the facility. The report states there was no physician order to place the wanderguard, no documentation that her representative was informed of the risks and benefits or consented, no documentation that less restrictive measures were offered or tried first, and no documentation that the device was re-evaluated for continued need during the period reviewed.
Missed INR Monitoring for Resident on Warfarin
Penalty
Summary
The facility failed to ensure Resident #5 received PT/INR blood draws in accordance with the physician’s order for monitoring anticoagulant therapy. Resident #5, who was under age 65, had diagnoses including a prosthetic heart valve, type 2 diabetes mellitus, and long-term use of anticoagulants, and the MDS indicated the resident was receiving anticoagulant medication. The April 2026 physician orders included PT and INR testing every four weeks on Monday and warfarin sodium 5 mg by mouth in the evening. Record review showed the resident’s PT/INR had been monitored at least every four weeks throughout 2025, but in 2026 the tests were completed on 1/5/26, 2/12/26, and 4/21/26, with no PT/INR drawn in March 2026. The DON stated the March INR was not drawn because the facility had a new charge nurse and she did not follow up with the charge nurse on the lab draws for that month. The DON also stated nursing staff should follow physician orders. Pharmacist #1 stated the resident’s PT/INR should be measured at a minimum monthly and that INR monitoring was important for warfarin management.
Failure to Supervise and Individualize Fall Prevention for a Resident with Repeated Falls
Penalty
Summary
The facility failed to provide supervision, assistance, services, and effective person-centered interventions to prevent falls for one resident with vascular dementia, anxiety, PTSD, and impaired decision-making. The resident required staff supervision for toileting, showering, dressing, standing, transfers, and walking, and had a history of multiple falls. The fall care plan identified risks related to muscle weakness, back pain, dementia, insomnia, tremors, a new-onset seizure, and medication side effects, but the record did not show that the care plan was reviewed or updated with new interventions after several falls in late February through early April 2026. The resident experienced repeated falls and near-fall events, including unwitnessed and witnessed incidents in her room, doorway, near the nurses' station, and common area. Documentation showed varying root causes such as unsteady gait, medication changes, weakness, inability to rise fully, attempting to sit on a chair, slippery non-skid socks, difficulty sitting in a recliner, and forgetting to use her wheelchair. Some post-fall reviews documented no new interventions, and some events had no progress notes or huddles in the record. Therapy recommendations included removing environmental obstacles, redirecting the resident with television or music, reviewing medications, sensory activities, and family-provided preferred snacks, but the record did not show consistent implementation of skilled services or other individualized interventions after the falls. The resident was also receiving multiple medications identified by the pharmacist as increasing fall risk, including clonazepam, sertraline, mirtazapine, and Abilify. The pharmacist recommended considering a slow taper of clonazepam and assessing vision as a possible contributor to falls, but the record did not show an optometrist appointment. Physical therapy notes showed the resident had bilateral lower extremity weakness, impaired transfers, inability to walk, decreased activity tolerance, and high fall risk, and later stopped agreeing to therapy. During survey observations, the resident repeatedly attempted to stand from her wheelchair in the common area while staff were nearby or at the nurses' station, but staff often did not acknowledge her, did not redirect her, and did not closely monitor her despite her repeated attempts to rise and her distress.
Failure to Monitor Dialysis Fistula
Penalty
Summary
The facility failed to ensure a resident who required dialysis received care consistent with professional standards of practice because staff did not routinely assess and document the resident’s left arm dialysis fistula. The resident was cognitively intact, had end stage renal disease, chronic stage 5 kidney disease, diabetes, sepsis, and dependence on renal dialysis. The resident also had a left arm arteriovenous fistula and a right chest dialysis port, with the left arm noted to be edematous in the admission and re-admission evaluations. The record showed physician orders to monitor the right chest central venous catheter site every shift for signs of infection and to monitor the right chest dialysis site for bleeding and signs or symptoms of infection. However, there was no physician order in the April 2026 CPO to assess and monitor the left arm fistula site. Review of the EMR, including progress notes and skilled nursing documentation, did not show routine assessment or documentation of the left arm fistula, despite the resident’s dialysis dependence and left arm edema. During interviews, the dialysis RN stated the resident had both a right chest dialysis port and a left arm AV fistula, and the DON stated the fistula should be monitored daily for bruit and thrill and documented in the skilled nursing assessments. The DON also acknowledged there was no physician order to assess the fistula and that one would be added. The report states there was no documentation showing nursing staff were assessing and documenting the left arm dialysis fistula until the concern was brought to the facility’s attention during the survey.
Failure to Document Rationale for Disagreeing With Pharmacist Medication Review Recommendations
Penalty
Summary
The facility failed to provide a documented rationale for not acting on the pharmacist’s medication regimen review recommendations for one resident. The facility policy stated that when the pharmacist submits a medication recommendation report, the physician reviews and responds to it and documents in the medical record what actions were taken to address the recommendation. In this case, the physician marked disagreement with several pharmacist recommendations but did not document why the recommendations were not followed, and the resident’s electronic medical record also did not contain a rationale for the decisions. The resident was less than 65 years old and had diagnoses including traumatic brain injury, bed confinement, anxiety disorder, quadriplegia, neuromuscular dysfunction, dementia, and insomnia. The resident’s assessment showed cognitive intactness with a BIMS score of 15, use of a wheelchair, dependence for several activities of daily living, and use of multiple psychoactive and pain medications. The resident was receiving mirtazapine for insomnia, risperidone for yelling, gabapentin, oxycodone, Tylenol, and Lexapro for anxiety. Pain assessments documented during the review period showed pain scores of 0 out of 10. The pharmacist made three recommendations that were not accompanied by a documented rationale when the physician disagreed. One recommendation was to decrease the oxycodone dose or frequency because the resident’s pain scores were consistently zero. Another was to obtain routine A1c levels or monthly finger stick blood sugar checks because the resident was receiving risperidone twice daily. A third was to decrease Lexapro from 20 mg to 15 mg after mirtazapine was started for insomnia, since Lexapro could contribute to insomnia. The DON stated she was aware the physician disagreed with the recommendations but did not know the rationale for the decisions, and the pharmacist stated that physician disagreement should include a rationale on the form.
Failure to Monitor and Stop Antibiotics After Negative Urine Culture
Penalty
Summary
The facility failed to establish an effective antibiotic stewardship program that included antibiotic use protocols and a system to monitor antibiotic use for one resident reviewed for antibiotic stewardship. The deficiency involved Resident #34, who had diagnoses including vascular dementia, seizures, osteoarthritis, and adult failure to thrive, and who was unable to complete the BIMS assessment and had severely impaired cognition. On 2/2/26, Resident #34 reported pain and burning with urination, and the charge nurse was notified and planned to notify the physician and perform a urine dip. On 2/3/26, the urine dip showed protein and leukocytes, the physician was notified, Macrobid was ordered for a UTI, and a urine sample was sent for C&S testing. The resident’s representative was notified by phone. The urine C&S results returned on 2/6/26 showing less than 10,000 CFU/mL of urogenital flora and 20,000-30,000 CFU/mL mixed flora. The physician was notified, and on 2/7/26 the resident continued to receive Macrobid even though the note stated the C&S was negative for UTI. The physician was not contacted for a stop date until 2/10/26, and the medication was discontinued then. The MAR showed the resident received eight additional doses of Macrobid after the negative C&S result was received and before the order was discontinued.
Failure to Monitor and Assess Foley Catheter Care Resulting in Resident Harm
Penalty
Summary
A deficiency occurred when staff failed to provide appropriate care and monitoring for a resident with quadriplegia and an indwelling Foley catheter. The resident, who was severely cognitively impaired and dependent on staff for all activities of daily living, had a history of acute renal failure, dementia, and dysfunctional bladder. Over a 24-hour period, the resident's urine output was significantly decreased, with only 300 ml recorded, and then zero output documented for the following shift. This decrease in urinary output was not communicated to nursing staff or the physician, and no assessment was performed for possible urinary retention or catheter obstruction. Nursing staff did not conduct assessments or monitor the resident for impaired urinary elimination or changes in urine characteristics, such as color, odor, or clarity, which could indicate a problem with the resident's urinary status. The facility's baseline care plan lacked specific interventions for assessing catheter patency, placement, or complications related to quadriplegia, such as autonomic dysreflexia. Documentation showed that CNAs were responsible for recording urine output, but there was confusion and lack of knowledge among staff regarding what constituted low output and when to notify a nurse or physician. Additionally, a CNA with medication authority signed off on nursing orders, which was outside their scope of practice. The resident was eventually found unresponsive and in respiratory distress, with vital signs indicating a critical condition. Upon transfer to the hospital, the resident was found to have a distended bladder containing 2000 ml of bloody urine with pus, bilateral hydronephrosis, and was diagnosed with severe sepsis, acute respiratory failure, and myocardial infarction. Staff interviews revealed a lack of training and knowledge regarding the care of residents with indwelling catheters and those with special needs such as quadriplegia. The failure to monitor, assess, and communicate changes in the resident's urinary status directly led to the resident's hospitalization and critical illness.
Removal Plan
- Education for all nurses and CNAs on daily catheter care, as well as monitoring and reporting of urinary output, was completed by the DON or designee.
- Nurses were educated on how to perform bladder assessments for residents with indwelling catheters, with a special focus on residents unable to communicate or who are paralyzed.
- All residents with indwelling catheters were audited for their last catheter change date and ensured accurate physician's orders were obtained for the next catheter change.
- The electronic medication administration record (eMAR) was reviewed to ensure accurate orders were in place, including those for catheter care, urinary output monitoring, and catheter replacement.
- All residents with indwelling catheters were assessed by the DON for bladder fullness to ensure proper catheter drainage.
- An as needed catheter change physician's order was added for another identified resident affected by the deficient practice.
- A shift evaluation for residents with dwelling catheters was implemented, including assessments of bladder status, urine output, potential blockages, and urine characteristics, to be conducted by floor nurses and documented in the eMAR.
- Abnormal findings from the floor nurse will be reported to the director of nursing and the on-call physician.
- All new admissions, readmissions, and newly ordered indwelling Foley catheters will be audited by the DON or designee to ensure catheter insertions are completed in accordance with physician's orders.
- All new admissions with indwelling catheters will be audited by the DON or designee to confirm the presence of appropriate physician orders and nursing interventions for daily catheter care.
- The audit will be completed by the director of nursing or designee.
Failure to Prevent Resident-to-Resident Physical Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident, resulting in a significant injury. On the date of the incident, a resident with a history of autistic disorder, dementia, and depression entered the facility from outside and was approached by another resident diagnosed with dementia and schizophrenia. The second resident pushed the first to the floor, causing the first resident to sustain a femur fracture that required surgical repair. The incident was observed by staff, and the injured resident reported pain and was subsequently transferred to the hospital for evaluation and treatment. Review of facility records and interviews revealed that both residents had documented behavioral histories, though neither had exhibited recent physical aggression or altercations according to their care plans and assessments. The resident who committed the abuse had severe cognitive impairment and was noted to have difficulty focusing and disorganized thinking, but no recent behaviors towards others were documented. The victim had moderate cognitive impairment and required supervision for mobility, using a cane or crutch for walking. At the time of the incident, staff were present in the area, but the altercation still occurred as the two residents passed each other near an exit doorway. Facility policy states that all residents have the right to be free from abuse, and the investigation substantiated that physical abuse occurred in this case. Staff interviews confirmed awareness of the incident and described standard practices for monitoring and redirecting residents with behavioral risks. However, the actions taken prior to the incident were insufficient to prevent the physical altercation and resulting injury.
Failure to Provide Wound Care and Complete Skin Assessments
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards for two residents reviewed for wound care and weekly skin assessments. For one resident with a history of heart failure, multiple sclerosis, dementia, and diabetes, the facility did not complete weekly skin assessments as required by policy. This resident, who had a history of hemorrhoids and was receiving topical medication, was admitted to the hospital with a perianal abscess that required surgical intervention and IV antibiotics. Facility documentation did not show that skin assessments were performed from early to late October, and there was no documentation of the resident's hemorrhoids in the care plan. Another resident, who had quadriplegia, acute renal failure, dementia, and a dysfunctional bladder, was admitted with stage 3 pressure wounds and an indwelling Foley catheter. The facility did not enter or initiate physician's orders for wound care as outlined in the hospital discharge instructions. There was no documentation of wound care being provided or skin assessments being completed after the initial wound care note, despite the resident having significant skin breakdown upon hospital readmission. Interviews with facility staff, including the DON and wound care nurse, confirmed that required wound care orders were not entered or followed, and that skin assessments were not completed as per facility policy. The breakdown in communication and documentation led to a lack of appropriate wound care and monitoring for both residents, resulting in unaddressed and worsening skin conditions.
Failure to Prevent Involuntary Seclusion for Resident with Behavioral Symptoms
Penalty
Summary
The facility failed to ensure a resident's right to be free from involuntary seclusion not required to treat medical symptoms. According to record review and staff interviews, a resident with dementia and depressive episodes, who required supervision for activities of daily living and had memory problems, was told by staff to return to her room or was taken to her room as a response to her behaviors. The care plan for this resident did not include interventions involving sending her to her room as a behavioral management strategy. Nursing progress notes documented that the resident was asked to eat lunch in her room due to her behavior in the dining room, which included yelling and taunting other residents, and was told by staff that if she was not nice, she had to go to her room. Staff interviews revealed that an LPN would tell disruptive residents they would be removed from activities or returned to their rooms, making decisions based on the situation. The DON confirmed that the facility did not have a policy allowing staff to send residents to their rooms as a disciplinary action and stated that if residents were redirected, they should be offered alternative activities or interventions rather than being sent to their rooms. The facility's policy emphasized residents' rights to be free from involuntary seclusion and to be treated with dignity and respect.
Failure to Provide Appropriate Dementia Care
Penalty
Summary
A resident who displays or is diagnosed with dementia did not receive the appropriate treatment and services. The facility failed to ensure that the necessary care was provided to address the resident's dementia-related needs, as required by regulatory standards. This deficiency was identified during the survey process.
Failure to Complete Annual Performance Reviews and In-Service Education
Penalty
Summary
The facility failed to complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four staff members. Specifically, CNA #2, CNA #3, CNA #4, and CNA #5 did not have annual performance reviews completed, nor did they have an in-service education plan based on the outcome of the reviews. During an interview, the nursing home administrator admitted she could not locate the performance reviews for these CNAs and was unaware that the reviews needed to include a regular in-service plan based on the outcomes.
Failure to Ensure Residents Were Free from Unnecessary Psychotropic Medications
Penalty
Summary
The facility failed to ensure that three residents were free from unnecessary psychotropic medications. Specifically, the facility did not implement effective individualized behavior monitoring in the medical records to determine the efficacy of psychoactive medications for the residents. Additionally, the facility did not ensure that consents to review the risks versus benefits were in place prior to the administration of psychotropic medications for two of the residents. Resident #36, who was under 65 and had diagnoses including stroke, anxiety disorder, and depressive disorder, was on psychotropic medications Amitriptyline and Seroquel. The facility's documentation failed to indicate what non-pharmacological interventions were tried and what medication the interventions were associated with. There were no behaviors observed in the resident's progress notes from January to March 2024, and non-pharmacological interventions indicated in the MAR and TAR were not documented in the progress notes. Resident #40, also under 65, had diagnoses including mild cognitive impairment, anxiety, depression, obsessive-compulsive disorder, and mild intellectual disabilities. The facility's documentation failed to indicate what non-pharmacological interventions were tried and what medication the interventions were associated with. Additionally, no consents that reviewed the risks versus benefits associated with taking the medications were located for Lorazepam. Resident #49, aged 93, had dementia with behavioral disturbances and was on Seroquel. The facility failed to document non-pharmacological interventions in the progress notes and did not have consents in place for Seroquel.
Failure to Incorporate PASRR Recommendations
Penalty
Summary
The facility failed to incorporate recommendations from the preadmission screening and resident review (PASRR) level II determination and evaluation for a resident with serious mental illness. Specifically, the facility did not arrange and incorporate the recommendations for psychiatric case consultation and individual therapy for a resident diagnosed with bipolar disorder. Additionally, the resident had requested to see a rheumatologist for rheumatoid arthritis, but no referral or appointment was made. The PASRR evaluator also recommended ruling out an inaccurate diagnosis of Huntington's disease, which was not addressed by the facility. The comprehensive care plan for the resident, revised in April 2023, included interventions for Huntington's disease, despite the PASRR evaluator's recommendation to remove this diagnosis. The care plan did not include a PASRR-focused care plan, and there were no progress notes indicating the status of the PASRR recommendations or communication with the State Mental Health Agency. The medical director and other staff members were unaware of the resident's request to see a rheumatologist and had not taken steps to correct the inaccurate diagnosis of Huntington's disease. Interviews with staff revealed a lack of communication and follow-through on the PASRR recommendations. The social services director was unaware of whether a referral had been made for a rheumatologist, and the medical records clerk had not received any referrals or made any appointments for the resident. The director of nursing was also unaware of the PASRR recommendations and the need to correct the resident's diagnosis. This lack of coordination and communication resulted in the facility's failure to meet the resident's needs as outlined in the PASRR level II determination.
Failure to Provide Vision and Hearing Services
Penalty
Summary
The facility failed to ensure proper treatment and assistive devices to maintain vision and hearing abilities for two residents. Resident #54, who was admitted with type II diabetes mellitus and required assistance with various activities of daily living, reported that she could not see out of her glasses and had not been offered an eye exam. Despite her care plan indicating the need for visual aids and consultations with an eye care practitioner, no appointment had been made. Interviews with staff revealed a lack of awareness and communication regarding the resident's need for an eye exam, with the Medical Records Director (MRD) and Director of Nursing (DON) both unaware of the issue until it was brought to their attention during the survey. The Social Service Director (SSD) also did not know the last time the resident had her eyes checked and had not communicated the need for an eye exam to the MRD. This lack of coordination and follow-through resulted in the resident not receiving the necessary eye care services in a timely manner. Resident #40, who had mild cognitive impairment, anxiety, depression, and mild intellectual disabilities, experienced significant hearing difficulties. The resident reported increased anxiety and self-harm behaviors due to his inability to hear properly. Despite having a hearing exam and recommendations for new hearing aids, the resident had not received the necessary devices. The SSD was not aware of the status of the insurance claim for the hearing aids and had not reached out to an organization that provided grants for such services. The resident's care plan indicated the need for hearing aids, but there was no documentation of assistance with these devices. Interviews with staff revealed confusion about the resident's hearing aid status and a lack of consistent support in managing his hearing needs. The DON acknowledged the resident's impaired hearing and the agitation caused by staff having to yell to communicate with him, but there was no clear plan to address the issue. The facility's failure to ensure timely and appropriate vision and hearing services for these residents highlights significant gaps in communication, coordination, and follow-through among staff. The lack of awareness and action regarding the residents' needs resulted in prolonged periods without necessary assistive devices, negatively impacting their quality of life and well-being. Staff interviews consistently pointed to a lack of clarity about responsibilities and procedures for managing ancillary services, contributing to the deficiencies identified in the survey.
Failure to Ensure Medication Order for Resident
Penalty
Summary
The facility failed to ensure the resident environment remained as free of accident hazards as possible for one resident reviewed for accidents/hazards. Specifically, the facility did not ensure that a resident had an order for a medication (Icy Hot) found at his bedside. The resident, who was under 65 years old and had diagnoses including autistic disorder, dementia, and fibromyalgia, was observed with Icy Hot at his bedside on two consecutive days. The resident's cognitive status was intact with a BIMS score of 15 out of 15. A registered nurse confirmed that Icy Hot was considered a medication and that the resident did not have an order for it nor an assessment for self-administration. The director of nursing also confirmed the lack of a physician's order for the Icy Hot and stated that the medication had been removed.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to assist a resident in obtaining routine or emergency dental services as needed. Specifically, the facility did not ensure that dental services were offered to a 66-year-old resident who had been admitted on 11/3/23. The resident, who was cognitively intact and required moderate assistance with daily activities, reported tooth pain and had not seen a dentist since her admission. Despite the resident marking on her admission packet that she wanted an initial dental consult, there was no documentation in her medical records indicating that dental care had been initiated or completed. Interviews with facility staff revealed a lack of clarity and responsibility regarding the scheduling of dental appointments. The Social Service Director stated that the Medical Records Director was responsible for arranging these appointments, while the Medical Records Director believed the resident had been seen by a mobile dentist who visited the facility in February 2024. However, the Director of Nursing confirmed that the mobile dentist had only visited once and was supposed to see all residents without a regular dentist. The lack of coordination and follow-through resulted in the resident not receiving the necessary dental care.
Failure to Implement Pneumococcal Immunization Policies
Penalty
Summary
The facility failed to develop and implement policies and procedures related to pneumococcal immunizations for one of the three residents reviewed for vaccinations. Specifically, the facility did not ensure that Resident #17, who was over the age of 65 and had been admitted with a diagnosis of nontraumatic intracerebral hemorrhage, was offered the secondary pneumococcal immunization. The resident had received the Prevnar 23 vaccine on 9/7/16, but there was no evidence in the facility's records of an offer or refusal of the subsequent pneumococcal vaccine as recommended by the CDC guidelines. During staff interviews, the MDS coordinator admitted to not knowing that the facility was required to offer the vaccine annually, even if the resident had previously refused it. The director of nursing also acknowledged that the facility needed to follow CDC guidelines. This lack of awareness and adherence to vaccination protocols led to the deficiency in ensuring that Resident #17 was properly offered the secondary pneumococcal immunization.
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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