Rock Canyon Respiratory And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Pueblo, Colorado.
- Location
- 2515 Pitman Pl, Pueblo, Colorado 81004
- CMS Provider Number
- 065100
- Inspections on file
- 30
- Latest survey
- December 11, 2025
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Rock Canyon Respiratory And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia and a history of aggressive behavior struck another cognitively impaired resident in the dining area after attempting to take her food. Staff and care plans documented the assailant's behavioral risks, including wandering and food-seeking, but did not fully address triggers related to resistance from others. The incident resulted in physical abuse, with no injuries noted, and both residents were unable to recall the event due to cognitive impairment.
Housekeeping staff failed to consistently disinfect high-touch surfaces and perform proper hand hygiene, including after glove changes and when cleaning resident bathrooms. Additionally, a nurse did not follow manufacturer guidelines for disinfecting a glucometer, using only one wipe and not maintaining the required contact time. These actions resulted in lapses in the facility's infection prevention and control program.
Two residents with significant cognitive and physical impairments were unable to consistently reach their call lights while in bed, despite facility policy requiring call lights to be accessible. Staff observations and resident interviews confirmed that call lights were often placed out of reach, and care plans specifically noted the need for call lights to be accessible due to the residents' ADL deficits and risk for pressure ulcers. Staff interviews revealed inconsistent practices and a lack of awareness regarding the adequacy of call light cord lengths.
A resident with multiple psychiatric and medical diagnoses was observed repeatedly exhibiting symptoms of tardive dyskinesia, such as constant lip smacking, while on antipsychotic medications. Nursing staff and the social services director were aware of these symptoms but failed to document them or notify the physician or psychiatrist, and required monitoring assessments were not accurately completed. This resulted in a lack of appropriate monitoring and reporting of adverse medication effects.
A resident with multiple complex medical conditions received topical steroid and antifungal creams for a rash based on a physician's order that did not specify the dosage to be applied. Nursing staff applied the creams using their own judgment, leading to inconsistent administration practices. The lack of a clear dosage in the order was not identified or clarified before administration, resulting in a failure to meet professional standards of medication administration.
A resident with severe contractures and anoxic brain damage did not consistently receive prescribed bilateral hand splints for contracture management, as observed on multiple occasions. Staff failed to document the application and fit of the splints, and the care plan lacked specific interventions for checking splint placement. Responsibility for restorative care had shifted among staff, leading to inconsistent implementation of physician orders and facility policy.
An LPN failed to properly prime an insulin pen before administering Humalog insulin to a resident with diabetes and hypertension. The pen was not primed with the needle attached as required by manufacturer guidelines, resulting in a significant medication error.
A resident with cognitive and mental health impairments was involved in a drug sting operation orchestrated by the NHA, who provided money for the resident to purchase methamphetamines from another resident. The resident experienced mental anguish, fear, and discomfort as a result, and was not provided with adequate support or a private counseling environment following the incident. The facility failed to document an internal investigation or update the resident's care plan to address the incident.
A resident with impaired decision-making skills and a history of falls experienced four falls over three months, resulting in a fractured nose. The facility failed to update and implement individualized fall interventions, such as ensuring proper footwear and call light accessibility. Observations and staff interviews revealed inconsistencies in adhering to the care plan, contributing to the resident's repeated falls and injuries.
The facility failed to provide adequate nutrition and hydration for two residents, resulting in significant weight loss. One resident lost 14 pounds in six weeks due to insufficient meal assistance and lack of new interventions despite ongoing weight loss. Another resident was not weighed upon admission, leading to inappropriate nutritional interventions based on an incorrect hospital weight. Staff interviews revealed inconsistencies in documentation and oversight of residents' nutritional intake and weight monitoring.
The facility failed to manage tube feeding properly for several residents, including those in a vegetative state and on respirators. Containers were not labeled with necessary information, and prescribed formulas were not administered as per physician orders. Instead, Jevity 1.5 was used without proper documentation, and water flushes were not given at the correct rate. Feeding pumps were also not calibrated, and staff interviews revealed a lack of communication and adherence to orders.
The facility's QAPI program failed to address compliance concerns, resulting in repeated deficiencies in areas like the resident call system and ADL care. Issues with nutrition and hydration led to actual harm, including severe weight loss and incorrect tube feeding administration. The NHA admitted to inadequate monitoring processes and the need for dietician training.
The facility failed to provide necessary ADL services and meal assistance for several residents. Residents in vegetative states and with severe cognitive impairments were not repositioned or provided with toileting care as required. Additionally, a resident did not receive adequate meal assistance, leading to missed meals. Staff interviews confirmed inconsistencies in care provision.
The facility failed to provide a working call light system for two residents and in the shower facilities. A resident with severe cognitive impairment was found without a call light and reported that staff did not respond to a service bell. Another resident, initially assessed as unable to use a call bell, was later provided with one. Additionally, the shower rooms lacked a functioning call light system, with an emergency button that did not work.
The facility failed to maintain the dignity and privacy of two residents. One resident was left exposed in bed for two hours with the door open, while another was repeatedly observed in the dining room with improperly positioned clothing, exposing him to others. Staff did not take action to cover or assist the residents, leading to a deficiency in care.
The facility failed to provide a clean, comfortable, and homelike environment for its residents, with issues such as peeling paint, broken blinds, improperly labeled closet spaces, and poor furniture condition. Residents expressed dissatisfaction, and staff interviews revealed inconsistencies in maintenance requests and cleaning responsibilities.
The facility failed to maintain proper sanitation in the secure unit kitchen, leading to pest harborage conditions. Observations revealed dirty walls and floors under the dish machine, a pest glue trap with roaches, and live cockroaches behind the cove base. Staff interviews indicated a lack of a cleaning list and inadequate cleaning practices.
The facility failed to maintain accurate and complete medical records for three residents regarding their Medical Orders for Scope of Treatment (MOST) forms. The forms lacked mandatory signatures and proper documentation of verbal consents, revealing gaps in the process of obtaining and documenting these consents.
The facility failed to ensure the call light system was functioning properly for all 27 residents on the secure unit. A resident with multiple medical conditions confirmed that the call light system in his room did not work. Staff performed 15-minute checks due to the non-functional call light system, but these checks were not documented. The maintenance supervisor acknowledged the call light system was not functional, and staff interviews revealed a lack of awareness about its functionality.
The facility failed to follow the appropriate procedure for a facility-initiated discharge for a resident who requested an appeal. Despite the resident's multiple medical conditions and concerns about managing pain and oxygen needs, the facility did not properly document or address the appeal request. Interviews with staff revealed a lack of communication and proper procedure in handling the resident's appeal, resulting in a deficiency in care.
The facility failed to ensure a resident with dementia received appropriate treatment and services, as staff did not implement wandering interventions listed in the care plan or consistently document the resident's wandering behavior and interventions used. The resident frequently entered other residents' rooms and triggered an alarmed exit door without staff intervention or redirection.
The facility reported a medication error rate of 6.25%, exceeding the acceptable threshold of 5%. Two RNs failed to prime insulin pens before administering Lispro insulin to two residents, contrary to manufacturer guidelines and facility policy.
The facility failed to ensure residents were free from significant medication errors by not priming insulin pens before administration. Two residents received incorrect doses of insulin due to this oversight by the nursing staff.
The facility failed to maintain an infection control program by not ensuring that a glucometer was cleaned in a sanitary manner. An RN used PDI Sani Hand wipes instead of the required EPA-registered disinfectant wipes, leading to a failure in preventing potential infection transmission. Interviews revealed discrepancies between the facility's policy, the manufacturer's guidelines, and the actual practice observed.
A resident with normal cognitive function was involved in an inappropriate relationship with a respiratory therapist, including holding hands, kissing, and exchanging suggestive texts. Despite the facility's policy against abuse, the incident was not classified as abuse, leading to a deficiency in protecting the resident.
Failure to Prevent Resident-to-Resident Physical Abuse in Secured Unit
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident took place in the secured unit dining area, where one resident with a history of behavioral disturbances and dementia attempted to take food from another resident. When the second resident refused, the first resident struck her in the head. Staff present separated the residents, and the victim was assessed with no injuries noted. Both residents were unable to recall the incident due to cognitive impairment. The resident who committed the abuse had documented behavioral issues, including aggression, wandering, and attempts to take food from others. His care plan noted these behaviors and included interventions such as providing his meal immediately upon seating and redirecting him as needed. However, the care plan did not specifically address the trigger of resistance or argument when he tried to take items from others. Staff interviews confirmed that this resident frequently wandered, attempted to take food from others, and could become aggressive if confronted or not redirected promptly. There was also a prior incident where this resident fell while trying to take food from another resident, resulting in injury to himself. The victim of the abuse was also severely cognitively impaired and required supervision or assistance for most activities of daily living. She did not have a history of behavioral issues and was not involved in previous incidents. Staff and representatives confirmed that she would become upset if others tried to take her belongings but had not previously had altercations with other residents. The facility's failure to anticipate and prevent the interaction between these two residents, despite known behavioral risks, led to the occurrence of physical abuse.
Infection Control Deficiencies in Housekeeping and Glucometer Disinfection
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program on one of four units, as evidenced by multiple deficiencies in housekeeping and clinical practices. Housekeeping staff did not consistently follow proper cleaning techniques for resident rooms and high-touch surfaces. Observations revealed that a housekeeper neglected to disinfect high-touch areas such as bed remotes, call lights, light switches, over-bed tables, and nightstands. Additionally, the housekeeper did not perform hand hygiene after removing gloves and before donning new gloves, despite facility policy and CDC guidelines requiring hand hygiene at these points. The housekeeper also used a toilet brush outside of the toilet bowl, which is not in accordance with facility procedures, and failed to clean the base of the toilet. The housekeeper admitted to not always cleaning high-touch areas and not documenting which rooms required additional cleaning, relying instead on memory. Interviews with staff confirmed gaps in training and adherence to infection control protocols. The housekeeper stated she had received hand hygiene education but had developed poor habits from previous employment. She was unaware that the toilet brush should not be used outside the toilet bowl and did not consistently clean all required high-touch areas. The housekeeping and laundry manager and the director of nursing both confirmed that hand hygiene should be performed after glove changes and that high-touch areas must be cleaned daily, but these practices were not consistently followed by staff. In addition to housekeeping deficiencies, clinical staff failed to properly disinfect individual glucometers according to manufacturer guidelines. A registered nurse was observed cleaning a resident's glucometer with only one disinfectant wipe and not allowing the device to remain wet for the required four-minute contact time. The nurse believed a two-minute drying time was sufficient, which does not meet the manufacturer's instructions. The clinical nurse resource and infection preventionist both acknowledged that glucometers should be cleaned according to manufacturer recommendations, but the observed practice did not align with these standards.
Failure to Ensure Call Lights Were Within Reach for Two Residents
Penalty
Summary
The facility failed to provide reasonable accommodation for mobility and accessibility by not ensuring that two residents' call lights were within reach while they were in bed. According to facility policy, call lights are to be placed within the resident's reach before staff leave the room. However, multiple observations revealed that both residents had their call lights positioned out of reach on several occasions, including being placed on the floor, clipped above the head with no slack, or left on a side table or under a pillow, making it difficult or impossible for the residents to access them when needed. One resident, who was severely cognitively impaired and required substantial to maximal assistance for most activities of daily living, reported that her call light was often too far away, requiring her to rely on her roommate for assistance. Observations confirmed that her call light was sometimes on the floor or stretched tightly above her head, and staff did not consistently reposition it within her reach after providing care. Her care plan specifically included the intervention to keep the call light within reach due to her risk for pressure ulcers and ADL deficits. The second resident, who had a history of stroke, repeated falls, and muscle wasting, also required significant assistance and reported difficulty reaching his call light. He stated that he had informed staff about the issue, and observations showed his call light was sometimes clipped above his head or under his pillow, both out of his reach. Staff interviews indicated awareness of the need to keep call lights accessible, but also revealed inconsistent practices and a lack of awareness about the specific issues with these residents' call light cord lengths.
Failure to Monitor and Report Tardive Dyskinesia in Resident on Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that a resident receiving antipsychotic medications was free from chemical restraints and received appropriate monitoring for side effects, specifically tardive dyskinesia. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and cognitive impairment, was observed repeatedly smacking her lips, a symptom consistent with tardive dyskinesia, during multiple observations over several days. Despite these visible symptoms, there was no documentation in the resident's medical record, medication administration records, or progress notes indicating that these symptoms were recognized, monitored, or reported to the physician. Staff interviews revealed that nursing staff, including RNs and LPNs, were aware that the resident had been exhibiting signs of tardive dyskinesia since admission. However, this information was not documented in the resident's records, nor was it communicated to the attending physician or psychiatrist. The facility's policy required monitoring and documentation of side effects, including tardive dyskinesia, and completion of the Abnormal Involuntary Movement Scale (AIMS) assessment quarterly. The most recent AIMS assessment did not reflect the observed symptoms, and there was no evidence of ongoing monitoring or timely notification to medical providers regarding the resident's condition. Additionally, the social services director acknowledged awareness of the resident's tardive dyskinesia but did not communicate this to the physician or psychiatrist. The resident's care plan included interventions for monitoring side effects, but these were not implemented as required. The lack of documentation and communication resulted in a failure to ensure the resident was appropriately monitored for adverse effects of antipsychotic medications, as required by facility policy and professional standards.
Failure to Specify Dosage in Physician's Order for Topical Medications
Penalty
Summary
The facility failed to ensure that services provided to a resident met professional standards of quality, specifically regarding the administration of medicated creams for a skin rash. The physician's order for the resident directed staff to mix prednisone cream and antifungal cream and apply to the affected body area every shift, but did not specify the dose or measurement for each cream. This omission left nursing staff without clear guidance on the amount of medication to administer, which is contrary to both professional standards and the facility's own medication administration policy requiring the 'five rights,' including the right dosage. The resident involved had significant medical conditions, including vascular dementia, hemiplegia, type 2 diabetes, and mesothelioma, and was dependent on staff for all activities of daily living. Observations noted the presence of a rash on the resident's abdomen and other body areas. Staff interviews revealed inconsistency in how the creams were applied: one nurse used a measured amount based on personal judgment, while another applied a thin layer to cover the affected areas, also relying on personal judgment. Both nurses indicated that the order was unclear regarding the specific amount to use. The Director of Nursing confirmed that a key component of a prescription is the amount to administer and stated that nurses should clarify incomplete orders with the physician before administering medication. However, the lack of a specified dose in the physician's order was not identified or addressed prior to administration, resulting in the deficiency.
Failure to Consistently Apply and Document Hand Splints for Resident with Contractures
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received appropriate treatment and services to increase or maintain ROM and prevent further decline, as required by physician orders and facility policy. Specifically, the resident, who had diagnoses including anoxic brain damage and contractures of the upper and lower extremities, was observed multiple times without the prescribed bilateral hand contracture soft splints in place. The resident was dependent for all activities of daily living and was in a persistent vegetative state, requiring staff to provide passive ROM and apply hand splints as ordered. Observations over several days revealed that the resident's hands were consistently found without the soft splints, despite a physician's order for their use and regular checks for fit and skin integrity. Documentation of passive ROM was inconsistent, with some days lacking any record of care, and there was no documentation indicating whether the hand protectors were applied or checked for fit. The care plan did not include specific interventions for checking the placement of the hand splints, and staff training records indicated that staff were instructed to apply the hand protectors daily, but this was not consistently done in practice. Interviews with staff confirmed that the responsibility for applying the splints and providing passive ROM had shifted from a restorative nurse aide to CNAs and the therapy department, following the departure of the restorative nurse aide. Staff acknowledged challenges in applying the splints due to the resident's contractures and occasional removal of the splints by the resident, but also admitted that documentation and consistent application of the splints were lacking. The rehabilitation resource noted that refusals and application of splints were not adequately documented in the care plan.
Failure to Properly Prime Insulin Pen Before Administration
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) failed to properly prime an insulin pen before administering a dose of Humalog insulin to a resident. According to manufacturer guidelines, priming the insulin pen with the needle attached is necessary to remove air from the needle and cartridge, ensuring the correct dose is delivered. During observation, the LPN dialed two units and pushed on the cartridge before attaching the disposable needle, then dialed the prescribed dose and administered the insulin to the resident without priming the pen with the needle in place. The resident involved was under 65 years old, had diagnoses including hypertension and diabetes, and was cognitively intact with a BIMS score of 15. The resident required assistance with some activities of daily living. The failure to follow proper insulin administration technique was confirmed through staff interviews and review of manufacturer instructions, which specify that the needle must be attached before priming to ensure accurate dosing.
Resident Subjected to Mental Abuse During Administrator-Led Drug Sting
Penalty
Summary
The facility failed to protect a resident from mental abuse and anguish when the nursing home administrator (NHA) orchestrated a drug purchase involving the resident. The resident, who had developmental disabilities, dementia, depression, anxiety, and schizophrenia, was approached by the NHA after staff found a pipe used for methamphetamines in his possession. The NHA asked the resident to participate in a sting operation to identify the source of drugs within the facility, providing him with $20 to purchase methamphetamines from another resident while the NHA observed. The NHA then confiscated the drugs and pipe and notified the police. The resident reported feeling compelled to participate in the drug purchase to prove he was not a drug dealer, and subsequently experienced fear, discomfort, and mental anguish. He expressed concerns about being arrested or discharged from the facility, and reported that staff referred to him as a drug dealer. The resident also stated that he was not informed of the potential consequences of participating in the sting operation, and that he was unhappy with the counseling services provided afterward, as they were not conducted in a private setting and did not address his emotional needs. The facility's own abuse prevention policy required residents to be free from all forms of abuse, including mental abuse, and mandated immediate investigation and support for affected residents. However, there was no documentation of an internal investigation into the incident, and the resident's care plan did not reflect interventions related to the incident. Interviews with staff confirmed awareness of the NHA's actions, but no further investigation or support was documented for the resident involved.
Failure to Implement Individualized Fall Interventions for Resident
Penalty
Summary
The facility failed to maintain a safe environment for Resident #20, who was at risk for falls due to severely impaired daily decision-making skills and other health conditions. Despite being identified as a fall risk upon admission, the facility implemented generalized fall risk interventions that were not tailored to the resident's specific needs. Over a three-month period, Resident #20 experienced four falls, with the last fall resulting in a fractured nose. The facility did not consistently update the resident's care plan with new interventions following each fall, nor did they ensure staff consistently implemented the identified interventions. Observations during the survey revealed several deficiencies in the implementation of fall interventions for Resident #20. The resident was not always wearing appropriate non-slip footwear, and there was no call light in her room, despite these being part of her fall prevention plan. Interviews with staff indicated a lack of consistent adherence to the care plan, with CNAs acknowledging the need for proper footwear but failing to ensure it was worn. Additionally, the facility's fall investigations did not consistently document whether the resident was wearing appropriate footwear at the time of each fall. The facility's failure to update and implement individualized fall interventions was further compounded by inadequate documentation and communication. The resident's care plan was not updated with new interventions after each fall, and there was no documentation of family decisions regarding room changes or wheelchair modifications. Interviews with the DON and MDSC highlighted discrepancies in the care plan, such as the inappropriate inclusion of a call light intervention for a resident without a call light. These oversights contributed to the repeated falls and injuries sustained by Resident #20.
Failure to Ensure Adequate Nutrition and Hydration
Penalty
Summary
The facility failed to ensure adequate nutrition and hydration for two residents, leading to significant weight loss and lack of proper care. Resident #23, who was admitted at nutritional risk, lost 14 pounds in six weeks. Despite initial interventions such as nutritional supplements and fortified foods, the facility did not adequately encourage, cue, or assist the resident during meals. Observations showed that the resident was not offered alternatives or refills and was not provided a new meal after spilling his food. The care plan did not reflect the ongoing weight loss, and no new interventions were considered when the resident continued to lose weight. Resident #1 was not weighed upon admission, which is a critical step in establishing a baseline for nutritional assessment. The facility relied on an incorrect hospital weight, which was not verified, leading to inappropriate nutritional interventions. The resident, who was dependent on tube feedings, experienced significant weight loss, and the facility failed to adjust the feeding regimen based on an accurate weight. The RD had requested a weight to determine the correct amount of tube feeding, but this was not obtained until 36 days after admission. Interviews with staff revealed a lack of proper documentation and oversight in monitoring residents' nutritional intake and weight. The CNAs were responsible for documenting meal consumption, but there were inconsistencies in the records. The dietary manager and registered dietitian consultants acknowledged the need for accurate weights and proper meal assistance, but these were not consistently provided. The facility's failure to adhere to its own policies and procedures regarding weight monitoring and nutritional support contributed to the deficiencies identified in the report.
Deficiencies in Tube Feeding Management
Penalty
Summary
The facility failed to ensure proper management and care for residents with percutaneous endoscopic gastrostomy (PEG) tubes, leading to several deficiencies in tube feeding management. Specifically, the facility did not label tube feeding containers with necessary information such as the resident's name, room number, date, start time, formula type, feeding rate, and nurse initials. This oversight affected multiple residents, including those in a persistent vegetative state and those dependent on respirators, highlighting a lack of adherence to professional standards and facility policies. Additionally, the facility did not provide the prescribed formula as per the computerized physician orders (CPO) for several residents. Instead of administering Fibersource HN, the residents were given Jevity 1.5, which was not an equivalent formula. This substitution was made without proper documentation or physician orders, as the facility was experiencing a backorder of Fibersource HN. The registered dietitian was unaware of the discrepancies between the physician's orders and the actual formula being administered, which could potentially lead to nutritional imbalances. Furthermore, the facility failed to provide water flushes at the prescribed rate for some residents, and the feeding pumps were not calibrated as required. Observations revealed that the water flushes were either not administered at the correct rate or not documented properly. Staff interviews indicated a lack of communication and understanding of the physician's orders, with some staff members not questioning incorrect orders or failing to label feeding containers due to busy shifts. These deficiencies in tube feeding management could lead to serious health complications for the residents involved.
Ineffective QAPI Program Leads to Repeated Deficiencies
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program to address and rectify compliance concerns, particularly in areas affecting residents' quality of life and care. The QAPI committee did not adequately identify or prioritize performance improvement plans (PIPs) for issues such as the resident call system and activities of daily living (ADL) care for dependent residents. These deficiencies were repeatedly cited in surveys, indicating a pattern of non-compliance. Additionally, the facility did not effectively address concerns related to nutrition and hydration, resulting in actual harm to residents, including severe weight loss and incorrect administration of tube feedings. Interviews with the nursing home administrator (NHA) revealed that the interdisciplinary team met monthly for QAPI meetings, but significant issues like tube feedings were not identified as concerns. The NHA acknowledged the lack of an effective process for monitoring and managing tube feedings and recognized the need for training from the registered dietician. Despite discussions on falls and weight loss, the facility failed to implement effective interventions to prevent falls and maintain a working call light system, further contributing to the deficiencies.
Deficiencies in ADL Assistance and Meal Support
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living (ADLs), affecting six out of 13 residents reviewed. Specifically, the facility did not ensure timely repositioning and toileting/incontinence care for several residents. For instance, Resident #10, who was in a persistent vegetative state and dependent on two staff members for all ADLs, was not repositioned or provided with incontinence care during a two-hour and 18-minute observation period. Similarly, Resident #16, also in a persistent vegetative state, was not repositioned or provided with necessary care during the same observation period, despite being dependent on staff for all ADLs. Resident #14, who had multiple contractures and was dependent on a ventilator, was not repositioned or provided with incontinence care during a two-hour and 18-minute observation. Staff interviews revealed that residents were supposed to be repositioned and toileted every two hours, but this was not consistently done. Additionally, Resident #6, who had severe cognitive impairments and was dependent on staff for personal hygiene and mobility, was not repositioned or offered toileting care during a three-hour and 36-minute observation period. Resident #24, with similar dependencies, was also not repositioned or offered necessary care during a three-hour and 26-minute observation. Furthermore, the facility failed to ensure Resident #9 received assistance with meals. Despite being dependent on staff for all ADLs and requiring setup and supervision for eating, Resident #9 was not provided with adequate assistance during meal times. Observations showed that the resident left the dining area without eating, and no staff attempted to redirect or assist her. Interviews with staff indicated that Resident #9 needed cueing and encouragement to eat, but this was not provided, resulting in the resident not consuming her meals.
Deficiency in Call Light System for Residents and Shower Rooms
Penalty
Summary
The facility failed to provide a working call light system for two residents and in the shower facilities, which is a violation of their policy to ensure residents have a means of communication with nursing staff. Resident #24, who has severe cognitive impairment and multiple physical disabilities, was observed without a call light in his room and was found yelling for help. Despite being given a yellow service bell, the resident reported that staff did not respond when he used it. Staff interviews revealed that residents in the memory care unit, including Resident #24, did not have call lights due to concerns about safety and the residents' ability to use them. Resident #8, who has moderate cognitive impairments and is dependent on staff for most activities, was also found without a call light. Initially assessed as unable to use a call bell, the resident was later reassessed and provided with a bell. However, the initial lack of a call light system for Resident #8 highlights a failure in ensuring that residents have the necessary tools to communicate their needs effectively. Additionally, the men's and women's shower rooms on the memory care unit lacked a functioning call light system. A red button labeled 'emergency' was present but did not work when tested. Staff interviews confirmed that there was no alternative system in place for residents to call for assistance in these areas, and the maintenance supervisor acknowledged that the call light system in the shower rooms had not been functional for years.
Deficiency in Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity and respect of two residents, leading to deficiencies in their care. Resident #16, who is under 65 years old and has a history of traumatic brain injury, was observed lying in bed with his brief and the right side of his body exposed for two hours. During this time, the resident's bedroom door was left open, allowing passers-by to see him. Despite staff entering the room to administer medication and provide care, they did not cover the resident or close the door to ensure his privacy. Resident #28, a 69-year-old with diagnoses including morbid obesity and schizophrenia, was observed in the dining room with his clothing improperly positioned, exposing his intergluteal cleft. This occurred over three consecutive days, and no staff members were observed offering to adjust his clothing to prevent exposure. Although the DON mentioned that staff encouraged the resident to fix his clothing and offered assistance, these actions were not observed during the survey. Interviews with staff and residents revealed that the facility's policy on dignity and respect was not consistently followed. The DON acknowledged the issues but was unsure why staff left Resident #16 exposed and did not actively assist Resident #28 in adjusting his clothing. The facility's failure to ensure privacy and appropriate clothing for these residents resulted in a deficiency in maintaining their dignity and respect.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents. Observations revealed multiple deficiencies in the secure unit and rehabilitation unit, including peeling paint, chipped wood, and splatters on walls and floors. The common areas and resident rooms were not maintained in good repair, with issues such as broken blinds, missing handles on dressers, and improperly labeled closet spaces. Additionally, the common area furniture was found to be in poor condition, with cracked and worn surfaces. The outdoor patio area was littered with cigarette butts and burn marks, indicating a lack of cleanliness and maintenance. Interviews with residents highlighted their dissatisfaction with the state of their living environment. One resident expressed concerns about the broken handle on his dresser and the condition of his blinds, which did not adequately block out light. Another resident mentioned the old and worn-out furniture in his room and the presence of names written on his closet shelf from previous occupants. Staff interviews revealed that maintenance requests were not consistently submitted, and there was a lack of clarity regarding responsibilities for cleaning and labeling. The maintenance supervisor acknowledged the issues and indicated that some corrective actions were planned, such as repainting shelves and cleaning walls. However, the overall findings demonstrate a failure to maintain a safe, clean, and homelike environment for the residents, as required by regulations. The deficiencies observed and reported by residents and staff indicate systemic issues in the facility's maintenance and housekeeping practices.
Sanitation Issues in Secure Unit Kitchen
Penalty
Summary
The facility failed to store, prepare, and serve food in a sanitary manner in one of its two kitchens, specifically the secure unit kitchen. Observations revealed that the dish room sanitation was not maintained, leading to conditions that could harbor pests. The tile walls behind and under the dish machine tables were splattered with brown spots and small pieces of debris. A layer of black dirt and grime with pieces of debris and food crumbs was found on the floor under the dish machine and both dish machine tables, extending to the walls. Additionally, the black vinyl cove base under the clean dish table was pulled away from the wall in two spaces, and an undated pest glue trap with approximately 20 small roaches inside was found on the floor under the clean side dish table. Two dead and dried roach carcasses were also observed next to the pest glue trap, and two live cockroaches were found behind the cove base under the dirty side dish table when it was pulled away from the wall. Interviews with staff revealed that the dietary manager (DM) was aware of the need for a cleaning list but had not yet implemented one. The DM admitted that while the kitchen floors were cleaned daily, the area under the dish machine had not been specifically cleaned. The maintenance supervisor (MS) confirmed that the pest control company visited the facility regularly and placed sticky traps in areas likely to harbor pests, such as under the dish machine. However, the MS was unsure how long the pest sticky trap had been under the dish machine. The facility's failure to maintain proper sanitation in the dish room and eliminate pest harborage conditions led to the observed deficiencies.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents, specifically regarding the Medical Orders for Scope of Treatment (MOST) forms. For Resident #3, the MOST form indicated a wish to receive CPR but lacked the mandatory signature from the patient or legal decision maker, and there was no corresponding signature of who obtained the verbal consent. Similarly, Resident #22's MOST form, which indicated a wish for no CPR and comfort-focused treatment, also lacked the necessary signatures and had only a handwritten note of verbal consent from the POA without corresponding signatures. Resident #59's MOST form, which indicated a wish for CPR with selective treatment, also lacked the required signatures and had a handwritten note of verbal consent from the daughter and resident without corresponding signatures of who obtained the verbal consent. Interviews with staff revealed gaps in the process of obtaining and documenting verbal consents. An LPN stated that only one nurse needed to sign the form, while the medical records specialist was unaware that verbal consents required two signatures. The social work consultant confirmed that two staff members needed to witness verbal consents and sign the form, but acknowledged a gap in practice in ensuring these signatures were completed and reviewed during quarterly care conferences. This inconsistency in following the facility's policy and procedure for advanced directives led to the deficiencies noted in the report.
Non-Functional Call Light System in Secure Unit
Penalty
Summary
The facility failed to ensure the call light system was functioning properly for all 27 residents on the secure unit. The call light system in the secure unit was observed to be non-functional, with some call lights painted over and others not activating any notification system. Specifically, in Resident #111's room, the call light for the bed was non-functional, and the call light in the bathroom did not alert the nurses' station or activate the light over the resident's door. Staff performed 15-minute checks on residents due to the non-functional call light system, but these checks were not documented in the electronic medical record. Resident #111, a 65-year-old with multiple medical conditions including a fracture of the fourth vertebrae, encephalopathy, epilepsy, high blood pressure, muscle weakness, history of traumatic brain injury, and disorientation, was interviewed and confirmed that the call light system in his room did not work. The resident's care plan included interventions to encourage the use of the call light, but it did not address the non-functional call light system or provide alternative monitoring methods. Staff interviews revealed a lack of awareness about the call light system and its functionality. The maintenance supervisor acknowledged that the call light system on the secure unit was not functional and had not been in use for an unspecified period. The facility's policy for the secure unit assumed that residents with moderate to severe cognitive impairment could not use the call light system and required frequent checks by staff. However, Resident #111 had a call light with a pull cord in his bathroom and was able to explain its function, contradicting the facility's policy. The facility provided call light assessments for Resident #111, but there was no documentation on whether the call light remained in the resident's room or updates to the care plan.
Failure to Follow Discharge Procedure for Resident Requesting Appeal
Penalty
Summary
The facility failed to follow the appropriate procedure for a facility-initiated discharge for a resident who requested an appeal. The resident, who had multiple medical conditions including acute and chronic respiratory failure, anxiety disorder, and major depressive disorder, was given a 30-day notice of involuntary discharge. Despite the resident's request for an appeal, the facility did not properly document or address the appeal request in a timely manner. The resident had submitted a grievance form indicating his desire to appeal the discharge decision, but the facility's staff, including the social services assistant and the nursing home administrator, failed to follow up on this request appropriately. The resident had been involved in an incident with a female staff member, which was discovered in early February, and this incident was a contributing factor to the discharge decision. The resident expressed concerns about his ability to manage his pain and oxygen needs outside the facility. Despite these concerns, the facility did not ensure a safe and organized discharge plan, as required by their policy. The resident's care plan indicated that he was working towards self-reliance for discharge and had been receiving assistance with this process, but the facility did not adequately address his appeal or provide a clear discharge plan. Interviews with facility staff revealed a lack of communication and proper procedure in handling the resident's appeal. The social services assistant admitted to not being part of the discharge planning process and did not know how the 30-day notice of involuntary discharge worked. The nursing home administrator acknowledged that he had not saved a copy of the 30-day notice and was unaware of the resident's appeal request due to being out of town. The social services consultant and director also indicated that the grievance/appeal should have been addressed more promptly and involved the ombudsman. The facility's failure to follow its own policies and procedures for involuntary discharge and appeal resulted in a deficiency in the care provided to the resident.
Failure to Implement and Document Wandering Interventions for Dementia Resident
Penalty
Summary
The facility failed to ensure that a resident diagnosed with dementia received appropriate treatment and services to maintain her highest practicable physical, mental, and psychosocial well-being. Specifically, the facility did not implement wandering interventions as listed on the care plan for the resident and did not consistently document the resident's wandering behavior and the interventions used to determine their effectiveness. The resident, who had Alzheimer's disease, dementia, and bipolar disorder, was observed wandering into other residents' rooms and attempting to take their belongings without staff intervention or redirection. Additionally, the resident was not offered any activities or snacks as a diversion, as outlined in her care plan. Observations revealed that the resident frequently entered other residents' rooms and attempted to take personal items, such as a bath towel, without staff intervention. On multiple occasions, the resident was seen wandering in the dining room and attempting to interact with other residents' belongings without being redirected by staff. The resident also triggered an alarmed exit door multiple times, indicating a risk of elopement, but staff did not consistently document these incidents or the interventions used to address them. Interviews with staff members indicated a lack of awareness of the specific interventions listed in the resident's care plan for wandering behavior. The assistant director of nursing (ADON) acknowledged that the facility tried to schedule more staff to monitor and redirect residents but admitted that wandering behavior was not consistently documented unless it posed a safety hazard. The facility's follow-up documentation confirmed that the resident's wandering behavior placed her at significant risk and intruded on the privacy and activities of other residents, yet the interventions were not effectively implemented or recorded.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was not greater than five percent, with a reported error rate of 6.25%. Specifically, two errors were identified out of 31 medication administration opportunities. The errors involved the administration of Lispro insulin to two residents without priming the insulin pens as per manufacturer guidelines. According to the Humalog Kwikpen (Lispro insulin) manufacturer guidelines, priming the pen is essential to remove air from the needle and cartridge to ensure the correct dose of insulin is administered. The facility's Medication Administration policy also mandates that medications be administered as prescribed and in accordance with manufacturers' specifications. In the first instance, a registered nurse (RN) administered Lispro insulin to a resident without priming the pen. The RN acknowledged that she did not prime the pen, believing it was only necessary for new pens or when visible air was present. In the second instance, another RN administered Humalog insulin to a different resident without priming the pen. This RN also admitted to not priming the pen before administration. Interviews with the Director of Nursing (DON) and the involved RNs confirmed that the proper procedure for priming insulin pens was not followed, leading to the medication errors.
Failure to Prime Insulin Pens Leads to Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin. Resident #53, a 74-year-old with heart disease and diabetes mellitus, was observed receiving an insulin dose without the pen being primed by RN #1. The nurse did not follow the manufacturer's guidelines for priming the insulin pen, which is necessary to remove air and ensure the correct dose is administered. Similarly, Resident #73, a 79-year-old with diabetes mellitus and moderate cognitive impairment, was also administered insulin without the pen being primed by RN #2. Both nurses failed to prime the insulin pens before administration, leading to potential medication errors. Interviews with the staff revealed a lack of adherence to proper insulin administration protocols. RN #1 admitted to not priming the pen unless it was new or had visible air, while RN #2 acknowledged the need to prime the pen before every administration but did not do so. The Director of Nursing confirmed that insulin pens should be primed with two units before dialing the dose to ensure the correct amount of insulin is administered. This oversight in following proper procedures resulted in significant medication errors for the residents involved.
Failure to Properly Disinfect Glucometer
Penalty
Summary
The facility failed to maintain an infection control program by not ensuring that a glucometer was cleaned in a sanitary manner. Specifically, a registered nurse (RN) used PDI Sani Hand wipes to clean the glucometer before and after checking a resident's blood glucose level. The facility's policy and the manufacturer's guidelines require the use of EPA-registered disinfectant wipes, such as bleach wipes or Sani Cloth Germicidal Wipes, which need to stay wet for two minutes to ensure proper disinfection. The PDI Sani Hand wipes used by the RN were not approved for disinfecting the glucometer, leading to a failure in preventing potential infection transmission. During interviews, the RN confirmed that she used PDI Sani Hand wipes and believed they needed to stay wet for two minutes. Another RN and the Director of Nursing (DON) stated that the correct procedure involved using bleach wipes or Sani Cloth Germicidal Wipes, which should be wrapped and kept wet for the recommended time. The discrepancy between the facility's policy, the manufacturer's guidelines, and the actual practice observed led to the deficiency in maintaining a proper infection control program, potentially exposing residents to infection risks.
Failure to Protect Resident from Abuse by Employee
Penalty
Summary
The facility failed to ensure Resident #76 was safe from abuse by an employee. The resident, who had normal cognitive function with a BIMS score of 15 out of 15, was involved in a relationship with a respiratory therapist (RT #1). The relationship included holding hands, kissing, and exchanging text messages, including suggestive photos. The resident reported that RT #1 had sneaked into the facility to see him and had asked him to erase the messages on his phone. Despite the resident's normal cognitive function, the employee was in a position of power and acted outside of her role as a care provider, which constituted abuse. The facility's policy on abuse prevention and reporting, dated April 2014, clearly stated that residents should be free from all forms of abuse, including sexual abuse, and that any staff member suspected of abuse should be suspended immediately. The facility's investigation, however, unsubstantiated the allegation of sexual abuse, stating that the relationship was consensual and did not meet the criteria for abuse. The employee was terminated for violating the facility's code of conduct, but the facility did not classify the incident as abuse. Interviews with various staff members and a frequent visitor confirmed the inappropriate relationship between the resident and the employee. The Director of Respiratory Therapy and the Director of Nursing both acknowledged the relationship and stated that it was a reportable offense. Despite this, the facility's final stance was that the relationship did not constitute abuse because the resident was not considered an at-risk adult. This discrepancy between the facility's policy and its actions led to the deficiency in protecting the resident from abuse.
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A resident with severe dementia, hallucinations, delusions, and chronic pain, who was independent with mobility and at risk for wandering, was struck in the face by another cognitively impaired resident known to exhibit verbal and physical aggression and to be highly protective of her room. An RN heard a commotion, saw the victim outside the aggressor’s room, and attempted to intervene but witnessed the aggressor hit the victim before reaching them, resulting in a lip laceration and bruise. The aggressor’s care plan noted use of a doorway stop sign or closed door and the need to redirect others away from her room, but she often refused these measures. At the time of the incident, only one CNA and one nurse were on the memory care unit due to an unfilled CNA call-in, and staff reported it was difficult to manage when two CNAs were not present. The facility investigation substantiated the event as abuse and identified that both residents may have had increased pain contributing to agitation before the altercation.
A resident with severe cognitive impairment and multiple chronic conditions intentionally slid from a wheelchair to sit on the floor and refused assistance to return to the chair. An LPN directed two CNAs to place a blanket under the resident and drag the resident across the floor, onto an elevator, and to another floor, rather than allowing the resident to remain seated on the floor as requested. The resident later reported trying to resist and stated dislike of the experience. Documentation by the LPN omitted how the resident was actually moved between floors, despite care plan goals for dignity and autonomy and a facility policy requiring residents be treated with dignity and respect and that their choices and preferences be honored.
Surveyors found that staff repeatedly failed to follow hand hygiene and Enhanced Barrier Precautions (EBP) requirements. CNAs and an LPN provided direct care, including incontinence care, use of a mechanical lift sling, and gastric tube feeding, without performing hand hygiene before or after care and without using required gowns for residents on EBP. One CNA handled a soiled lift sling, touched his hair and face, used a touchscreen to document care, and then assisted another resident without cleaning his hands. Another CNA entered an EBP room wearing only gloves, not a gown, and did not perform hand hygiene after removing gloves. An LPN handled a feeding tube and provided care to residents on EBP without hand hygiene or gown use. A resident’s representative reported seeing staff work with a feeding tube without gloves or a gown, while staff interviews and facility policy described correct practices that were not followed in practice.
A resident with severe cognitive impairment and multiple serious diagnoses had a physician-appointed health care proxy who reported that the facility did not inform her when the resident’s condition changed or when an antibiotic was started, and that her calls were not returned for days. Another representative for the same resident stated that calls went to a general voicemail and were rarely or very slowly returned. Grievance records documented repeated concerns about delayed communication, lack of notification about new medications, and difficulty reaching staff. Other residents’ representatives similarly reported that calls to check on residents or report suspected verbal abuse went to voicemail and were returned late or not at all, while staff acknowledged that calls often went to voicemail and that several calls from representatives were missed or delayed.
The facility failed to investigate an allegation of verbal abuse and threats between two cognitively impaired roommates after a family member, who was on the phone with one resident, reported hearing the other resident yelling loudly and making threats. The resident’s representative could not reach staff by phone and contacted EMS, which responded to the facility, yet no investigation or documentation of the altercation, alleged threats, or EMS involvement was found in either resident’s record. Staff acknowledged loud yelling and arguing and initiated a room change, but the RN did not fully inform the DON, the SSD—who was not present—dismissed the event as a simple argument, and the NHA did not treat or report it as abuse, contrary to facility policies requiring identification, investigation, and reporting of possible verbal or mental abuse by other residents.
Unsafe food handling and kitchen sanitation practices were observed in the dining room and main kitchen. Staff handled ready-to-eat foods with bare hands, failed to wash hands between tasks and after bathroom use, and touched food, dishes, and meal tickets while plating and serving meals. The facility also kept moldy croissants in dry storage, used a pencil to prop up a hood drip pan, and allowed a dietary aide with artificial nails and multiple bracelets to serve residents.
The facility failed to maintain and document safe food temperatures during meal service, resulting in cold foods being held and served within the temperature danger zone and incomplete temperature logs on multiple days. During a lunch service observation, various forms of chicken salad were held at 45–55°F, yet plates were assembled and sent out, and a resident reported that meals delivered to the room were always cold and often not eaten. Staff interviews showed inconsistent understanding of required hot and cold holding temperatures and confirmed that temperature logs were sometimes not completed as required.
Failure to Honor Residents’ Choice of Attending Physician: Three cognitively intact residents said they were not allowed to choose their own attending physician and were required to see the facility MD instead. EMR and admission agreement review showed no documentation that they were offered a choice of physician, despite one resident wanting to continue with a community PCP. The NHA stated residents could choose their attending physician, but also said the facility had only one physician available for residents to choose from.
Psychotropic Medication Documentation and PRN Behavior Monitoring Deficiencies Survey review found that several residents had psychotropic medications ordered without documented physician rationale, resident-specific target behaviors, or individualized non-pharmacological interventions. Generic behavior-monitoring orders were used instead of approaches tied to each resident’s history, interests, and identified behaviors, and one resident’s PRN antipsychotic was administered multiple times without documentation of attempted non-pharmacological interventions before use. The EMR also showed notes of stability or no unwanted behaviors for some residents, yet the records still lacked rationale supporting continued psychotropic treatment.
Failure to Address Suicidal Ideation and Individualized Psychosocial Needs: The facility did not adequately address suicidal statements, trauma-related needs, or individualized behavioral interventions for multiple residents. One resident with dementia, anxiety, and PTSD made a suicidal threat, but the record did not show ongoing safety monitoring or documented follow-up. Another resident with PTSD, depression, and a history of trauma and suicide attempts had ongoing depressive symptoms, but the care plan and orders did not reflect the PASRR-identified need for therapeutic support, psychiatric oversight, coping skills, or a safety plan. A third resident with autism and mood disturbance had inappropriate sexual behavior toward the DON, but the care plan was not updated with person-centered interventions specific to that behavior.
Failure to Prevent Resident-to-Resident Physical Abuse on Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. On the date of the incident, an RN heard a commotion in the hallway outside the alleged assailant’s room and observed that resident strike another resident, causing the victim’s lip to bleed. The RN had seen both residents near the medication cart a few minutes earlier without concern and attempted to intervene when she saw the victim standing outside the assailant’s room, but was unable to reach them before the strike occurred. The two residents were then separated, and frequent checks were initiated. The victim was a younger-than-65 resident with vascular dementia (severe, with agitation), Alzheimer’s disease, Lewy body disease, bipolar disorder, and chronic pain. Her MDS showed short- and long-term memory problems, hallucinations, delusions, and physical and verbal behaviors toward others, with moderately impaired cognition and impaired decision-making. She was independent with mobility and had a care plan for wandering and dementia that identified her as pleasantly confused and easily redirected, with interventions to identify wandering patterns, offer diversions, and assess for pain or toileting needs when agitated. Documentation on the day of the incident noted her involvement in a resident-to-resident altercation, a small laceration to the middle of her upper lip, and a small bruise below her lower lip. The assailant was an older resident with severe vascular dementia with agitation, memory deficit after intracranial hemorrhage, and recurrent depressive disorder. Her MDS documented short- and long-term memory problems, fluctuating disorganized thinking, and verbal behaviors directed toward others that could significantly intrude on others’ privacy or disrupt the environment. Her behavior/dementia care plan identified verbal aggression (yelling/screaming), physical aggression (hitting), refusal of care, withdrawal, tearfulness, and negative statements, and noted that she was protective of her room and became upset if others entered or tried to enter. The care plan included use of a velcro stop sign across her doorway or keeping her door closed, but also documented that she often declined having the door closed, requiring staff to redirect other residents away from her room. Staff statements indicated that at the time of the incident there was one CNA and one nurse on the memory care unit, that one CNA had called in and was not replaced, and that it was hard when there were not two CNAs on the unit. The facility’s investigation substantiated the incident as abuse and identified that both residents may have been experiencing increased pain leading up to the altercation, with pain, constipation, and urinary retention noted as contributing factors for the victim and hand contracture pain and refusal of interventions noted for the assailant.
Resident Dragged on Blanket Instead of Honoring Request to Sit on Floor
Penalty
Summary
The deficiency involves a failure to honor a resident’s right to dignity and self-determination when staff did not allow the resident to remain seated on the floor per his wishes and instead dragged him on a blanket between floors. Late at night, the resident, who lived on the second floor, was in his wheelchair on the first floor and intentionally slid out of his wheelchair to sit on the ground according to his own wishes. When staff offered assistance to help him back into his wheelchair, he refused. Despite this refusal, an LPN directed two CNAs to move the resident from the first floor back to the second floor. Following the resident’s refusal to get back into his wheelchair, the LPN instructed the CNAs to place a blanket underneath the resident so he could be dragged while lying on it. The CNAs and the LPN maneuvered the blanket under the resident by moving him from side to side. One CNA positioned herself behind the resident and placed her arms under his armpits, while the other CNA held the resident’s pants at his ankles. The LPN then pulled on the blanket with the resident on it. Together, the three staff members dragged the resident on the blanket across the floor and onto the elevator, transported him to the second floor, and then dragged him off the elevator onto the second floor hallway. Once on the second floor, the resident agreed to have two staff members assist him back into his wheelchair, and a two-person transfer was performed to lift him from the floor into the chair. The resident later reported that he remembered being pulled on the blanket, stated that he "tried to fight them like crazy," and said he did not like what had been done. The nursing progress note written by the LPN the following morning documented that the resident had remained on the first floor until late at night, refused to talk with staff, refused care, and declined snacks, fluids, and redirection, but the note did not document how he was actually relocated to the second floor. The resident’s records showed he had severe cognitive impairment with a BIMS score of 3/15, diagnoses including Parkinson’s disease, depression, unspecified intellectual disabilities, traumatic brain injury, seizures, and chronic kidney disease stage 3, and care plan goals that included being treated with dignity and autonomy. The facility’s dignity policy stated that residents are to be treated with dignity and respect at all times, that their choices and preferences are to be honored, and that demeaning practices are prohibited, which was not followed in this incident.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to hand hygiene and adherence to Enhanced Barrier Precautions (EBP) on all four units. The facility’s own policies require hand hygiene before and after direct patient care and the use of gowns and gloves during high-contact care activities for residents on EBP. CDC guidance cited in the report emphasizes that hand hygiene protects both healthcare personnel and patients, and that EBP requires targeted gown and glove use during high-contact resident care activities, particularly for residents with wounds, indwelling devices, or MDRO colonization or infection. Surveyors observed multiple instances where staff did not follow these requirements. An unidentified CNA exited a room of a resident on EBP without wearing a gown while providing care. On another occasion, a CNA exited a resident’s room carrying a soiled mechanical lift sling without gloves, failed to perform hand hygiene, touched his hair and face, used a touchscreen to document care, and then entered another resident’s room to answer a call light and assist with a request without performing hand hygiene before or after assisting that resident. Another CNA entered the room of a resident on EBP, donned only gloves without a gown, provided incontinence care, then left the room with soiled linens and trash properly disposed of, removed gloves, but did not perform hand hygiene before caring for another resident. Additional observations showed an LPN entering the room of a resident on EBP for gastric tube feeding, setting up and handling the feeding tube without performing hand hygiene beforehand and without wearing a gown. The same LPN later entered another EBP room, provided care, and left without performing hand hygiene. A resident’s representative reported seeing staff work with the resident’s feeding tube without gloves or a gown. In interviews, CNAs and nursing staff described correct hand hygiene and EBP practices, including washing hands for about 20 seconds and using gowns and gloves for residents on EBP, and the DON stated she expected staff to perform hand hygiene when entering and exiting rooms and to follow EBP procedures requiring gown and glove use. These stated practices conflicted with the observed failures in hand hygiene and EBP adherence documented by surveyors.
Failure to Notify Health Care Proxy and Return Calls Regarding Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to inform a resident’s physician-appointed health care proxy of changes in the resident’s condition and new treatments, and to return the proxy’s calls in a timely manner. Facility policy on Notification of Changes required informing the resident, consulting with the physician, and notifying the family member or legal representative when there was a change requiring such notification, and specified that when residents were incapable of making their own decisions, the representative would make necessary decisions. Resident #1 was under 65, admitted with diagnoses including paralysis and weakness following a stroke, respiratory failure, cognitive communication deficit, and encephalopathy, and was documented as severely cognitively impaired with a BIMS score of 0/15, indicating reliance on the health care proxy for decision-making. The health care proxy reported that the facility made it very difficult to contact the resident, stating that staff did not return calls for days and that she was not informed when the resident developed an infection and was started on an antibiotic until after the medication had already been initiated. She stated she had several questions about the medication and was not consulted on the medical decision prior to its start. Another representative reported that calls to the facility went to a general voicemail and that her messages were either not returned or took several days for a response. Grievance records showed repeated concerns from the resident’s representatives about delays in speaking with the resident, delays in return calls, and lack of notification about new medications and changes in condition. Additional interviews with other residents’ representatives supported a broader pattern of delayed or absent communication. One representative of another resident reported that his call to check on a newly admitted resident went to voicemail and was not returned for two days. Another resident’s representative and a secondary witness reported that when they attempted to report suspected verbal abuse, their calls to the facility and to the SSD went to voicemail and were never returned. Staff interviews confirmed that calls first went to the front desk and then to the nurses’ stations, that calls often went to voicemail when nurses were unable to answer, and that voicemail messages were expected to be returned within 24 hours. The NHA acknowledged that several calls from the resident’s representatives went to voicemail and that calls were often made during shift change when it was harder to reach the nurse on duty, but there was no documentation to support the claimed regular communication with the health care proxy.
Failure to Investigate Alleged Verbal Abuse Between Cognitively Impaired Roommates
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of verbal abuse and threats between two cognitively impaired residents after a family member reported overhearing the incident. Facility policy on abuse, neglect, exploitation, and misappropriation requires that all possible incidents of abuse, including verbal and mental abuse by other residents, be identified, investigated, and reported within required timeframes, with residents protected from further harm during investigations. The policy on identifying types of abuse specifies that yelling or hovering over a resident with intent to intimidate is an example of mental and verbal abuse. Despite these policies, the facility did not initiate or document an investigation into a reported verbal altercation that included alleged threats. One resident, under age 65, with dysphagia, left-sided hemiplegia, attention and concentration deficit, delusional disorder, and major depressive disorder, had moderate cognitive impairment and was dependent on staff for most ADLs. He reported that he and his roommate yelled back and forth at each other after the roommate told him to “shut the [expletive],” but he did not recall the specific words used and denied any physical contact. His guardian stated that he later reported being fearful of his roommate after the incident. Another representative, who was on the phone with him during the event, reported hearing the roommate yelling loudly and making threats toward him, then hearing a nurse enter to calm the situation. This representative attempted to call the facility to report the yelling and threatening behavior, was sent to voicemail without a return call, and subsequently contacted emergency services. The roommate, an older resident with dementia, cognitive communication deficit, depression, and insomnia, also had moderate cognitive impairment and required staff assistance for most ADLs. He did not recall the incident, and his representative only learned of it the following day and was told it involved yelling about loud phone use. A review of both residents’ medical records revealed no documentation of the verbal altercation, the alleged threats, or related concerns, and no investigation documents were produced when requested. Staff interviews confirmed there had been loud yelling and arguing, that EMS responded to the facility, and that a room change was initiated due to the incident, but the RN who responded did not report the EMS involvement to the DON. The SSD, who was not present during the incident, characterized it as just an argument and stated there were no threats, and the NHA stated the event was not reported as abuse because they believed no threats were made. No contemporaneous interviews with the residents were documented, and no inquiry was made by facility staff into why EMS had been called in relation to the altercation, resulting in a failure to investigate the allegation of verbal abuse as required by facility policy.
Unsafe Food Handling and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the main kitchen and dining areas. During meal service observations, staff repeatedly handled ready-to-eat foods with bare hands and did not perform hand hygiene when changing tasks, after touching dirty dishes, after using the bathroom, or before serving food. An LPN cut a resident’s patty melt and handed pieces to the resident with her bare hand without sanitizing her hands. A DA passed drinks by touching the rims of cups, and another DA tore a resident’s patty melt into smaller pieces with bare hands and handed food to the resident. During a later observation, kitchen staff continued to work without washing hands between tasks and while handling food, dishes, and meal tickets. A DA entered the kitchen from the dishroom and did not wash his hands before putting away snacks. A cook did not wash her hands after working at the sink, after touching dirty dishes, after exiting the bathroom in the kitchen, or before serving room trays. She was observed touching shrimp, corn bread, rice, squash, cheese, and frozen fries with bare hands while plating and preparing meals, and she also handled fryer baskets and food items without washing her hands. Another cook wiped her hands on her clothing, handled meal tickets, and touched ready-to-eat foods with bare hands while assembling plates and serving meals. The facility also failed to discard expired or spoiled food, maintain equipment in good repair, and prevent staff from wearing prohibited items while preparing or serving food. A plastic bag of croissants in dry storage contained bread-like food covered in dark green and black fuzz and remained on the bread rack on two separate observations. In the kitchen hood system above the grill, a half wooden pencil was being used to hold up the grease drip pan on two observations. In addition, a dietary aide taking meal orders, passing drinks, and serving meals had artificial nails approximately half an inch long and multiple fabric bracelets on her wrists while working with residents.
Failure to Maintain and Document Safe Food Temperatures During Meal Service
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner by not maintaining appropriate food temperatures during meal service and by not consistently documenting food temperatures as required. During a continuous observation of lunch meal service, chicken salad, including soft and bite-sized and pureed versions, was found on the steam table at temperatures of 55°F and 45°F, which were within the documented temperature danger zone and below the required cold-holding standard. Despite these temperatures, plates with wedge chicken salad and a Hawaiian roll were assembled and placed on the meal cart for service. A resident reported that meals delivered to his room were always cold, leading him not to eat them and to attempt to obtain food from outside the facility. Review of the facility’s April 2026 food temperature logs showed multiple instances where temperatures were not documented for breakfast, lunch, and dinner services on numerous dates. Staff interviews revealed inconsistent understanding and application of proper holding temperatures, with the cook and dietary manager providing varying temperature thresholds that did not align with the facility policy or the Colorado Retail Food Establishment Rules and Regulations. The cook acknowledged that the wedge chicken salad should not have been served at 55°F and attributed difficulty maintaining proper temperatures to a hot room with inadequate ventilation, while the dietary manager stated that cooks sometimes forgot to complete the temperature logs.
Failure to Honor Residents’ Choice of Attending Physician
Penalty
Summary
The facility failed to ensure three cognitively intact residents were allowed to choose their own attending physician. Resident #15, Resident #28, and Resident #30 each stated during a group interview that they did not have a choice in who their physician could be while in the facility and that they had to see the facility’s MD. Resident #15 said she had a primary care physician in town that she wanted to continue seeing, but she was told she could not see that physician. Resident #28 and Resident #30 each said they were required to see the facility’s MD instead of choosing their own physician. Record review for each of the three residents, including the admission agreement and EMR, showed no documentation that they were provided a choice of attending physician. Resident #15 had diagnoses including COPD, cirrhosis of the liver, and osteoarthritis, and her MDS showed she was cognitively intact with a BIMS score of 15. Resident #28 had diagnoses including type 2 diabetes mellitus, asthma, osteoarthritis, and TIA/cerebral infarction, and was also cognitively intact with a BIMS score of 15. Resident #30 had diagnoses including type 2 diabetes mellitus, wedge compression fracture of T11-T12 and L3, and hypertension, and his MDS likewise showed a BIMS score of 15. The NHA stated residents were able to choose their attending physician when admitted, but also said the facility had one physician residents could choose from and was not aware that these residents wanted different physicians.
Psychotropic Medication Documentation and PRN Behavior Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure four residents were free from unnecessary psychotropic medication use and chemical restraint concerns. Survey review found that the facility did not document a physician’s rationale for the continued use of psychotropic medications for three residents, did not document resident-specific care approaches with medication-specific target behaviors and person-centered interventions for those residents, and did not ensure one resident’s PRN antipsychotic use had corresponding documentation of identified behaviors and non-pharmacological interventions. For one resident with PTSD, anxiety, and depression, the record showed buspirone, Valium, duloxetine, and Lexapro orders with behavior-monitoring language, but the orders did not identify resident-specific non-pharmacological interventions for specific behaviors. The resident’s PASRR described a history of self-harm, suicidal thoughts, mood swings, loss of interest, and low energy, and recommended therapeutic interventions, coping skills, psychiatric oversight, increased socialization, and activities such as puzzles, games, and painting. The EMR review did not show documented behaviors during the review period, and it did not show a physician rationale to justify continued psychotropic use. For another resident with schizoaffective disorder, dementia, anxiety, and depression, the care plan and orders listed generic interventions and behavior targets such as screaming, hallucinations, kicking, and yelling, but the resident-specific behaviors and interests identified in the PASRR, including hearing the devil inside her head and being soothed by prayer and rosary use, were not incorporated into the behavior-monitoring orders or care plan. The record also lacked documentation of non-pharmacological interventions used for the resident’s behaviors and lacked a physician rationale for continued psychotropic use despite notes stating the resident was stable and not experiencing unwanted behaviors. A third resident with vascular dementia, anxiety, and PTSD had orders for Abilify, mirtazapine, sertraline, clonazepam, and behavior monitoring tied to verbal aggression, exit seeking, tearfulness, and hitting staff, but the orders remained generic and did not reflect the resident’s individualized approaches such as listening to 80’s rock music or watching a favorite program when crying or confused. The EMR again did not show a physician rationale for continued psychotropic use despite notes indicating pleasant mood and no unwanted behaviors. For the resident who died during the stay and had dementia and depression, the record showed Lexapro, Seroquel, and PRN injectable haloperidol ordered for behaviors such as swinging at staff and agitation. The PRN haloperidol order did not list a diagnosed specific condition, only behaviors, and the order for non-pharmacological interventions was not initiated until after the resident had already been receiving psychotropic medications. MAR and order administration notes showed multiple PRN haloperidol administrations, but several entries lacked documentation of attempted non-pharmacological interventions before the medication was given, and one note only documented encouragement to sit down without identifying the other ordered interventions or their effectiveness.
Failure to Address Suicidal Ideation and Individualized Psychosocial Needs
Penalty
Summary
The facility failed to ensure that residents with mental disorders, psychosocial adjustment difficulties, and trauma histories received appropriate treatment and services to support their mental and psychosocial well-being. For one resident with vascular dementia, anxiety, and PTSD, the record showed repeated depression screens indicating little interest, depressed mood, poor appetite, sleep problems, low energy, and feelings of worthlessness, along with notes describing chronic behaviors potentially causing harm, tearfulness, withdrawal, and anxiety. A behavior note documented that the resident stated she was going to kill herself, but the record did not show documented interventions to keep her safe afterward or ongoing monitoring for suicidal ideation. A second resident with PTSD, anxiety, depression, and a documented history of trauma, self-harm, suicidal thoughts, and numerous suicide attempts had a PASRR evaluation identifying the need for therapeutic interventions, psychiatric oversight, coping skills development, and a safety plan. The resident told staff she had previously seen a therapist at the facility, but that therapy had stopped and no new arrangements had been made. She also reported that staff had not asked about her PTSD triggers or what interventions would help her. The record showed depression screens with ongoing depressive symptoms, but no follow-up documentation after those screenings, and the care plan and physician orders did not reflect the resident’s suicidal history or the specialized services identified in the PASRR. The facility also failed to provide individualized care approaches for a resident with autistic disorder, dementia with mood disturbance, anxiety disorder, major depressive disorder, and cognitive communication deficit. The resident had a history of inappropriate sexual behaviors and was documented as having sexually inappropriate contact with the DON when he squeezed her breast during a dining activity. Although the resident was placed on 15-minute behavior monitoring for 24 hours, the care plan was not revised to reflect a person-centered intervention specific to that sexual behavior. Staff interviews showed that interventions were inconsistently understood and that the nursing staff did not know what person-centered interventions were in place for the resident’s behaviors.
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