Suites At Someren Glen Care Center, The
Inspection history, citations, penalties and survey trends for this long-term care facility in Centennial, Colorado.
- Location
- 5000 E Arapahoe Rd, Centennial, Colorado 80122
- CMS Provider Number
- 065345
- Inspections on file
- 18
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Suites At Someren Glen Care Center, The during CMS and state inspections, most recent first.
A resident with orthostatic hypotension, dementia, chronic kidney disease, and other comorbidities had a physician order for midodrine with a hold parameter to stop the dose when systolic BP exceeded 100 mmHg. Review of the MAR showed that nursing staff administered midodrine 49 times despite documented systolic BP readings above the ordered threshold. Facility policy required medications to be given exactly as prescribed and vital signs to be obtained and reviewed before administration, but interviews with the regional nurse, medical director, NHA, and nursing staff confirmed a systemic pattern of not following BP parameters for this medication, resulting in a significant medication error.
A resident with severe dementia and Parkinson's disease was physically redirected by a CNA after spilling a drink, without any verbal explanation or reassurance, contrary to the individualized care plan that required verbal and person-centered interventions. Staff interviews confirmed that the care plan was not followed, resulting in a failure to provide a dignified and appropriate response.
Two residents with cognitive and physical impairments did not receive timely assistance with toileting and incontinence care, resulting in prolonged periods without being checked or changed. Staff did not follow care plans or facility policy, and one resident was found soiled with urine and skin redness, while another remained wet for over five hours due to delayed care and inability to use the call light.
The facility failed to provide timely interventions and proper documentation for two residents at risk of pressure injuries, leading to the development and worsening of stage 3 and unstageable pressure injuries. Staff did not offer frequent repositioning or toileting, and there was a lack of documentation for refusals of care.
The facility failed to complete annual performance reviews and provide regular in-service education for five CNAs. The NHA and DON confirmed that the evaluations were not conducted as required, and a previously scheduled evaluation fair was poorly attended due to an illness outbreak.
The facility failed to post accurate staffing information, including the actual working hours of licensed and unlicensed staff, on multiple days. Observations and staff interviews confirmed that the posted information was either outdated or incomplete.
The facility failed to properly store and label medications, including expired medications in a medication cart, unlabeled insulin pens, and medications stored in a dormitory-style refrigerator with significant ice build-up. The LPN and DON were unaware of proper storage requirements.
The facility failed to maintain an infection control program, as a resident's foley catheter bag was repeatedly found on the floor, and mechanical lifts were not disinfected between uses. Staff interviews confirmed these practices, which could lead to infections.
The facility failed to ensure that a CNA received the required 12 hours of annual in-service training, with one CNA completing only 0.75 hours. Staff interviews confirmed awareness of the deficiency, and a new staff development coordinator was hired to address training compliance.
Failure to Follow Blood Pressure Parameters for Midodrine Administration
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was kept free from significant medication errors when nursing staff did not administer a prescribed blood pressure medication according to physician-ordered parameters. Record review showed that the resident, an individual over 70 years old with orthostatic hypotension, unspecified dementia with behavioral disturbances, chronic kidney disease, hypomagnesemia, and osteoarthritis, had an order for midodrine 10 mg by mouth twice daily, later increased to three times daily, with instructions to hold the dose if the systolic blood pressure (SBP) was greater than 100 mmHg. Despite this clear order, the medication administration record documented that midodrine was administered 49 times when the resident’s SBP was outside the ordered parameters. The resident’s medical record indicated that the midodrine order with SBP parameters was in place from August through at least early September, and the medication administration record from 8/12/25 to 9/10/25 showed repeated administrations that did not comply with the hold parameter. These administrations occurred even when the documented SBP exceeded the threshold at which the medication was to be withheld. The facility’s own Medication Administration Guidelines policy required that medications be administered as prescribed, that nurses review and confirm orders on the MAR, obtain and record vital signs as necessary prior to administration, and clarify any questionable orders with the prescriber or pharmacy before giving the medication. Nonetheless, the documented practice for this resident did not align with those requirements. Interviews with facility staff further confirmed that the problem was systemic and involved multiple nurses not following physician orders for medication parameters. The regional corporate nurse stated that an audit of the resident’s electronic medical record revealed that nursing staff had failed to hold midodrine 49 times when the SBP was over 100 mmHg. The medical director reported that there was a systemic problem in the facility with following physician orders for medication parameters and stated that he expected nursing staff to follow those orders. The NHA also acknowledged a systemic problem with nurses following physician orders related to medication administration and adherence to blood pressure parameters. Nursing staff interviews referenced subsequent training on medication parameters, indicating that prior to that training, nurses had not consistently followed the ordered blood pressure parameters for midodrine, which led to the cited deficiency.
Failure to Provide Dignified, Person-Centered Redirection for Resident with Dementia
Penalty
Summary
A deficiency occurred when a certified nurse aide (CNA) failed to honor a resident's right to a dignified existence and person-centered care. The resident, a 70-year-old individual with severe dementia, mood disturbances, and Parkinson's disease, was observed during a lunch meal service to have spilled a glass of clear liquid on the food preparation counter. The CNA approached the resident from behind and physically redirected her by placing both hands under her armpits and moving her away from the area, without providing any verbal explanation, reassurance, or calming interaction. This action was not in accordance with the resident's care plan, which specified the use of verbal redirection, allowing time for response, and other person-centered interventions tailored to her cognitive and communication impairments. The resident's care plans, which addressed her impaired communication and cognitive functioning, outlined interventions such as providing verbal and visual cues, explaining procedures, and using calm, simple language. Physical redirection was not included as an intervention. Staff interviews confirmed that the CNA did not follow the care plan and that the expected approach was to use verbal redirection or comforting objects. The incident demonstrated a failure to implement the individualized care plan interventions, resulting in the resident not experiencing a dignified and person-centered response during the incident.
Failure to Provide Timely Incontinence and Toileting Care
Penalty
Summary
The facility failed to provide timely and appropriate assistance with activities of daily living (ADLs), specifically toileting and incontinence care, for two residents who were unable to perform these tasks independently. For one resident with severe cognitive impairment and total dependence on staff for ADLs, observations revealed that she was not offered or provided with incontinence care or toileting assistance for a period of four hours. Staff interviews confirmed that the resident was last changed at 7:45 a.m., and no further care was provided until a hospice aide arrived for a scheduled shower, at which point the resident was found soiled with urine and had a reddened area near her tailbone. The care plan for this resident required assistance with toileting throughout the day and always upon rising, but this was not followed during the observed period. Another resident, who had moderate cognitive impairment and required staff assistance for all ADLs, was also not provided with timely incontinence care. Observations showed that the resident was not checked or changed from 5:03 a.m. until 10:40 a.m., a period of over five hours. During this time, staff did not offer toileting or incontinence care before or after breakfast, and the resident was found to be wet and soiled when finally changed. Interviews with staff indicated that care was delayed due to workload and assumptions that the resident would use the call light if assistance was needed. However, the resident was unable to effectively use the call light due to physical limitations, and there was no documentation of her refusing care. Both residents had care plans and facility policies in place that required regular assessment and assistance with toileting and incontinence care, but these were not consistently implemented. Staff interviews revealed inconsistent practices and reliance on subjective judgment rather than adherence to scheduled care routines. The lack of timely incontinence care resulted in residents remaining soiled for extended periods, contrary to their care plans and facility policy.
Failure to Prevent and Treat Pressure Injuries
Penalty
Summary
The facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure injuries for two residents. Resident #27, who was at risk for skin breakdown due to immobility, developed two stage 3 pressure injuries to his left and right ischium. The care plan for Resident #27 did not include interventions to encourage repositioning while sitting in his recliner or frequent toileting/incontinence care. Continuous observations revealed that Resident #27 was not offered frequent repositioning or toileting by the staff, leading to the development of the pressure injuries. Resident #1, who was frequently incontinent of urine and bowel and at risk for developing pressure injuries due to decreased mobility, was identified to have an open area on her coccyx during a routine skin assessment. However, there was no documentation indicating that the wound care physician was notified, and no new physician's orders were obtained to treat the wound. It took 13 days for the facility to initiate treatment for the unstageable pressure wounds on Resident #1's coccyx and left buttock. The care plan for Resident #1 also failed to include interventions for frequent repositioning and incontinent care. Staff interviews revealed that CNAs and LPNs were aware of the need for frequent repositioning and toileting for residents at risk of pressure injuries but failed to document refusals of care or provide the necessary interventions. The Director of Nursing acknowledged that residents should be repositioned every two hours and that refusals should be documented, but there was no evidence of such documentation in the residents' electronic medical records. The facility's failure to provide timely interventions and proper documentation led to the development and worsening of pressure injuries in both residents.
Failure to Complete Annual Performance Reviews for CNAs
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 those reviews for five certified nurse aides. Specifically, the facility had not completed annual performance reviews for CNA #4, CNA #5, CNA #6, CNA #7, and CNA #8, which would have determined their potential training needs. The facility did not have a performance evaluation policy, as confirmed by the nursing home administrator (NHA). During record review and interviews, it was revealed that the annual performance reviews for the mentioned CNAs were requested but not available. The NHA admitted that the evaluations had not been completed and acknowledged that they should have been done annually. The director of nursing (DON) also confirmed that performance evaluations should be conducted annually and mentioned that a previously scheduled performance evaluation fair was poorly attended due to an illness outbreak. The facility plans to schedule another performance evaluation fair in the near future to comply with the regulations.
Failure to Post Accurate Staffing Information
Penalty
Summary
The facility failed to ensure that staffing information was posted in a prominent place and readily accessible to residents and visitors. Specifically, the facility did not include the total number of actual hours worked by the licensed and unlicensed staff directly responsible for resident care per shift. Observations on multiple days revealed that the staffing information was either not current or did not include the actual working hours for the staff. For instance, on 4/22/24, the staffing information was posted but did not include the actual working hours. Similar issues were observed on 4/23/24, 4/24/24, and 4/25/24, where the posted staffing information was either outdated or incomplete. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) confirmed the deficiencies. The DON mentioned that a receptionist who only worked occasionally was responsible for the incorrect posting on 4/23/24 and was unsure why the actual working hours were not included. The NHA acknowledged awareness of the regulatory requirement to include actual working hours in the daily staffing post but could not explain why it was not done. Both the DON and NHA indicated that they would take immediate steps to correct the issue.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure medications and biologicals were stored and labeled properly in one of three medication carts and one of two medication storage rooms. Specifically, expired medications were found stored with current medications in the medication carts, and insulin pens were not labeled with resident names and open dates. Additionally, medications were stored in a dormitory-style refrigerator/freezer combination, which is not recommended for medication storage due to the risk of freezing medications. An open bottle of Melatonin that expired in January 2024 and a Lantus insulin pen without a resident name or open date were found in the Juniper medication cart. The LPN acknowledged that the expired Melatonin should have been removed and that the insulin pen should have been labeled to ensure proper usage and effectiveness. The Juniper medication room contained a dormitory-style refrigerator with significant ice build-up, which was in contact with a box of Trulicity, potentially compromising the medication's integrity. The LPN and DON were unaware that medications should not be stored in such refrigerators, although temperature logs did not indicate any out-of-range temperatures.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment, specifically in the handling of a foley catheter and the cleaning of mechanical lifts. Observations revealed that Resident #69's foley catheter collection bag was repeatedly found on the floor, contrary to the facility's policy that required the catheter to be stored in a dignity bag or placed in a basin to avoid contact with the floor. Interviews with the resident and staff confirmed that the catheter bag was consistently placed on the floor, which could lead to infections due to the unsanitary conditions of the floor. Both the registered nurse and the director of nursing acknowledged that the catheter bag should not be on the floor as it could result in a urinary tract infection for the resident. Additionally, the facility failed to ensure that mechanical lifts were cleaned between residents. A certified nurse aide was observed transferring two residents using the same sit-to-stand mechanical lift without disinfecting it between uses. The aide stated that it was the night shift's responsibility to clean the lifts, while a licensed practical nurse and the director of nursing indicated that the lifts should be cleaned between each use with sanitization wipes. The lack of proper disinfection between uses, especially after the lift was in the bathroom, posed a risk of spreading bacteria among residents.
Failure to Ensure Annual In-Service Training for CNA
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNA) received the required 12 hours of annual in-service training for continued competence. Specifically, one CNA out of five reviewed had only completed 0.75 hours of the required 12 hours of continued education units (CEU). This deficiency was identified through a review of the CNA's training records and confirmed through staff interviews. The facility's policy, revised in July 2018, mandates comprehensive orientation and training programs to prepare associates for their roles, including legal and regulatory compliance. However, the facility did not adhere to this policy in the case of CNA #9. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that the facility was aware of the deficiency. The DON acknowledged that all CNAs should complete 12 hours of CEU annually and mentioned that CNA #9 had been written up for not meeting this requirement. The NHA indicated that a new staff development coordinator had been hired to track and ensure compliance with training requirements. Despite these measures, the deficiency remained unaddressed at the time of the survey, highlighting a lapse in the facility's training program implementation and oversight.
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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