Thornton Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Thornton, Colorado.
- Location
- 501 Thornton Pkwy, Thornton, Colorado 80229
- CMS Provider Number
- 065193
- Inspections on file
- 25
- Latest survey
- September 2, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Thornton Care Center during CMS and state inspections, most recent first.
Two residents with significant cognitive and physical impairments experienced multiple falls and injuries due to the facility's failure to provide adequate supervision, timely care plan updates, and individualized assessment. One resident suffered repeated falls, including a pelvic fracture and syncope, without prompt changes to her fall prevention plan or means to call for help in common areas. Another resident, with Alzheimer's and paralysis, was not assessed for safe use of a power wheelchair and fell during an outing, resulting in a spinal fracture. Staff interviews and record reviews revealed lapses in documentation, communication, and adherence to fall management policies.
Several residents reported uncomfortably high room and hallway temperatures, with some areas measured above 88°F. Despite repeated complaints to staff and management, there was no documentation of grievances or effective resolution. Staff acknowledged the persistent heat and limited ability to adjust cooling equipment, while residents described inadequate relief from fans and water coolers.
A resident's medical record lacked complete and accurate documentation for scheduled levetiracetam administration. An LPN initially could not locate the medication and used a code on the MAR, but after receiving the medication from another nurse, administered it without updating the EMR or adding a progress note. The DON confirmed the LPN was new and unsure how to document the event, resulting in incomplete records.
Two residents were repeatedly subjected to sexual abuse by another resident with a known history of public exposure and behavioral issues. Despite multiple reports and clear documentation of the perpetrator's behaviors, staff failed to implement effective, person-centered interventions or report incidents in a timely manner. The affected residents continued to experience discomfort and fear due to the facility's inadequate response and lack of targeted preventive measures.
The facility's QAPI program failed to effectively identify and address compliance concerns, leading to multiple deficiencies in areas such as resident choice, personal funds management, and maintaining a safe environment. Interviews revealed that significant issues were not promptly addressed, and systemic problems persisted despite efforts to improve communication and staff involvement.
The facility failed to maintain an effective infection control program, with deficiencies in PPE use, water management, and hand hygiene. A resident on Enhanced Barrier Precautions did not receive proper gown and glove use from staff during high-contact activities. The water management program lacked specific monitoring for Legionella, and staff did not consistently perform hand hygiene or sanitize equipment between resident interactions.
The facility failed to properly sanitize dishes and store food in the main kitchen. Observations showed that plate covers were not submerged in sanitizer for the required time, and a resident reported receiving dirty dishes. Additionally, raw chicken and ground beef were found undated in the walk-in refrigerator, and the facility did not follow proper labeling and storage practices. The DM acknowledged these issues, and the district supervisor suggested implementing a pull thaw system for better labeling.
The facility failed to honor the shower preferences of five residents, leading to a deficiency in care. Residents reported not receiving showers as preferred, with records confirming missed showers and lack of documentation. Staffing issues and documentation lapses contributed to the failure to meet residents' preferences.
The facility failed to maintain a homelike environment by not providing clean towels in multiple rooms, not cleaning a resident's closet with dried feces, and not addressing a clogged toilet in a timely manner. Residents reported a lack of towels, and staff interviews revealed confusion over responsibilities for maintenance issues.
The facility failed to provide adequate supervision and implement care-planned interventions for three residents, leading to safety hazards. A resident with dementia was observed without a required fall mat and transported in a wheelchair without foot pedals. Another resident was transferred without a gait belt, and a third resident was not properly assessed for safe smoking practices, despite evidence of unsafe behavior.
The facility failed to provide a varied and well-balanced diet for its residents, specifically for two residents who did not receive meals that met their preferences. One resident with severe cognitive impairments was not offered preferred Mexican foods, while another on a dysphagia diet was denied a requested ham and cheese sandwich due to dietary restrictions. Residents expressed concerns about repetitive menus and a lack of variety, which were not addressed by the facility.
The facility failed to provide residents with food that was palatable in taste, texture, appearance, and temperature. Residents reported issues such as cold, flavorless, and improperly cooked meals. Observations confirmed these complaints, with test trays showing over-salted tater tots, overcooked vegetables, and hard bread on sandwiches. Staff interviews acknowledged awareness of these concerns, and the dietary manager suggested changes in food preparation practices.
The facility failed to provide adequate access to personal funds for residents, with reports of limited availability on weekends and insufficient funds during weekdays. Residents were unable to access their money when needed, leading to canceled plans and inconvenience. Staff interviews revealed a lack of a process to replenish funds promptly, and the facility's prior administrator had restricted fund availability due to theft concerns.
The facility failed to properly store and manage medications, with issues including lack of disposal of medications after resident discharge, absence of date labels on opened medications, and expired medications not being discarded. Additionally, temperature logs for medication refrigerators were not maintained, indicating systemic issues in medication management practices.
The facility failed to investigate allegations of verbal abuse involving two residents. One resident reported feeling unsafe after being yelled at, but the facility only ensured they were separated in the dining room without further investigation. Another resident was involved in an altercation, but the facility did not document any investigation. The facility's actions did not align with its policy to ensure resident safety.
A resident with multiple medical conditions and cognitive impairment was discharged to the ED without proper documentation or education about the discharge. The facility issued a 30-day notice due to the resident's behavior, but an immediate discharge was executed after an incident with staff. The facility failed to follow its discharge planning policy, lacking necessary documentation and communication with the resident.
A facility failed to reassess a resident's status after a hospital transfer, preventing their return. The resident, with multiple health issues and moderate cognitive impairment, was transferred due to behavioral concerns. The facility did not document unmet needs or reassessment, leading to a deficiency in discharge planning.
A resident with severe cognitive impairments and multiple diagnoses was discharged without a proper discharge summary, which should have included a recapitulation of their stay and a final status summary. The resident left the facility to visit a family member in the hospital and did not return, and while medications were provided, the necessary discharge documentation was not completed.
The facility failed to provide necessary services for two residents, one dependent on staff for bathing and another legally blind needing meal assistance. A resident missed several scheduled showers due to staffing shortages, while another struggled to locate food on her plate as staff did not specify food locations, contrary to her care plan.
A resident with a history of diabetes and venous thrombosis sustained a skin tear on the left shin from a fall, which went untreated by the facility until several days later. Despite daily skin monitoring records indicating no concerns, the injury was not identified or documented in the electronic medical record, nor was the physician notified until 12/12/24. Staff interviews revealed a lack of awareness of the injury, highlighting a deficiency in timely treatment and care according to professional standards.
A resident with multiple health conditions did not receive new eyeglasses in a timely manner due to the facility's failure to initiate a funding request after an eye exam. Despite having a prescription since October, the request was delayed until December, and the glasses were not ordered, as confirmed by staff interviews.
Two residents in a LTC facility experienced significant medication errors. One resident was given hydralazine instead of hydroxyzine for itching due to a mix-up in medication orders, which was not caught by staff. Another resident received excessive acetaminophen dosages, exceeding safe limits, due to a lack of monitoring and adjustment of medication orders. These errors were due to failures in verification and oversight by the facility's staff.
A facility failed to ensure hospice agency notes for a resident were accessible to staff, affecting care coordination. The resident, over 65 with acute kidney failure and dementia, was receiving hospice services. Despite scheduled visits from hospice staff, recent notes were missing from the facility's EMR, as confirmed by staff interviews. This documentation lapse led to a deficiency in care coordination.
A resident in a therapeutic stipend program at an LTC facility experienced a delay in receiving payment for services rendered in November. The resident, who was cognitively intact and required assistance with daily activities, participated by calling Bingo and working in the soda store. The delay was due to the activity director's error in submitting the payment request, resulting in the stipend being paid in December.
A resident with dementia and other medical conditions was not provided with a personalized activity program to meet her needs and interests. Despite her care plan indicating preferences for activities like reading the Bible and attending religious services, observations showed she was often alone without engagement. The activity director was unaware of her specific interests, and records lacked documentation of offered activities.
A facility failed to provide consistent dialysis services for a resident, including accurate monitoring and documentation of pre- and post-dialysis weights. The resident, with multiple health conditions, required dialysis treatment, but the facility did not consistently document post-dialysis weights in the EMR or ensure thorough communication with the dialysis center. Staff interviews revealed inconsistencies in the process of acquiring and documenting dialysis communication forms.
The facility failed to administer pain medications timely for three residents, violating professional standards. One resident reported frequent delays, confirmed by records showing late administration of morphine, hydrocodone-acetaminophen, and acetaminophen. Another resident experienced inconsistent timing of acetaminophen doses, and a third resident's tramadol was often late. Staff interviews acknowledged the issue, but there was no documentation of physician notification or progress notes for late administrations.
The facility failed to manage pressure injuries for several residents, including a resident who developed multiple stage 2 to stage 4 pressure injuries and osteomyelitis due to inadequate assessment and treatment. Another resident was not properly assessed for pressure injury risk, lacked necessary interventions, and did not have an air mattress. Additional residents experienced similar failures in pressure injury assessment and timely treatment.
The facility failed to protect residents from physical abuse, including an incident where a CNA injured a resident, resulting in rib fractures and a pneumothorax. Additionally, two residents with known aggression histories were involved in a physical altercation, and another resident with cognitive impairment abused her roommate. The facility's investigations were delayed and lacked adequate interventions or monitoring strategies.
The facility's QAPI program failed to address compliance concerns, leading to serious harm from untreated pressure injuries and an abuse incident. The facility did not provide its QAPI policy during the survey, and repeat deficiencies were noted. Interviews revealed inadequate clinical oversight and staff training, with recent staff changes contributing to the issues.
Failure to Prevent Accidents and Provide Adequate Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure that two residents at high risk for falls and injury received adequate supervision and assessment to prevent accidents. One resident with a history of neurocognitive disorder, brain injury, and moderate cognitive impairment experienced four falls within a short period, two of which required emergency department evaluation. After a fall resulting in a pelvic fracture, there were no immediate changes to the resident's fall prevention care plan, and the resident was allowed to participate in an outing on the same day as another fall. The resident was not provided with a means to call for assistance in common areas, and there was no assessment of her ability to understand or use fall prevention interventions, despite her cognitive deficits. Another resident with Alzheimer's disease, right-sided paralysis, and a history of falls was transported by her spouse to an appointment, during which she fell from her power wheelchair and sustained a head laceration and thoracic spine fracture. The facility had not assessed her ability to safely operate power-mobility equipment, nor was there documentation of care plan review or revision after the fall. There was also no evidence that the facility provided education to the spouse regarding safe transfers or supervision during outings. Facility policy required prompt assessment, care plan updates, and interdisciplinary team (IDT) review after falls, but documentation revealed delays or omissions in these processes. Staff interviews confirmed gaps in communication, monitoring, and documentation of fall reviews and interventions. The lack of timely care plan updates, supervision, and individualized assessment contributed to repeated falls and injuries for both residents.
Failure to Address Resident Grievances Regarding Excessive Room Temperatures
Penalty
Summary
The facility failed to honor residents' rights to voice grievances and to provide prompt efforts to resolve them, as required by policy. Three residents reported that their rooms and common areas were uncomfortably hot, with temperatures measured as high as 88.9 degrees Fahrenheit in some rooms and 84.4 degrees Fahrenheit in common areas. Despite these complaints, there was no documentation of grievances related to room temperatures, and residents stated that their concerns were reported to staff and management multiple times without resolution. Staff interviews confirmed that high temperatures were a known issue, and that only maintenance personnel could adjust cooling equipment, which was sometimes nonfunctional or turned off due to other resident complaints. Residents described persistent discomfort due to the heat, with one resident noting that her room thermometer frequently registered temperatures in the upper 80s and up to 94 degrees Fahrenheit. Residents reported that fans provided little relief and that their rooms were located far from water coolers, which were sometimes not operational or effective. Staff responses to the heat included providing extra ice and closing shades, but these measures did not address the underlying temperature issues. The facility administrator was unaware of any current complaints about room temperatures and did not have records of grievances, despite multiple residents stating they had reported their concerns.
Incomplete Medication Administration Documentation in EMR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident who was prescribed levetiracetam for seizure management. The medication administration record (MAR) for this resident showed a code indicating 'other/see progress notes' for two consecutive days, but a review of the progress notes did not reveal any documentation clarifying whether the medication was administered as ordered. The facility's policy requires that each medication administration be documented, and any deviations or issues be recorded in the resident's medical record. Interviews with staff revealed that the LPN responsible for administering the medication on those days was unable to locate the medication initially and used the code to indicate this. However, after another nurse provided the medication from the emergency supply, the LPN administered it but failed to update the documentation or add a corresponding progress note in the electronic medical record (EMR). The DON confirmed that the LPN, who was new to the facility, was unsure how to properly document the administration after entering the initial code, resulting in incomplete and inaccurate medical records for the resident.
Failure to Protect Residents from Sexual Abuse and Inadequate Staff Reporting
Penalty
Summary
The facility failed to protect two residents from sexual abuse by another resident, despite documented history and ongoing incidents. Resident #3, who had diagnoses including Wernicke's encephalopathy, alcohol-induced dementia, and impulse disorder, was known to have a history of exposing himself and masturbating in public, as documented in his care plan. Both Resident #2 and Resident #5, who were cognitively intact or had moderate impairment, reported multiple incidents where Resident #3 exposed his genitals to them in the hallway and near his room. These incidents were reported to staff, but the residents stated that no effective action was taken to stop the behavior, and the exposure continued. The facility's investigation into the reported abuse was inadequate. Although Resident #2 reported the incident to staff, there was a delay in reporting to the nursing home administrator. The facility ultimately unsubstantiated the abuse claim due to lack of witnesses and denial by Resident #3, despite both victims consistently describing repeated exposure and discomfort. Staff interviews revealed that some were aware of the behavior but did not report it, either because they did not perceive the residents as upset or because the exposure occurred in Resident #3's room with the door open. The activity director admitted to witnessing the behavior but failed to report it, and the activity assistant overheard a resident discussing the incident but did not escalate it to management. Resident #3's care plan acknowledged his behavioral risks but lacked person-centered interventions specifically designed to prevent him from exposing himself to others. Staff members were either unaware of interventions or only referenced general behavioral management strategies. The care plan did not include targeted measures to address the specific risk of public exposure, and staff responses were limited to reminders in the dining room, despite incidents occurring in hallways. As a result, the facility did not ensure the safety and well-being of the affected residents, who continued to feel unsafe and uncomfortable.
Ineffective QAPI Program and Multiple Deficiencies
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program to identify and address compliance concerns, impacting the quality of care, quality of life, and resident safety. The QAPI committee did not operate in a manner that effectively identified and addressed issues related to quality of care. The facility's policy outlined a comprehensive program designed to monitor and evaluate residents' care and health services systematically and continuously, but this was not effectively executed. The report highlights several deficiencies across various areas, including self-determination, management of personal funds, and maintaining a safe, clean, and homelike environment. Specific failures included not honoring resident choices, not compensating residents timely for work performed, and not managing personal funds accounts adequately. Additionally, the facility did not ensure a safe environment, failed to investigate allegations of abuse, and did not meet transfer and discharge requirements. There were also issues with providing appropriate treatment and services for activities of daily living, maintaining hearing and vision, and ensuring residents were free from accident hazards. Interviews with facility staff revealed that the QAPI committee met monthly, but significant issues were not always identified or addressed promptly. The Director of Clinical Services (DOCS) noted that smoking assessments were not completed and that enhanced barrier precautions were overlooked due to changes in facility leadership. The Nursing Home Administrator (NHA) acknowledged that the facility had not identified residents needing assistance at meal times as an issue, despite having a schedule for managers to observe dining rooms. The facility also failed to recognize concerns in the activities department, although efforts were being made to revamp it with a new activity director. The Regional Director of Operations (RDO) mentioned that floor huddles were instituted to encourage staff to discuss concerns openly, but systemic issues persisted.
Infection Control Deficiencies in PPE, Water Management, and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several deficiencies observed during the survey. Staff did not adhere to the Enhanced Barrier Precautions (EBP) when caring for a resident with a fistula who required dialysis. Specifically, a certified nurse aide (CNA) did not wear a gown while changing the resident's bedding and assisting with dressing, despite the presence of an EBP sign indicating the need for gown and glove use during high-contact activities. Interviews with staff revealed a lack of understanding and inconsistent application of EBP protocols, contributing to the deficiency. The facility's water management program (WMP) was also found to be inadequate. The Legionella Surveillance policy did not identify specific areas where Legionella could grow and spread, nor did it outline how to monitor and document control measures. Observations showed that unoccupied rooms with potential dead legs in the plumbing system were not properly flushed or monitored for waterborne pathogens. Interviews with the maintenance director revealed a lack of awareness regarding the requirements for Legionella surveillance, further highlighting the deficiency in the facility's WMP. Additionally, staff failed to follow appropriate hand hygiene practices during resident care and meal delivery. Observations indicated that CNAs did not perform hand hygiene between resident interactions or sanitize shared vital signs equipment between uses. During meal delivery, staff did not offer hand hygiene to residents or perform hand hygiene themselves after handling meal trays. These lapses in hand hygiene practices were confirmed through staff interviews, indicating a need for further education and adherence to infection control protocols.
Deficiencies in Dish Sanitization and Food Storage
Penalty
Summary
The facility failed to ensure proper sanitization of dishes in the main kitchen, as observed during a survey. The dietary manager (DM) was seen submerging plate covers in the sanitizer compartment of a three-compartment sink for only five to twenty-five seconds, contrary to the manufacturer's instructions which required at least one minute of contact time. This discrepancy was confirmed by the DM, who initially believed the plate covers were submerged for the correct duration. A resident reported frequently receiving dirty dishes with dried food spots, indicating a persistent issue with the dishwashing process. Additionally, the facility did not adhere to safe food storage practices in the walk-in refrigerator. Observations revealed undated bags of raw chicken and ground beef, as well as improperly labeled containers of raw chicken thighs and shredded parmesan cheese. The DM admitted that the meat was not labeled because it was leftover and used for staff meals, and acknowledged that the ham was stored incorrectly next to raw chicken. The district supervisor noted that the facility should implement a pull thaw system to properly label and date meat. These deficiencies highlight a lack of compliance with professional standards for food storage and sanitization, as outlined by the FDA Food Code and the facility's own policies. The failure to follow proper procedures for dish sanitization and food storage could potentially compromise the safety and quality of food served to residents.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to honor the shower preferences of five residents, leading to a deficiency in resident care. Resident #35, who was cognitively intact and dependent on staff for showers, reported not receiving a shower in the past four weeks despite her preference for weekly showers. The records confirmed that she had not received a shower since 11/18/24, and there was no documentation of any refusals or reasons for missed showers. Resident #39, also cognitively intact, preferred two showers a week but only received four in the past 30 days. She refused showers offered in the morning, preferring them in the late afternoon or evening. The records showed multiple instances where showers were marked as not applicable without explanation. Similarly, Resident #6, who required staff assistance for showers, preferred three showers a week but only received eight out of 12 opportunities in November 2024. The discrepancy between her care plan and actual shower schedule was noted. Resident #23, who required assistance with showering, had not received a shower in 17 days, despite his preference for three showers a week. The records showed only one documented refusal, with no explanation for other missed showers. Resident #33, with moderate cognitive impairments, also had not received a shower in 17 days, with records showing three refusals but no documentation for other missed showers. Staff interviews revealed issues with staffing and documentation, contributing to the failure to meet residents' shower preferences.
Deficiencies in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for its residents, as evidenced by the lack of clean washcloths and hand towels in multiple rooms across the East and [NAME] units. Observations revealed that several rooms were missing these essential items, and residents reported that housekeepers removed dirty towels without replacing them with clean ones. Interviews with residents and staff indicated that the nursing staff was responsible for distributing towels, but this was not being done consistently, leading to residents having to use paper towels for personal hygiene. Additionally, the facility did not ensure timely cleaning of Resident #6's closet, which had remnants of dried feces on the floor, door, and wall. This issue arose after the resident experienced an accident while preparing for a colonoscopy months prior. Despite requests for cleaning, the feces remained, indicating a failure in maintaining a sanitary environment for the resident. The facility also failed to address a clogged toilet in a resident's bathroom in a timely and appropriate manner. Observations showed that the toilet was backed up with water and fecal matter, and despite a work order being placed, the issue persisted for several hours. Staff interviews revealed confusion over responsibilities for addressing such maintenance issues, with the maintenance director indicating that CNAs were expected to handle the situation without proper training or guidance on handling bodily fluids.
Inadequate Supervision and Care Planning in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision and implement care-planned interventions to prevent accidents for three residents. Resident #9, who had a history of falls and dementia, was observed multiple times without a fall mat beside her bed, despite a physician's order and care plan intervention requiring it. Additionally, Resident #9 was transported in a wheelchair without foot pedals, causing her feet to dangle, which was not addressed in her care plan. Resident #26, also with dementia and a history of falls, was similarly transported in a wheelchair without foot pedals, leading to her feet dangling during transport. The care plan for Resident #26 did not include an intervention to ensure foot pedals were used. Furthermore, Resident #26 was transferred from a chair to a wheelchair without the use of a gait belt, contrary to facility policy and her care plan, which required substantial assistance during transfers. Resident #24, who was cognitively intact and independent in activities of daily living, was not appropriately assessed for safe smoking practices. Despite evidence of smoking in his room and a history of unsafe smoking behavior, the facility failed to conduct timely smoking risk assessments and did not update his care plan to reflect the need for supervision during smoking.
Failure to Provide Varied and Preferred Diets
Penalty
Summary
The facility failed to provide a nourishing, palatable, and well-balanced diet that met the daily nutritional and special dietary needs of its residents, specifically for two residents out of a sample of 41. The deficiency was identified through observations, record reviews, and interviews, revealing that the facility did not offer a balanced menu with variety and failed to provide alternate items of preference when requested. Resident interviews and a resident group interview highlighted concerns about repetitive menus and a lack of variety, with specific complaints about the overuse of certain foods like chicken, rice, potatoes, and mixed vegetables. Despite having a food committee and voicing concerns during resident council meetings, residents felt their feedback was not being addressed. Resident #61, who had severe cognitive impairments and multiple health issues, was not provided with food that met his preferences, which included Mexican food, bananas, yogurt, and other specific items. His care plan was not updated to reflect these preferences, and staff did not offer encouragement or preferred items during meals. The resident's representative expressed concerns about his weight and eating habits, noting that the facility staff were unaware of his food preferences and did not provide a menu when requested. Resident #48, who had cognitive impairments and was on a dysphagia diet, requested a grilled cheese with ham sandwich but was only provided with a grilled cheese sandwich due to dietary restrictions. The registered dietitian initially denied the request for ham, citing safety concerns, but later acknowledged that the resident could have chopped ham. This incident highlighted a lack of communication and understanding of the resident's dietary needs and preferences, contributing to the deficiency in providing a well-balanced diet.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that residents consistently received food that was palatable in taste, texture, appearance, and temperature. Multiple resident interviews revealed dissatisfaction with the food quality, citing issues such as food being served cold, lacking flavor, and being improperly cooked. Specific complaints included grilled cheese sandwiches being microwaved instead of grilled, repetitive menus, and overcooked or tough meat. Residents expressed that attending food meetings did not result in improvements, and they felt their concerns were not being addressed by the facility. Observations during meal preparation and service confirmed the residents' complaints. During a continuous observation, it was noted that the temperature of the tater tots was 99 degrees F, and the mixed vegetables were 160 degrees F. A test tray evaluation revealed that the tater tots were over-salted, the vegetables were overcooked and bland, and the philly cheesesteak sandwich had hard, chewy bread with burnt cheese. These findings were consistent with resident complaints about the food being served cold and lacking in quality. Interviews with staff, including the nursing home administrator and dietary manager, acknowledged awareness of the food quality concerns. The dietary manager mentioned that the facility had recently switched food vendors, which might have affected residents' perceptions of food quality. Despite conducting test tray audits, the facility had not identified significant issues. The dietary manager suggested that assembling sandwiches during meal service and batch cooking tater tots could improve food quality, indicating a need for changes in food preparation practices.
Inadequate Access to Personal Funds for Residents
Penalty
Summary
The facility failed to ensure that residents had adequate access to their personal funds accounts, affecting four residents out of a sample of 41. Residents reported being unable to access their money on weekends and sometimes during weekdays due to the facility running out of funds. Interviews with residents revealed that they were unable to obtain money when needed, which led to canceled plans and inconvenience. Observations confirmed that the facility's banking hours were limited to weekdays, and staff interviews indicated that the resident council had voted to restrict access to funds on weekends. Staff interviews further revealed that there was no established minimum balance to trigger obtaining additional funds, leading to situations where residents could not access the requested amounts. The business office manager and activity director acknowledged the limitations in fund availability and the lack of a process to replenish funds promptly. The regional director of operations noted that the facility's prior administrator had restricted fund availability due to concerns about theft, but acknowledged that residents should have access to funds on weekends and that the resident council's restrictions should not override required access. The facility lacked a process to ensure funds were available when needed, contributing to the deficiency.
Medication Storage and Management Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and management of medications in two medication storage rooms and two medication carts. Observations revealed that medications were not disposed of after residents were discharged, and medications were not labeled with the dates they were opened. Additionally, expired medications were not removed and discarded from the medication carts and storage refrigerators. The facility also failed to maintain temperature logs for the medication refrigerators, which is a critical aspect of ensuring medication efficacy and safety. During observations, it was noted that the medication storage refrigerators in both the [NAME] hall and East hall lacked temperature logs. Several medications, including Tuberculin Purified Protein Derivative and Insulin Glargine, were found opened without labels indicating the date they were opened. Medications labeled with discharged residents' names were still present in the storage, and some medications were found to be expired, such as Phenalephrine suppositories and Amlactin lotion. Nursing staff acknowledged the lack of proper labeling and the presence of expired medications, indicating a lapse in adherence to the facility's medication storage policy. Interviews with nursing staff and the Director of Nursing (DON) revealed a lack of clarity and responsibility regarding the maintenance of temperature logs and the removal of medications post-discharge. The DON confirmed that it was the night shift nurses' responsibility to check and record refrigerator temperatures and that medications should be removed on the day of a resident's discharge. However, the absence of a temperature monitoring log and the presence of expired and improperly labeled medications suggest a systemic issue in the facility's medication management practices.
Failure to Investigate Allegations of Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of verbal abuse involving two residents, Resident #37 and Resident #21. Resident #37, who had moderate cognitive impairment, reported feeling unsafe after being yelled at by another resident. The facility's response was limited to ensuring the two residents did not sit near each other in the dining room, without conducting a comprehensive investigation. There was no documentation of staff or resident interviews, and the nursing home administrator (NHA) did not provide evidence of an investigation before the survey exit. Resident #21, who was cognitively intact, was involved in an altercation with another resident, Resident #44. The incident involved yelling and aggressive behavior, but the facility did not document any investigation into the matter. The NHA claimed to have interviewed both residents, but there was no documentation to support this. The grievance form completed by the NHA did not include interviews with staff or other residents, and the facility failed to provide evidence of a thorough investigation. In both cases, the facility did not adhere to its policy of conducting a thorough investigation into allegations of abuse. The lack of documentation and failure to interview relevant parties indicate a deficiency in the facility's response to these incidents. The facility's actions did not align with its policy to ensure resident safety and prevent abuse.
Inadequate Discharge Process for Resident
Penalty
Summary
The facility failed to provide an appropriate discharge process for a resident, leading to a deficiency in their care. The resident, who was under 65 and had multiple medical conditions including diverticulitis, frontal lobe deficit, hemiplegia, major depressive disorder, anxiety disorder, and acute kidney failure, was discharged to the emergency department without proper documentation or education regarding the discharge. The facility's discharge planning policy required an effective discharge process focusing on the resident's goals and ensuring a smooth transition to post-discharge care, which was not followed in this case. The resident was documented as moderately cognitively impaired and had a history of physical and verbal behaviors directed at others. The facility issued a 30-day notice of involuntary discharge due to the resident's behavior, citing safety concerns for the resident and others. However, on the day of discharge, the resident was immediately discharged after an incident where he assaulted a staff member. The facility failed to document that the resident was provided education about his immediate discharge or that he understood it. The regional director of operations confirmed that the decision for immediate discharge was made after the resident fell and initially refused to go to the emergency department. The facility's management team decided on the immediate discharge due to the resident's behavior, but the necessary documentation and communication with the resident were lacking.
Failure to Reassess Resident Post-Hospital Transfer
Penalty
Summary
The facility failed to permit a resident to return after a facility-initiated transfer to the hospital, violating the discharge planning policy. The resident, under 65, had multiple diagnoses including diverticulitis, frontal lobe deficit, hemiplegia, major depressive disorder, anxiety disorder, and acute kidney failure. The resident required setup assistance with eating and was independent in other ADLs, with no active discharge plan. The resident was moderately cognitively impaired with a BIMS score of nine out of 15 and exhibited physical and verbal behaviors directed at others. The facility did not reassess the resident's status after the transfer to the emergency department, nor did it document any unmet needs that would prevent the resident's return. The regional director of operations stated that the resident had fallen and initially refused hospital transfer but later agreed. The facility management decided on an immediate discharge due to the resident's behavior, which included assaulting a staff member. The charge nurse communicated the discharge to the emergency department, but there was no documentation of reassessment or refusal of care in the resident's EMR.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure a discharge summary was in place for a resident who was discharged home with family. The discharge summary was supposed to include a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge. The facility's policy, last revised in October 2022, mandates that a discharge summary and post-discharge plan be developed when a resident's discharge is anticipated. However, for this resident, the electronic medical record did not contain documentation of a final summary of the resident's status or a recapitulation of their stay. The resident, who was under 65 years old, had diagnoses including congestive heart failure, pulmonary hypertension, severe protein-calorie malnutrition, and psychoactive substance abuse. The resident had severe cognitive impairments and was dependent on staff for personal hygiene. On the day of discharge, the resident left the facility to visit his mother in the hospital and did not return. The nurse on duty provided a one-day supply of medications and later arranged for the resident's mother to pick up additional medications. Despite these actions, the facility did not complete the required discharge summary documentation.
Deficiencies in Personal Hygiene and Meal Assistance
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #32, who was dependent on staff for bathing, did not receive her scheduled showers. Despite being scheduled for showers twice a week, records indicated that she missed several showers, with no documentation explaining the missed showers or any interventions attempted. Interviews with staff revealed that there were often staffing shortages, which led to missed showers, and that Resident #32 was generally cooperative and did not refuse care. Additionally, the facility failed to provide adequate meal assistance to Resident #48, who was legally blind. During meal observations, it was noted that staff informed the resident of the food items on her plate but did not specify their locations, leaving the resident to struggle to locate her food. This was contrary to the care plan, which required staff to inform the resident of the location of her food items. Interviews with staff confirmed that the resident needed assistance in identifying the location of her food to eat independently. These deficiencies highlight a lack of adherence to the facility's policies and procedures regarding personal hygiene and meal assistance for residents with specific needs. The failure to provide scheduled showers and appropriate meal assistance compromised the residents' ability to maintain personal hygiene and independence in eating, respectively.
Failure to Timely Treat Resident's Skin Injury
Penalty
Summary
The facility failed to provide timely treatment and care for a resident's skin injury, which was not addressed according to professional standards of practice. The resident, under 65 years old, with a history of type 2 diabetes and venous thrombosis, was cognitively intact and independent in activities of daily living. The resident sustained a skin tear on the left shin from a fall at his daughter's house. Despite daily skin monitoring records from 12/7/24 to 12/12/24 indicating no concerns, the skin tear was not identified or treated by the facility until 12/12/24. Observations on 12/11/24 and 12/12/24 revealed the untreated skin tear, and the facility's electronic medical record lacked documentation of the injury or notification to the physician prior to 12/12/24. Interviews with staff indicated a lack of awareness of the injury, with an LPN not noticing the injury during a medication round and an RN only becoming aware of the injury on 12/12/24. The facility's director of nursing provided undated wound education emphasizing the importance of immediate nurse notification, physician notification, risk management occurrence initiation, and appropriate documentation when a new skin breakdown is identified.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to ensure timely access to vision services for a resident, leading to a deficiency in maintaining the resident's vision abilities. The resident, a 69-year-old with diagnoses including hemiplegia, peripheral vascular disease, mood disorder, and chronic obstructive pulmonary disease, was admitted to the facility and had no cognitive impairment. Despite being independent in some activities of daily living, the resident required supervision or assistance with most others. The resident had an eye exam on October 21, 2024, which resulted in a new prescription for eyeglasses. However, the facility did not document the receipt of these glasses in the resident's electronic medical record. Interviews with facility staff revealed that the social services consultant acknowledged the delay in initiating the request for funding the eyeglasses, which should have been done shortly after the eye exam. The request for funding was not initiated until December 13, 2024, during the survey, and the eyeglasses had not been ordered by that date. A certified nurse aide also confirmed that she had not seen the resident wearing glasses and was unaware of the resident's need for them. This inaction resulted in the resident not receiving the necessary eyeglasses in a timely manner, as expected by the facility's procedures.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, specifically involving two residents. For one resident, the facility did not order and administer the correct medication for itching. Instead of hydroxyzine, which was prescribed for itching, the resident was given hydralazine, a medication for high blood pressure. This error occurred due to a mix-up in medication orders, which was not caught by the staff, including the CNA-Med, the registered pharmacist consultant, and the nurse practitioner. The resident identified the error when the wrong medication was attempted to be administered, leading to the discontinuation of the incorrect medication order. Another resident received excessive dosages of acetaminophen, exceeding the recommended daily limit. The resident was prescribed multiple medications containing acetaminophen, which, when combined, resulted in dosages above the safe threshold. The facility's staff, including the RN and LPN, failed to monitor and adjust the medication orders to prevent this excessive dosage. The pharmacist also did not identify the potential for overdose during the medication regimen review. The errors were compounded by a lack of proper verification and oversight by the facility's staff and systems. The medication administration policy was not adhered to, and there was a failure in communication and coordination among the healthcare providers, pharmacists, and nursing staff. These lapses led to the administration of incorrect and excessive medications, posing potential risks to the residents involved.
Deficiency in Coordination of Hospice Care Documentation
Penalty
Summary
The facility failed to ensure that hospice agency notes regarding a resident's care were easily accessible to the facility staff, which hindered effective coordination of care with the hospice agency. The resident, who was over 65 years old and had diagnoses including acute kidney failure, a history of falling, and dementia, was receiving hospice services. The resident's care plan indicated that hospice staff, including a nurse and a certified nurse aide (CNA), were involved in the resident's care, with visits scheduled multiple times a week. However, the hospice documentation was not up to date, with the last notes from the hospice nurse and CNA being from several months prior. Interviews with facility staff revealed that the hospice nurse and CNA were visiting as scheduled, but the notes from these visits were not being properly documented in the facility's electronic medical record (EMR). The registered nurse (RN) responsible for the resident's care was unable to find any recent hospice notes in the EMR, and the health information specialist confirmed that there were no notes from the hospice agency for the resident. This lack of documentation and communication between the hospice agency and the facility staff led to a deficiency in the coordination of care for the resident.
Resident Payment Delay in Therapeutic Stipend Program
Penalty
Summary
The facility failed to ensure that a resident participating in the Resident Therapeutic Stipend Program was compensated in a timely manner for services rendered. The resident, who was cognitively intact and required assistance with daily activities, participated in the program by calling Bingo and working in the resident soda store. Despite completing her work program commitment log for November 2024, the resident did not receive her stipend until December 12, 2024, which was during the survey. The delay in payment was attributed to the activity director, who was new to the role and did not submit the payment request correctly for November 2024. This error caused a delay in the issuance of the stipend check, which was eventually cashed and deposited into the resident's petty cash account. The business office manager confirmed that there was inconsistency in receiving checks from corporate, which contributed to the delay in payment.
Failure to Provide Personalized Activity Program for Resident
Penalty
Summary
The facility failed to provide a personalized activity program for a resident, leading to a deficiency in meeting the resident's needs and interests. The resident, over 65 years old, with diagnoses including acute kidney failure, history of falling, and dementia, was observed multiple times without engagement in meaningful activities. Despite the resident's care plan indicating a preference for activities such as reading the Bible, listening to music, and participating in religious services, there was no evidence of these activities being offered or facilitated. Observations showed the resident alone in bed or in common areas without interaction or engagement in activities. Interviews and record reviews revealed that the resident's preferences for spiritual and sensory activities were not being met. The activity director, new to the facility, was unaware of the resident's specific interests and acknowledged the absence of sensory programs on the calendar. The resident's electronic medical record showed a lack of documentation for one-on-one activities, spiritual activities, or assistance in going outside, as per the resident's preferences. The activity director admitted to not having the resident on a one-to-one program and was unaware of the resident's enjoyment of outdoor activities.
Inconsistent Dialysis Documentation and Monitoring
Penalty
Summary
The facility failed to provide dialysis services consistent with professional standards of practice for a resident who required such services. Specifically, the facility did not consistently and accurately monitor pre- and post-dialysis weights for the resident, nor did they consistently document the resident's post-dialysis weight from the dialysis communication form in the resident's electronic medical record (EMR). Additionally, the facility did not ensure that communication forms between the facility and the dialysis center were obtained consistently and completed thoroughly. The resident in question, who was over 65 years old, had multiple diagnoses including ischemic cardiomyopathy, dysphagia, type 2 diabetes mellitus, heart disease, chronic kidney disease, and vascular dementia. The resident was dependent on staff for various activities of daily living and received dialysis treatment. A physician's order required the documentation of the resident's post-dialysis weights on specific days, but the facility failed to record these weights in the EMR on numerous occasions. Interviews with facility staff revealed that there was a lack of consistency in the process of acquiring and documenting dialysis communication forms. The registered nurse indicated that certified nurse aides were responsible for weighing the resident before dialysis, and the communication forms were supposed to be sent to and returned from the dialysis center with the resident. However, the director of nursing and the director of clinical services acknowledged that the facility's process for obtaining these forms was inconsistent, and the forms were not always reviewed or placed in the resident's EMR as required.
Failure to Administer Pain Medications Timely
Penalty
Summary
The facility failed to administer pain medications in a timely manner for three residents, as per physician orders, which is a violation of professional standards of practice. Resident #3, who was cognitively intact, reported that her medications were rarely administered on time, and she had filed grievances regarding this issue. The medication administration records confirmed multiple instances where her pain medications, including morphine sulfate, hydrocodone-acetaminophen, and acetaminophen, were administered outside the allowed time window, sometimes by several hours. Resident #1, also cognitively intact, expressed uncertainty about the timing of his pain medication administration, as different nurses administered them at varying times. The medication administration records showed that his acetaminophen doses were frequently given late, with delays ranging from minutes to several hours. This inconsistency in medication administration timing was not addressed by notifying the physician or documenting the deviations in the residents' medical records. Resident #2, who had moderate cognitive impairments, also experienced delays in receiving his pain medication, tramadol. The medication administration records indicated that his doses were often administered late, with delays extending up to nearly four hours. Interviews with nursing staff and facility leadership revealed an acknowledgment of the issue, with staff indicating that pain medications should be administered within a specific time window for effective pain management. However, there was no documentation of physician notification or progress notes for the late administrations.
Deficiency in Pressure Injury Management
Penalty
Summary
The facility failed to provide necessary treatment and services to manage pressure injuries and minimize risks for four residents, leading to a deficiency. Resident #3 was hospitalized multiple times between January and June 2024, during which he developed several pressure injuries ranging from stage 2 to stage 4, including osteomyelitis of the sacral wound. The facility repeatedly failed to assess Resident #3's wounds upon readmission, monitor the wounds, and obtain and implement treatment orders in a timely manner. This lack of action resulted in the resident being without treatment orders for significant periods, contributing to the worsening of his condition. Resident #5 also experienced inadequate care, as the facility failed to assess her wounds on admission and did not accurately assess her risk for pressure injury development. Despite having pressure injuries and being frequently incontinent, the resident was not identified as at risk for pressure injuries, and timely pressure prevention interventions and treatments were not implemented. Additionally, the resident did not have an air mattress, which was necessary to prevent further pressure injuries. Residents #4 and #12 faced similar issues, with the facility failing to ensure proper assessment and timely treatment of their pressure injuries. Resident #4 had an air mattress that was not inflated appropriately, increasing the risk of pressure injuries, while Resident #12's pressure injuries were not assessed on admission, and treatment was not ordered or provided in a timely manner. These failures in pressure injury management and prevention highlight significant deficiencies in the facility's care practices.
Removal Plan
- The director of nursing (DON) completed pressure injury assessments on two other residents and updated the plans of care.
- Current treatment orders were verified and treatment was completed as ordered.
- A community-wide audit of all residents was completed by the DON or designee to obtain a baseline on current skin concerns in the community. Any identified area was corrected.
- The DON completed an audit to ensure all treatments, supplies, and equipment were readily available for pressure injury treatments.
- The Director of Clinical Operations completed an audit of all air mattresses and support surfaces to ensure proper use in accordance with manufacturer's recommendations or resident preferences. All identified areas were corrected.
- The DON or designee initiated education with nursing staff regarding proper identification, documentation, and monitoring of pressure ulcers, as well as implementing interventions to prevent breakdown and completion of treatments as ordered for resident's skin injuries. Education to be provided to agency staff.
- The DON or designee to complete wound rounds and ensure documentation is inputted in the electronic health record.
- The DON or designee to complete wound dressing change observations and complete chart review for wound documentation for two residents to ensure that orders in place and are being followed as written, that staff is following appropriate infection control practices, that the physician is notified as needed, and that documentation is consistent throughout the chart. Identified concerns to be addressed with staff.
- The Nurse consultant or designee to complete a review of the resident's wound documentation to ensure that it is consistent with documentation from the wound physician and that the physician is being contacted as necessary for the wound. Identified concerns to be addressed with DON/designee.
- Any residents admitted to the facility or returning from the hospital will be assessed for any area of skin breakdown. Any areas identified requiring treatment will have orders verified or obtained and wound care appointments will be transcribed and overseen by nurse leadership. A review to include an additional skin check will be completed.
- DON or designee to report on wound data in the quality assurance performance improvement QAPI meeting. Identified concerns to be tracked and trended.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving both staff and resident-to-resident interactions. In one case, a certified nurse aide (CNA) physically abused a resident by pressing his forearm into the resident's chest after the resident used a racial slur. This resulted in the resident suffering multiple rib fractures and a pneumothorax, requiring hospitalization. The facility's investigation into the incident was delayed, and there were inconsistencies in the documentation, including a lack of interviews with key staff members present during the incident. In another incident, two residents with known histories of aggression were involved in a physical altercation, resulting in one resident sustaining an eye injury. The facility's investigation revealed that both residents had a history of physical and verbal aggression, yet there were no new interventions added to their care plans following the altercation. The facility failed to implement adequate monitoring or behavior management strategies to prevent such incidents. Additionally, a resident with severe cognitive impairment and a history of aggressive behavior physically abused her roommate by twisting her arm and wrapping a call light cord around her neck. Despite previous aggressive incidents, there was no behavior care plan in place for the aggressor until after the incident. The facility's response to the abuse was inadequate, as the abuse was deemed unsubstantiated due to the aggressor's dementia, and there was a lack of documented frequent monitoring or intervention strategies in the care plans.
Deficiencies in QAPI Program and Resident Care
Penalty
Summary
The facility failed to implement an effective Quality Assurance Performance Improvement (QAPI) program to address and rectify compliance concerns, particularly in the areas of quality of life and care for residents. The QAPI committee did not adequately identify and address issues related to pressure injuries and abuse prevention. Specifically, the facility did not ensure timely assessment and intervention for pressure injuries, leading to a resident developing a wound infection with osteomyelitis, which resulted in immediate jeopardy and actual serious harm. Additionally, the facility failed to prevent an abuse incident where a staff member intentionally caused harm to a resident, resulting in multiple rib fractures and a pneumothorax. The facility's QAPI policy was not provided during the survey, indicating a lack of adherence to established procedures. The facility had a history of repeat deficiencies, with previous citations for pressure injuries and abuse prevention. Interviews with the nursing home administrator and the medical director revealed gaps in clinical oversight and staff training, particularly in wound care and abuse prevention. The use of agency staff and recent changes in wound care providers were noted as contributing factors to the facility's failures. The medical director, who was new to the facility, was unaware of the extent of the issues, highlighting a lack of communication and continuity in care practices.
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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