Wheatridge Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Wheat Ridge, Colorado.
- Location
- 2920 Fenton St, Wheat Ridge, Colorado 80214
- CMS Provider Number
- 065308
- Inspections on file
- 19
- Latest survey
- July 2, 2025
- Citations (last 12 mo.)
- 0
Citation history
Health deficiencies cited at Wheatridge Care Center during CMS and state inspections, most recent first.
A resident with multiple sclerosis and a history of falls, who required total staff assistance for showers, was left unsupervised in the shower room. The CNA assisting the resident left to seek help without using the call light, and the resident fell, sustaining a right femur fracture that required surgery.
The facility did not have a designated or certified infection preventionist to oversee the infection prevention and control program, as required by policy. Instead, the role was temporarily filled by staff members who lacked the necessary infection control certification, potentially affecting all residents.
Three residents receiving psychotropic medications did not have individualized, person-centered non-pharmacological interventions or behavior monitoring documented in their care plans or physician orders. Instead, generic interventions and behaviors were used, and staff lacked awareness and training on resident-specific approaches, resulting in inadequate documentation and monitoring of behaviors related to medication use.
Nursing staff failed to follow professional standards by not observing residents as they took oral medications and by leaving medications at the bedside or in residents' possession. In several cases, residents were not monitored for safe ingestion, including one who experienced difficulty swallowing and required intervention after a family member alerted staff. These actions were inconsistent with facility policy and accepted nursing practice.
The facility did not have a designated RN serving as the full-time DON, as required. Instead, DON duties were shared among an LPN, an RN serving as the MDS coordinator, and a regional clinical resource, with each holding separate full-time responsibilities. The NHA confirmed the absence of a full-time RN in the DON role, and records did not identify anyone currently acting as DON.
Surveyors identified deficiencies in kitchen sanitation, food storage, and staff hygiene, including unclean kitchen areas, improperly labeled and stored food, dented cans in dry storage, and staff entering the kitchen without hairnets or proper hand hygiene. The dietary manager acknowledged lapses in cleaning oversight, food labeling, and staff compliance with hygiene protocols.
Two residents with mental health diagnoses did not receive appropriate treatment and services to support their mental and psychosocial well-being. One resident with a history of suicide attempts and ongoing depressive symptoms was not monitored for suicidal ideation, and staff were unaware of her mental health history. Another resident, traumatized by a fall in the shower, expressed fear of showering but did not receive follow-up assessment or interventions, and staff failed to communicate her concerns to management.
A nurse failed to observe multiple residents taking their prescribed oral medications, instead leaving medication cups with residents and exiting the room without confirming ingestion. This practice resulted in a medication error rate of 24%, significantly exceeding the acceptable threshold. The nurse also demonstrated uncertainty about handling medication refusals, contrary to facility policy requiring direct observation of medication administration.
Surveyors found that drugs and biologicals, including insulin and Ozempic pens, were not labeled with open dates in two medication carts, and inhalers were stored unsanitarily and unlabeled in a basket. The medication storage room was observed to be unsanitary, with trash, used gloves, and other debris present. Staff interviews revealed a lack of knowledge regarding proper medication labeling and storage requirements.
A housekeeper failed to follow proper cleaning and disinfection protocols, including not removing personal hygiene items before spraying disinfectant, missing high-touch surfaces, and not performing correct hand hygiene between glove changes. The staff member also donned gloves while hands were still wet with sanitizer and did not clean certain surfaces after contact with soiled gloves, contrary to facility policy and CDC guidelines.
Resident Left Unsupervised in Shower Resulting in Fall and Fracture
Penalty
Summary
A deficiency occurred when a resident with multiple sclerosis, a history of falls, and significant weakness was left unsupervised in the main shower room. The resident required total staff assistance for activities of daily living, including showers, and was identified as being at risk for falls. Despite these needs, the resident was left alone during a shower, which resulted in an unwitnessed fall and a fracture of the right femur. The incident took place when a certified nurse aide (CNA) assisting the resident became unable to understand the resident's needs, leading to the resident becoming upset and agitated. The CNA left the resident unattended in the shower room to seek help from another staff member, rather than using the call light and remaining with the resident. Upon returning, the CNA found the resident on the floor with the shower chair tipped over her. The resident sustained a right femur fracture, which required surgical intervention and hospitalization. Interviews with staff confirmed that the resident should not have been left unsupervised due to her dependence on staff for showers and transfers. The facility's fall management policy required that interventions be implemented based on assessed needs and communicated to direct care staff. Documentation and staff statements indicated that the resident's care plan called for maximum assistance and supervision during bathing activities, but these measures were not followed at the time of the incident.
Failure to Employ Qualified Infection Preventionist
Penalty
Summary
The facility failed to employ a qualified infection preventionist (IP) who had completed specialized training in infection prevention and control, as required by facility policy. The policy specified that the infection preventionist is responsible for coordinating, implementing, and updating the infection prevention and control program (IPCP), as well as providing education and training on evidence-based practices. The policy also required the IP to be employed onsite and at least part-time. However, during the survey, it was found that the facility did not have a designated person in charge of the IPCP, and the role was being temporarily filled by the regional clinical resource (RCR) and the minimum data set coordinator (MDSC), neither of whom had the required infection control certification. Interviews with the MDSC, NHA, and RCR confirmed that there was no designated or certified infection preventionist overseeing the IPCP at the time of the survey. The MDSC stated she did not oversee the IPCP and did not have the required certification, while the RCR, who was temporarily filling in, also lacked the necessary certification. The NHA acknowledged that the facility did not have a designated person in charge of the IPCP, and the RCR was only filling in until the position could be filled. This failure had the potential to affect all residents residing in the facility at the time of the survey.
Failure to Individualize Psychotropic Medication Management and Behavior Interventions
Penalty
Summary
The facility failed to ensure that three residents were free from chemical restraints and were receiving the least restrictive approach for their needs. Specifically, the facility did not provide resident-specific, non-pharmacological care approaches in the behavior care plans for residents who were prescribed psychotropic medications. For example, one resident with diagnoses including bipolar disorder, anxiety, depression, PTSD, and vascular dementia had care plans and physician orders that lacked individualized non-pharmacological interventions and did not include all relevant target behaviors such as physical and verbal aggression or delusions. Additionally, there was no documentation of behavior monitoring for antipsychotic medication use, and medication administration records showed no documentation of behaviors over several months. Another resident with bipolar disorder and dementia was prescribed antipsychotic and mood stabilizer medications, but the care plan did not identify medication-specific target behaviors or person-centered interventions for the mood stabilizer. Physician orders for behavior monitoring failed to include all relevant behaviors such as mania, racing thoughts, and psychosis, despite progress notes indicating the presence of these symptoms. There was also a lack of documentation showing that non-pharmacological interventions were attempted for these behaviors, and staff interviews revealed a lack of awareness and training regarding individualized interventions and behavior documentation. A third resident with schizophrenia and anxiety had care plans and physician orders that listed generic behaviors and interventions, which were not specific to the resident's actual behaviors such as paranoia, removing clothing, and inappropriate use of hand sanitizer. Documentation in the medical record indicated ongoing behavioral issues and medication adjustments, but the care plans and orders did not reflect these changes or provide individualized interventions. Staff interviews further revealed that CNAs and nurses were not familiar with resident-specific behaviors or interventions and relied on generic templates, with limited access to care plans and no formal training on documentation expectations.
Failure to Observe and Monitor Medication Administration
Penalty
Summary
The facility failed to ensure that nursing services met professional standards of practice regarding medication administration for four residents. Specifically, nursing staff did not remain with residents to observe them swallowing their oral medications and, in several cases, left medications at the bedside or in the resident's possession without confirming ingestion. Facility policy and professional guidelines require that staff observe residents taking medications and do not leave medications unattended with residents. For one resident with peripheral vascular disease and malnutrition, a registered nurse handed the resident a cup containing metoprolol and Lyrica, then left the room before confirming the medications were taken. Another resident, admitted for low sodium and post-hip surgery pain, was given Tylenol and sodium chloride tablets; the nurse left the room without ensuring the medications were swallowed. This resident subsequently experienced difficulty swallowing, with water spilling from her mouth and a family member alerting staff to the situation. The nurse only returned after being notified of the issue. A third resident with rheumatoid arthritis was given Tylenol tablets while in bed at a 30-degree angle and eating lunch; the nurse did not reposition the resident upright or observe medication ingestion. For a fourth resident with a cognitive communication deficit, the nurse left a cup of liquid protein solution at the bedside after the resident initially refused it. Staff interviews confirmed that the nurse did not consistently observe residents taking medications and sometimes left medications in the room, contrary to facility policy and professional standards.
Failure to Designate Full-Time RN as Director of Nursing
Penalty
Summary
The facility failed to ensure that a registered nurse (RN) was designated as the full-time director of nursing (DON), as required. Record review showed that the facility's DON job description outlined essential administrative and supervisory functions, but the staff list provided did not identify anyone currently serving as the acting DON. The nursing home administrator (NHA) confirmed that there was no designated RN acting as the full-time DON at the time of the survey. Interviews with staff revealed that DON responsibilities were being shared among an LPN, the minimum data coordinator (MDSC), and a regional clinical resource (RCR). The LPN stated she was sharing DON duties with the MDSC and RCR, and the NHA confirmed that the facility had been without a full-time RN in the DON role for over a month. The MDSC, who is an RN, was also responsible for restorative therapy and MDS duties, and the RCR was not present in the building daily. Each of these roles was described as a full-time position, indicating that the DON responsibilities were not being fulfilled by a single, full-time RN as required.
Deficiencies in Kitchen Sanitation, Food Storage, and Staff Hygiene
Penalty
Summary
The facility failed to maintain food service operations in accordance with professional standards, resulting in multiple deficiencies related to kitchen cleanliness, food storage, and staff hygiene. Observations revealed that the kitchen and dish room were not kept clean and sanitary, with food debris found under preparation tables, shelves, and equipment, as well as buildup and grime on handwashing sinks and refrigerator handles. The floor had cracked and missing tiles, cove base was peeling or missing, and trash cans in the food preparation area were uncovered and often full. Equipment such as the large mixer and meat slicer were left uncovered when not in use, and the dish room had debris along the baseboards and under the dishwashing machine. The dietary manager acknowledged that cleaning schedules were not consistently checked and that maintenance issues had not been reported. Food storage practices were also deficient. In the walk-in refrigerator and freezer, several food items, including tinfoil-wrapped sandwiches and containers of dressing or sauce, were not labeled or dated. Some food items were stored directly on the floor, contrary to policy and regulations. In the dry storage area, dented cans of sauerkraut were found, which the dietary manager stated should have been returned to the supplier. The dietary manager confirmed that food should be labeled, dated, and stored off the floor, and was unaware of the presence of the dented cans. Additionally, staff failed to adhere to hygiene protocols by not wearing hairnets when entering the kitchen. On multiple occasions, a registered nurse and another unidentified staff member entered the kitchen without hairnets, with one staff member also failing to wash hands before handling items. The dietary manager confirmed that all employees entering the kitchen should wear hairnets, as required by professional standards.
Failure to Address Mental Health and Psychosocial Needs
Penalty
Summary
The facility failed to provide appropriate treatment and services to two residents diagnosed with mental disorders or psychosocial adjustment difficulties. For one resident with bipolar disorder, Parkinson's disease, and dementia, the care plan did not identify a history of suicide attempts or suicidal ideation, despite psychotherapy notes documenting such history and ongoing depressive symptoms. The resident expressed feelings of depression, loneliness, and discouragement, and made statements indicating possible suicidal ideation, but there was no evidence in the medical record that the facility was monitoring for signs and symptoms of depression or suicidal ideation. Staff interviews revealed a lack of awareness among CNAs, LPNs, and the social services director regarding the resident's mental health history and current symptoms, and the behavioral health notes were not regularly reviewed by the social services director. Another resident, with multiple sclerosis, bipolar disorder, and a recent major injury from a fall in the shower, expressed ongoing fear of taking showers after the incident. The resident reported this fear to several staff members and had not received a shower since the fall, instead receiving bed baths. Although the psychiatric evaluation noted the resident's fear, there was no follow-up assessment, evaluation, or referral to behavioral health services documented in the medical record. The care plan did not include interventions to address the resident's fear of showers, and staff who were aware of the concern did not report it to management or document it in the progress notes. Interviews with staff confirmed that the resident's fear was known to CNAs and LPNs, but this information was not communicated to the social services director or management. The social services director and primary care physician were unaware of the resident's expressed fear, and the regional clinical resource acknowledged a breakdown in communication and documentation. The lack of follow-up and failure to address the residents' mental health needs resulted in the facility not ensuring the highest practicable mental and psychosocial well-being for these residents.
Failure to Ensure Safe Medication Administration and Observation
Penalty
Summary
The facility failed to ensure that the medication error rate remained below five percent, as required by policy, resulting in a medication error rate of 24% (six errors out of 25 opportunities). Observations revealed that a registered nurse (RN) repeatedly did not observe residents swallowing their oral medications. In several instances, the RN dispensed medications into cups, handed them to residents, and left the room without confirming ingestion. For example, one resident was given metoprolol and Lyrica, another was given Tylenol and sodium chloride, and a third was given Tylenol while eating lunch and not properly positioned. In each case, the RN did not remain to ensure the medications were taken as prescribed. Additionally, the RN left a cup of liquid protein supplement with a resident who refused it, instructing the resident to drink it but leaving the room without confirming compliance. Interviews with the RN revealed a lack of understanding regarding the need to observe residents taking medications and uncertainty about how to handle medication refusals. The facility's policy clearly states that staff must observe residents swallowing oral drugs and not leave medications with them, but these procedures were not followed during the observed medication passes.
Improper Storage and Labeling of Medications and Unsanitary Medication Room Conditions
Penalty
Summary
Surveyors identified that the facility failed to ensure all drugs and biologicals were properly stored and labeled in two of three medication carts and one of two medication storage rooms. Specifically, insulin pens (Humalog, Lantus, and Semgee) and an Ozempic pen were found in medication carts without open dates, contrary to manufacturer instructions and facility policy, which require labeling with the date opened to ensure medications are not used past their safe period. Additionally, the vaccine storage refrigerator contained both vaccines and insulin, which is not in accordance with proper storage practices. Further observations in the medication storage room revealed unsanitary conditions, including a large trash bin filled with trash, a basket with used gloves and food wraps, a non-working bidet filled with plastic and paper scraps, and a box with filled sharps containers. The room also contained a deflated air mattress in a dusty sink, an empty bucket, a brush, and a broken walker. The countertop was stained and dusty, and the controlled emergency medication box was stored on top. These conditions do not meet standards for sanitary storage of medications and supplies. In one medication cart, a basket was found containing seven inhalers, some missing mouthpiece covers and two without resident names, which is not compliant with labeling and sanitary storage requirements. Interviews with nursing staff revealed a lack of knowledge regarding the importance of labeling insulin pens and proper storage of inhalers. Staff were also unaware of the specific timeframes for safe use of medications after opening, and could not locate the binder with medication expiration dates.
Failure to Maintain Infection Control Due to Improper Cleaning and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program on one of its units, as evidenced by improper cleaning techniques and inadequate hand hygiene practices by housekeeping staff. During a continuous observation, a housekeeper was seen cleaning resident rooms and bathrooms without following established protocols. Specifically, the housekeeper did not remove residents' personal hygiene items from the bathroom counter before spraying disinfectant, failed to disinfect high-touch areas such as door knobs, bed remotes, call lights, light switches, over-bed tables, and night stands, and did not clean the bathroom door knob after touching it with soiled gloves. The housekeeper also used a wet rag from a bucket containing sanitizing solution to wipe down surfaces and handled cleaning equipment and room surfaces with the same gloves, increasing the risk of cross-contamination. Hand hygiene practices were not properly followed, as the housekeeper applied alcohol-based hand sanitizer and immediately donned gloves while her hands were still visibly wet, rather than allowing the sanitizer to dry as required. On several occasions, the housekeeper changed gloves without performing hand hygiene in between, and did not rub her hands with sanitizer until dry before putting on new gloves. These actions were inconsistent with both facility policy and CDC guidelines, which emphasize the importance of proper hand hygiene and thorough cleaning of high-touch surfaces to prevent the transmission of healthcare-associated infections. Interviews with the housekeeper revealed that she was primarily a laundry attendant and only occasionally worked as a housekeeper. She acknowledged receiving training on housekeeping and hand hygiene but admitted to forgetting to clean high-touch areas and not allowing her hands to dry after using hand sanitizer. The maintenance director was unaware of his responsibility for housekeeping oversight, and the regional clinical resource confirmed that staff were trained at hire and annually, reiterating the importance of proper cleaning and hand hygiene 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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