Accel At Longmont Health And Rehab, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Longmont, Colorado.
- Location
- 1960 S Fordham St, Longmont, Colorado 80503
- CMS Provider Number
- 065429
- Inspections on file
- 29
- Latest survey
- March 10, 2026
- Citations (last 12 mo.)
- 49 (1 serious)
Citation history
Health deficiencies cited at Accel At Longmont Health And Rehab, Llc during CMS and state inspections, most recent first.
A resident with severe cognitive impairment, multiple comorbidities, and a known history of alcohol use left the facility and was later found outside yelling for help and lying on the ground. Police identified the individual, determined the resident was intoxicated, and returned him to the facility, where he required wheelchair transport to his room despite normally walking without assistive devices. Officers helped the resident into bed, but nursing staff did not complete a change of condition assessment, obtain vitals, perform a head-to-toe or post-fall evaluation, or document his condition or monitoring afterward. The physician and legal guardian were not notified of the intoxication or change in condition, and there was no care plan addressing alcohol use or intoxication despite existing orders to monitor for substance use and notify the provider. A few hours later, a CNA found the resident face down on the floor, unresponsive, and he was pronounced dead, with the death certificate citing respiratory failure, aspiration event, and alcoholism; the incident was not promptly reported or thoroughly investigated at the time.
A resident with CHF and multiple comorbidities was readmitted from the hospital with an order for metolazone 2.5 mg PRN, to be given only when weight increased by 5 lbs over baseline and 30 minutes before Lasix. Due to incorrect transcription of the hospital discharge orders into the EMR by the ADON, and the absence of a required second-nurse verification, metolazone was entered and administered as a scheduled daily medication instead of PRN. Nursing staff gave the drug daily for eight days without confirming the weight-based parameter, including on days when no weight was obtained and when the resident’s weight was stable or decreasing. During this period, the resident experienced a 12–14 lb weight loss, marked weakness, fatigue, excessive somnolence, and was later found to have hypokalemia, while continuing on other diuretics (Lasix and spironolactone). Interviews with the resident, her representative, nursing staff, the DON, PCP, and pharmacist linked these changes to the medication error, which did not follow the prescriber’s PRN order or the facility’s medication error policy.
The facility failed to maintain a full-time RN DON when the existing DON was reassigned as a temporary emergency NHA, leaving no separate RN designated to the DON role. Records showed the acting NHA held a temporary administrator permit while the staffing list indicated no full-time DON in place, despite a job description assigning the DON responsibility for 24-hour nursing oversight, staffing, and key clinical systems. Staff interviews revealed that nurses were unaware of the DON’s reassignment and continued to view this person as their direct supervisor, while the acting NHA reported performing both administrative and DON functions, including abuse coordination and state occurrence reporting, without any formal announcement or signage to inform staff, residents, or families of these role changes.
The facility’s QAPI program failed to identify and address critical quality of care issues related to resident change in condition, despite a written policy requiring comprehensive, data‑driven performance monitoring and corrective action. The facility had repeat F684 citations for quality of care and, in the current survey, was found to have not adequately assessed, monitored, documented, or communicated a resident’s change in condition, which was associated with the resident’s death and resulted in an immediate jeopardy finding. The MD reported he reviewed only those cases and policies presented to him and was unaware that the DON was also serving as the temporary emergency NHA amid leadership changes. The DON/acting NHA stated that QAPI meetings focused on standard topics and that change of condition evaluations were limited mainly to skin alterations and falls, acknowledging that staff were new to other types of change of condition assessments requiring thorough evaluation and provider/family notification.
Staff failed to follow infection prevention protocols, including not changing gloves or performing hand hygiene between catheter care and incontinence care for a resident with wounds and an indwelling device. A shared shower chair was not cleaned after use and was visibly soiled before being used again. Additionally, the facility's main water heater was broken, resulting in laundry being washed at insufficient temperatures and in areas lacking proper infection control measures, with no physical separation from resident spaces.
A resident with chronic respiratory conditions and moderate cognitive impairment was allowed to keep and self-administer an albuterol inhaler without a documented assessment or physician's order authorizing self-administration. Staff interviews confirmed that required assessments and documentation were missing from the medical record, and the care plan did not reflect the resident's ability to self-administer medication.
Surveyors found that two linen storage closets lacked essential clean linens, such as fitted sheets and pillowcases. Two residents reported frequent shortages, and staff—including a CNA and the laundry aide—confirmed that the facility did not maintain an adequate linen supply, requiring them to rotate and prioritize available items to meet resident needs. Facility leadership acknowledged the ongoing linen shortage and its impact on maintaining a safe and comfortable environment.
A resident with a history of behavioral disturbances physically grabbed another resident's arm after a dispute over a sugar packet in the dining room, resulting in visible injuries. Despite a care plan requiring one-to-one supervision, the resident was left unsupervised for several minutes, allowing the incident to occur. Staff and family interviews confirmed lapses in supervision and documentation showed the injuries sustained.
Two residents requiring BiPAP and CPAP therapy did not receive appropriate respiratory care due to lack of proper device setup, missing or incomplete physician's orders, and insufficient staff training. One resident was unable to use his BiPAP machine for an extended period because settings were not adjusted by a physician, and his care plan lacked necessary details. Another resident's CPAP orders were not documented until the time of survey, and staff were not adequately trained on respiratory device care.
Surveyors found that confidential resident information was left unsecured in open bags at the nurse's station for several weeks due to the lack of shred box containers. Additionally, a medication cart was left unattended in a hallway with its computer screen displaying a resident's medication administration record, visible to anyone passing by. Staff confirmed these lapses in maintaining the privacy and confidentiality of residents' medical records.
The facility did not adequately promote or facilitate resident self-determination, resulting in a failure to support resident choice as required. This was due to actions or omissions by staff that did not encourage or honor the resident's right to make decisions about their care or daily activities.
Two residents in the facility developed severe pressure injuries due to the facility's failure to provide timely and necessary treatment. One resident, with diabetes and kidney disease, developed deep tissue injuries and sepsis after the facility did not implement care plan interventions or notify the physician of heel discoloration. Another resident, with a history of vascular disease, developed deep tissue injuries on his foot and heel, leading to cellulitis and sepsis, due to the facility's failure to off-load heels and document skin condition changes. The facility's systemic failure created an immediate jeopardy situation.
The facility failed to employ a qualified infection control preventionist (ICP) with specialized training, affecting all residents. The acting ICP, also the wound care nurse, had not completed her certification, and the regional nurse consultant was unaware of this. This deficiency was identified during a survey.
The facility did not have a full-time RN designated as the Director of Nursing (DON) after the previous DON resigned. Staff interviews revealed that there was no charge nurse on duty, and nursing staff deferred questions to LPNs who were not in management positions. The nursing home administrator confirmed the vacancy and stated that corporate support was assisting until the position could be filled.
The facility reported a medication error rate of 16.67%, exceeding the acceptable threshold. Errors included incorrect application of lidocaine patches, failure to verify vital signs before administering metoprolol, and late administration of Parkinson's medication. Staff interviews confirmed the importance of adhering to prescribed medication guidelines.
The facility failed to follow proper infection prevention practices during medication administration and patient care. An LPN did not perform hand hygiene before or after administering medications and failed to clean a pulse oximeter before and after use. Another LPN prepared medications without hand hygiene, and a staff member disposed of a pill from the floor without performing hand hygiene. The wound care nurse confirmed the importance of hand hygiene and equipment cleaning to prevent infection spread.
The facility failed to properly store and label medications, leaving multi-dose medications unlabeled and a resident's inhaler improperly stored. Medications were left unsecured when an LPN left a cart unattended with keys in the lock. Improper disposal of medications was noted, with unused drugs discarded in trash cans instead of using drugbuster bottles. The medication storage room was cluttered and unclean, with expired medications and a dirty refrigerator. Staff interviews revealed unclear responsibilities for cleaning and medication disposal.
The facility's QAPI program failed to address compliance concerns, leading to repeat deficiencies in medication administration and infection control. A resident developed a wound infection with sepsis due to inadequate pressure injury assessment and treatment. The new NHA was unaware of these issues and could not locate previous documentation, indicating a lack of oversight and continuity.
A resident's electric tricycle was stolen from a locked area in the facility, and the facility failed to replace or reimburse the resident. The tricycle was not listed on the resident's inventory sheet, and the facility lacked a policy for personal property responsibility. The resident filed a grievance, but the facility's corporate management did not authorize reimbursement for the tricycle, valued at $4,000.
A resident with osteomyelitis required IV antibiotics through a PICC line, but the nursing staff removed the line prematurely without a physician's order, leading to missed doses. The error was not reported promptly, delaying the line's replacement. Additionally, the facility failed to change the PICC line dressing as ordered, risking infection. Staff interviews revealed a lack of clarity on PICC line care and the importance of timely reporting and replacement.
The facility did not conduct required annual performance reviews for two CNAs, as identified through record reviews and staff interviews. The HR director and regional nurse consultant confirmed the oversight, acknowledging that the reviews were not completed within the mandated timeframe.
The facility failed to honor the preferences of two residents regarding their care and scheduling. One resident was not assisted in scheduling a wound care appointment at an in-network clinic, leading to financial strain, while another resident's shower preferences were ignored, with no documentation of their requests. Staff interviews revealed a lack of communication and adherence to the facility's policy on residents' rights.
A resident with severe cognitive impairments and multiple diagnoses frequently refused medications and treatments, but the facility failed to update the care plan to address these refusals. Despite known refusals of medications like Aspercreme and Haloperidol, and refusal to be moved to a chair for meals, the care plan lacked person-centered interventions. Staff interviews confirmed awareness of refusals but highlighted a deficiency in care management due to the lack of updated strategies in the care plan.
A resident with multiple diagnoses, including severe cognitive impairments, did not receive showers as per her preference and care plan. Despite her grievance, there was no documentation of showers being offered since her admission. Staff interviews revealed that showers were scheduled by room number, not resident preference, and staff were unaware of the resident's shower status. The regional nurse consultant acknowledged the grievance and the need for timely showers.
The facility failed to ensure two CNAs received required training in abuse, dementia management, behavioral health management, infection control, communication, QAPI, compliance and ethics, and resident rights. Additionally, there was no documentation of the CNAs completing at least 12 hours of annual in-service training. Interviews with the HRD and RNC confirmed the lack of training completion and documentation.
Failure to Assess and Respond to Resident Intoxication and Change in Condition Resulting in Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with multiple complex medical conditions received treatment and care in accordance with professional standards of practice following a clear change in condition related to alcohol intoxication. The resident had diagnoses including alcoholic polyneuropathy, history of traumatic brain injury, CHF, type 2 diabetes mellitus, alcoholic cirrhosis of the liver, hypertension, long-term anticoagulant use, and alcohol use with an unspecified alcohol-induced disorder. His MDS showed severe cognitive impairment and functional dependence for many ADLs, though he typically ambulated without a mobility device. Physician orders included monitoring for potential substance use each shift and documenting and notifying the physician if any substance use indicators were noted, but the January TAR documented no substance use behaviors for that month. On the day of the incident, the resident signed out of the facility in the morning and was later found outside the facility grounds by bystanders, yelling for help and lying on the ground near a hotel with a shopping cart. Police dispatch records show multiple calls reporting the resident on the ground and yelling for help, and the police ultimately identified him and returned him to the facility. The police reported to staff that the resident was intoxicated and had been wandering. Upon return, he required wheelchair transport from the front door to his room, despite normally walking without assistive devices. According to an IDT note, officers assisted him in removing his shoes and coat and helped him into bed, after which he was observed resting in his room, but no time or assessment details were documented. Record review revealed no documentation that nursing staff completed a change of condition assessment, a post-fall or post-ground-level event assessment, or any RN assessment when the resident was returned by police in an intoxicated state. There was no documentation of vital signs, head-to-toe assessment, skin evaluation, or monitoring between the time of his return and the time he was later found unresponsive. The physician and the resident’s legal guardian were not notified of his intoxication or change in condition, and there was no progress note describing his condition upon return or how he was transferred to bed. The resident’s comprehensive care plan contained no care plan addressing alcohol use, intoxication, or potential substance use, and there were no interventions related to his known history of alcohol abuse and drinking while away from the facility. Staff interviews, including with the DON/acting NHA, ADON, and RNs, confirmed that no change of condition assessment, vital signs, or physician/guardian notifications were completed despite their own descriptions of what should occur when a resident returns intoxicated. The resident was later found face down on the floor in his room, unresponsive, and was pronounced dead; his death certificate listed respiratory failure, aspiration event, and alcoholism as the causes of death. The facility also failed to promptly recognize and investigate the incident as an unexpected death associated with a significant change in condition. A frequent visitor reported that the DON/acting NHA initially did not believe an occurrence report was required for the resident’s intoxicated return and unexpected death, and the occurrence report to the state was not submitted until eight days after the death. There was no evidence of an immediate, thorough internal investigation or root cause analysis at the time of the event to determine why nurses did not complete a change in condition assessment or follow the existing physician order to monitor for substance use and notify the physician. Surveyors determined that the facility did not thoroughly assess and monitor the resident’s alcohol use and change in condition, did not document changes, and did not seek medical treatment or notify the physician and guardian when required, and that these failures contributed to serious harm and death for the resident.
Removal Plan
- NHA notified the facility medical director of the incident.
- Nursing supervisors/designees completed physical assessments/interviews on all residents to identify any changes in condition and notified the physician of any noted changes.
- Initiated a look-back audit of current and discharged residents to ensure change-of-condition policy was followed.
- Identified one current resident without a required 72-hour alert monitoring order; educated the assigned nurse regarding timely initiation of the 72-hour alert monitoring order after completing the eINTERACT change-in-condition evaluation.
- Initiated the missing 72-hour change-in-condition alert monitoring order for the identified resident, including nursing assessments and documentation on the TAR and in progress notes each shift for three days per physician-indicated frequency.
- Reviewed resident change-in-condition and notification policies/procedures for clinical accuracy.
- Educated all nursing staff on addressing changes of condition (assessment, monitoring, physician/family notification, orders, and facility policies/procedures); staff were not permitted to work a shift until education was completed.
- Educated new hires (licensed nurses and nurse aides) during orientation on change-of-condition and physician/family notification requirements and facility policies/procedures.
- DON/designee to conduct audits five times per week for three months of the 24-hour report and progress note report to ensure change-of-condition policies/procedures are followed.
- DON/designee to conduct daily nursing staff huddles Monday through Friday to monitor for changes in resident condition.
- Regional director of clinical services and regional vice president to provide clinical/administrative oversight to ensure education and audits are completed and accurate.
- DON educated by the CNO on appropriately addressing changes of condition (assessment, monitoring, physician orders, and facility policies/procedures).
- DON/designee to complete chart audits to verify detailed assessments/documentation and physician/family notification related to changes of condition.
- Regional Director of Clinical Services to visit the facility to provide general oversight and monitoring of the plan.
Failure to Follow PRN Diuretic Order Leads to Significant Weight Loss and Hypokalemia
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a diuretic, metolazone, was entered and administered as a scheduled daily medication instead of as a PRN medication with specific weight-based parameters. After an acute hospitalization for conditions including acute on chronic CHF, acute respiratory failure with hypoxia, COPD, atrial fibrillation, hypertension, morbid obesity, COVID-19, and MDRO history, the resident was readmitted to the facility. The hospital discharge order specified metolazone 2.5 mg to be taken once daily as needed for pulmonary edema due to chronic heart failure, only when the resident had a weight gain of 5 lbs over baseline, and to be given 30 minutes prior to Lasix. However, when the orders were transcribed into the facility’s EMR on readmission, metolazone was entered as a scheduled daily medication without PRN parameters, and this incorrect order did not match the hospital discharge instructions. The assistant DON, who entered the readmission orders from the hard-copy discharge packet because the phone lines were down and the usual electronic admission process was not used, input metolazone as a daily scheduled medication. The normal process of having two nurses verify and enter orders was not completed; the ADON entered the orders alone, and the second nurse verification did not occur. As a result, nursing staff administered metolazone 2.5 mg daily for eight days, in addition to the resident’s other diuretics (Lasix and spironolactone), without confirming that the resident had experienced the required 5 lb weight gain from baseline. The MAR documented daily administration of metolazone over this period, including on days when no weight was obtained, and on days when the resident’s weight was stable or decreasing rather than increasing. During this time, the resident experienced significant weight loss and symptoms consistent with a change in condition. Weight records showed a decline from approximately 190 lbs prior to hospitalization to 176.6 lbs when the error was identified, reflecting a loss of about 12–14 lbs over a short period. The resident and her representative reported that she became severely weak, excessively tired, and felt she could not regain her strength, with the representative describing the resident as very tired, exhausted, and feeling as though she could not “hang on any longer.” Clinical documentation noted significant weakness, excessive sleepiness during therapy, and that the resident was triggering for significant weight loss. Laboratory testing later showed hypokalemia, with a potassium level of 3.2 mEq/L. Interviews with nursing staff, the DON, the ADON, the PCP, the pharmacist, the resident, and the resident’s representative consistently attributed the resident’s weight loss, weakness, and low potassium at least in part to the erroneous daily administration of metolazone instead of PRN dosing based on weight gain. The facility’s own medication error policy defined a medication error as preparation or administration of medications not in accordance with the prescriber’s order, manufacturer’s specifications, or accepted professional standards, and defined a significant medication error as one that causes resident discomfort or jeopardizes health and safety. In this case, the metolazone order in the EMR did not reflect the prescriber’s PRN order with weight-based parameters, and the medication was administered without verifying the required 5 lb weight gain. The resident’s care plan for diuretic therapy called for administering diuretics as ordered, monitoring for side effects such as fatigue and increased fall risk, and reporting pertinent lab results, including potassium. Staff interviews acknowledged that the error persisted for about eight days, that medication reconciliation was not completed upon readmission, and that the lack of a second nurse verification contributed to the error. The pharmacist and PCP described the effects of metolazone, especially in combination with Lasix, as including electrolyte abnormalities, weight loss, and weakness, and characterized the error as moderate, with the potential to increase electrolyte depletion and require close monitoring.
Failure to Maintain a Full-Time RN Director of Nursing During Temporary NHA Appointment
Penalty
Summary
The deficiency involves the facility’s failure to designate a registered nurse (RN) to serve as the full-time director of nursing (DON) while the existing DON was reassigned to act as the temporary emergency licensed nursing home administrator (NHA). Record review showed that the acting NHA held an active temporary permit for emergency situations beginning on 12/30/25 and expiring on 3/30/26. A staffing list review revealed there was no full-time DON in the building during this period. The DON job description, signed by the DON, specified that the DON’s primary purpose was to plan, organize, develop, and direct nursing operations, ensure quality resident care on a 24-hour basis, oversee recruitment and hiring of licensed personnel, manage nursing schedules, monitor staffing levels, and oversee implementation of nursing service objectives, policies, and procedures, including key clinical systems such as infection prevention and control, psychotropic and controlled substance management, skin and weight systems, risk management, and hospice liaison. Staff interviews confirmed that the individual serving as the full-time temporary NHA was also functioning as the full-time DON, with no other person appointed to the DON role. The chief nursing officer stated that the temporary NHA was also acting as the full-time DON and reported not knowing there was a regulation preventing this. Nursing staff, including an LPN and an RN, reported they were unaware that the DON had been appointed as the temporary NHA and continued to view the DON as their supervisor. The acting NHA described performing both administrative and clinical leadership duties, including occurrence reporting to the state, serving as abuse coordinator and investigator, and leading stand-up meetings, while relying on two unit managers, an LPN assistant DON, and an infection preventionist to assist with clinical duties and audits. There had been no announcement to staff, residents, or families about the acting NHA appointment or her role as abuse coordinator, and there was no signage indicating this responsibility.
Failure of QAPI Program to Address Change in Condition Leading to Immediate Jeopardy
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective, comprehensive, data‑driven QAPI program that identified and addressed quality of care concerns, particularly related to changes in resident condition. The facility’s QAPI policy required ongoing tracking and measuring of performance, identification and prioritization of quality deficiencies, systematic analysis of underlying causes, and development and monitoring of corrective actions, with a focus on resident safety, health outcomes, and high‑risk or problem‑prone areas. Despite this written policy, the facility did not operate its QA program in a manner that prevented repeat deficiencies, as evidenced by prior citations at F684 (quality of care) in consecutive annual recertification surveys. Surveyors found that the QAPI committee failed to identify and address concerns related to quality of care by not ensuring that resident changes in condition were assessed, monitored, documented, and communicated when indicated. This failure rose to the level of immediate jeopardy and was associated with a serious adverse outcome resulting in a resident’s death. The cross‑referenced F684 citation states that the facility failed to provide quality care by not assessing, monitoring, documenting, and communicating a resident’s change in condition when indicated. The facility’s regulatory history showed that F684 had been cited twice previously at a D scope and severity, indicating a potential for more than minimal harm, isolated, without effective QA‑driven prevention of recurrence. Interviews further demonstrated gaps in the QAPI program’s functioning and oversight. The medical director reported he visited at least twice a month, reviewed cases and policies presented to him, and made changes based on what was brought forward in QAPI, but he was not informed that the DON was also serving as the full‑time temporary emergency licensed NHA for several months, and he described multiple leadership changes. The DON/acting NHA stated that QAPI meetings were held monthly and covered standard topics such as admissions, discharges, falls, staffing, abuse, infection control, and grievances, with use of audit tools and tracking spreadsheets. However, she acknowledged that while change of condition evaluations were being done for skin alterations and falls, staff were “new to the other types of change of condition assessments” that required thorough assessment and notification of the physician and family/guardian, and that change of condition evaluations beyond those limited areas had not been a focus of QAPI until after the incident that led to the immediate jeopardy finding.
Infection Control and Laundry Deficiencies Compromise Resident Safety
Penalty
Summary
The facility failed to maintain and follow its infection prevention and control program on two of three units, resulting in lapses in hand hygiene, improper use of personal protective equipment (PPE), and inadequate cleaning of shared equipment. Specifically, a certified nurse aide (CNA) did not change gloves or perform hand hygiene after emptying a resident's indwelling urinary catheter and before providing incontinence care. The same CNA also failed to clean a shared shower chair after use, leaving it visibly soiled with stool before it was placed outside the resident's room for use. The resident involved had an indwelling urinary catheter and wounds, and was on enhanced barrier precautions (EBP), as indicated by signage on the door. Staff interviews confirmed that these actions were contrary to facility policy and infection control expectations. Additionally, the facility's main water heater was broken, resulting in laundry being washed at temperatures significantly below the recommended threshold for effective sanitation. The laundry aide reported that the water temperature during wash cycles was only sixty-eight degrees Fahrenheit, well below the CDC-recommended 160 degrees Fahrenheit for hot-water washing. As a result, the facility resorted to laundering some resident clothing and linens in the rehabilitation area, which was not equipped with industrial washers and dryers and lacked proper infection control or isolation measures. There was also no physical barrier separating the laundry area from resident spaces, further compromising infection prevention. Interviews with staff, including the infection preventionist, director of nursing, nursing home administrator, and laundry aide, confirmed awareness of the deficiencies. Staff acknowledged that the facility's infection control and laundry practices did not meet regulatory standards, and that the lack of functioning equipment and proper procedures contributed to the failure to provide a safe, sanitary, and comfortable environment for residents.
Failure to Assess Appropriateness of Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a proper assessment was conducted to determine the clinical appropriateness of self-administration of medications for a resident with multiple chronic conditions, including chronic respiratory failure, COPD, and moderate cognitive impairment. The resident was observed with an albuterol inhaler at his bedside and reported that staff allowed him to keep and use the inhaler as needed. However, there was no documentation in the electronic medical record of a self-administration assessment or a physician's order permitting the resident to self-administer the inhaler or to keep it at the bedside. The resident's care plan did not reflect the ability to self-administer medication, and the physician's order only specified the medication and dosage, not self-administration privileges. Interviews with staff, including an LPN, RN, and the DON, confirmed that an assessment should have been completed and documented before allowing the resident to self-administer medication. Staff were unable to locate any such assessment in the resident's record, and the DON acknowledged uncertainty about whether the assessment had been completed. The lack of assessment, physician's order, and care plan documentation led to the deficiency in ensuring safe and clinically appropriate self-administration of medication for the resident.
Insufficient Clean Linen Supply for Resident Care
Penalty
Summary
The facility failed to provide clean linens in sufficient quantities for residents, as evidenced by observations of two out of three linen storage closets lacking essential items. Specifically, one closet contained only flat sheets, comforter sheets, pillowcases, and blankets, but no fitted sheets, while another closet had flat sheets, comforter sheets, and blankets, but no pillowcases or fitted sheets. These shortages were directly observed during facility rounds. Interviews with residents confirmed that clean linens were often unavailable or insufficient, with one resident describing the issue as ongoing. Staff interviews further corroborated the deficiency, with a CNA and the laundry aide both stating that the facility did not maintain an adequate supply of linens, requiring staff to rotate and prioritize available items. The maintenance director and the NHA also acknowledged awareness of the linen shortage, noting that it affected the facility's ability to meet regulatory requirements for a safe, sanitary, and comfortable environment.
Failure to Prevent Resident-to-Resident Abuse During Meal Service
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from abuse by another resident during a meal service. The incident involved one resident taking a sugar packet from another resident's dining table, which led to the second resident approaching and physically grabbing the first resident's right arm. This altercation was witnessed by the dietary manager, who reported the event to nursing staff. The affected resident was found to have a pinch mark, bruising, and redness on her right arm, as well as a redness mark at the base of her posterior head. The incident and resulting injuries were documented in the resident's medical record, including photographs and a detailed skin assessment. The resident who initiated the physical contact had a history of behavioral disturbances, including yelling, cursing, and throwing objects when served an inappropriate diet texture. However, prior assessments did not document physical or verbal behaviors directed at others. The resident was cognitively impaired and required behavioral interventions as outlined in her care plan. Despite these interventions, the resident was able to approach and physically harm another resident in the dining room. Interviews with staff and the resident's family revealed that the resident responsible for the altercation had previously entered the dining room unattended, even after being placed on one-to-one supervision following the incident. Observations confirmed that the resident was left unsupervised in the dining area for several minutes before staff intervened. The failure to provide continuous supervision as required contributed to the occurrence of the abuse and the resulting injury to the other resident.
Failure to Provide Appropriate Respiratory Care and Documentation
Penalty
Summary
The facility failed to provide appropriate respiratory care for two residents who required the use of BiPAP and CPAP machines. One resident, who had diagnoses including quadriplegia and sleep apnea, reported not using his BiPAP machine for approximately two months due to incorrect settings and lack of physician adjustment. He stated that he had only seen a respiratory therapist once during his stay, and the settings were not corrected at that time. The resident also indicated that staff asked him for the correct settings, which caused frustration as he expected the facility to have this information. The care plan for this resident did not include specific interventions or settings for the BiPAP machine, and there was no documentation of a follow-up pulmonology appointment as recommended by the physician. Another resident, with chronic respiratory failure and sleep apnea, reported independently managing his CPAP machine and receiving minimal assistance from staff. The care plan referenced the use of CPAP and oxygen, but there were no detailed physician's orders for the CPAP machine in the electronic medical record until the time of the survey. This lack of documented orders meant that staff did not have clear guidance on the application and management of the resident's CPAP therapy prior to the survey. Staff interviews revealed that certified nurse aides had not received training on the care of CPAP or BiPAP machines and were unfamiliar with facility policies regarding these devices. The infection preventionist confirmed that staff education on respiratory devices had not yet been provided and emphasized the need for physician's orders with specific settings in the electronic medical record. The director of nursing acknowledged that nurses were responsible for following up on missed pulmonology appointments and ensuring that physician's orders for respiratory devices were in place, but these actions had not occurred prior to the survey.
Failure to Secure and Maintain Confidentiality of Resident Medical Records
Penalty
Summary
The facility failed to ensure the secure and confidential storage of residents' personal and medical records, as required by its own policies and HIPAA regulations. Surveyors observed three brown paper bags and one large black trash bag containing confidential resident information left open and unattended at the nurse's station. Staff interviews confirmed that these bags, filled with resident documents, had been at the nurse's station for several weeks due to the absence of designated shred box containers. Staff were instructed to place confidential documents in these bags, and the director of nursing acknowledged that the facility did not have shred boxes at the time of the survey. Additionally, a locked medication cart was found unattended in the hallway with its computer screen visible to passersby, displaying a portion of a resident's medication administration record. Both the regional nurse consultant and a registered nurse confirmed that the screen should not have been visible to the public and that there was a lock button available to secure the screen. These actions and inactions resulted in the failure to maintain the privacy and confidentiality of residents' medical records.
Failure to Support Resident Self-Determination and Choice
Penalty
Summary
The facility failed to honor the resident's right to self-determination by not promoting and facilitating resident choice. This deficiency was identified based on observations or findings that the facility did not adequately support or encourage residents to make their own choices regarding their care or daily life, as required by regulations. Specific actions or omissions by the facility staff led to a lack of support for resident autonomy and decision-making.
Failure to Prevent and Manage Pressure Injuries
Penalty
Summary
The facility failed to provide timely and necessary treatment and services to prevent and manage pressure injuries for two residents, leading to severe health complications. Resident #85, who had diabetes and kidney disease, was admitted with a stage 2 pressure injury on her coccyx/sacrum and was at moderate risk for further pressure injuries. Despite an assessment on 11/16/23 revealing discoloration on her heels, the primary care physician was not informed until 11/20/23. By then, the resident had developed deep tissue injuries on both heels, cellulitis, and sepsis, requiring hospitalization. The facility did not implement the care plan interventions for turning, repositioning, and off-loading heels, nor did they update the care plan with new interventions after the heel discoloration was noted. Resident #140, with a history of sacral fracture and peripheral vascular disease, was admitted with intact skin but developed a blister on his right foot two days later. The wound care physician later documented deep tissue injuries on his right toe and heel. The facility failed to off-load the resident's heels as per the care plan and did not accurately document the resident's skin condition in daily notes. The resident's condition worsened, leading to cellulitis and sepsis, necessitating ICU care. The facility did not ensure timely physician notification of the resident's condition changes, and the care plan was not updated with appropriate interventions. The systemic failure to provide timely interventions and necessary treatment for pressure injuries created an immediate jeopardy situation, posing a likelihood of serious harm to other residents with similar conditions. The facility's medical director confirmed that the pressure injuries were avoidable if proper care had been provided, indicating that the facility's protocols and care plans were not followed by staff.
Lack of Qualified Infection Preventionist
Penalty
Summary
The facility failed to employ a qualified infection control preventionist (ICP) who had completed specialized training in infection prevention and control, which had the potential to affect all residents residing in the facility at the time of the survey. The Centers for Disease Control and Prevention (CDC) guidelines recommend that nursing homes assign individuals with training in infection prevention and control (IPC) to manage the IPC program on-site. However, the facility was unable to provide documentation that the acting infection preventionist, who was also the wound care nurse, had completed the necessary specialized training. During interviews, the wound care nurse confirmed that she was the acting infection preventionist but had not yet completed her certification, although she was enrolled in a training program. Additionally, the regional nurse consultant, who was providing assistance due to the recent departure of the director of nursing, was unaware that the wound care nurse had not completed her IP training. This lack of a qualified infection preventionist involved in the facility's infection prevention and control program was identified as a deficiency during the survey.
Failure to Designate a Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full-time basis after the previous DON resigned. A review of the facility's staffing list and assessment revealed the absence of a full-time DON. Interviews with staff, including a licensed practical nurse (LPN) and the minimum data set (MDS) coordinator, confirmed that there was no designated DON or charge nurse on duty. Instead, nursing staff deferred questions to the wound care nurse and the MDS nurse, both of whom were LPNs and not in management positions. The nursing home administrator (NHA) acknowledged the vacancy in the DON position and stated that the facility had been actively searching for a replacement. In the interim, two nurse managers, who were LPNs, were managing the DON duties. The NHA also mentioned that corporate leadership provided support, with a regional clinical support RN present in the building to assist until the position could be filled.
Medication Administration Errors Exceed Acceptable Rate
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with an observed error rate of 16.67%. During medication administration, an LPN did not apply a prescribed lidocaine patch to the correct location on a resident's body and documented the administration despite not applying it. Another resident was administered a lidocaine patch to an incorrect area, contrary to the physician's order, and the LPN failed to verify the resident's heart rate or blood pressure before administering metoprolol tartrate. Additionally, the LPN documented the administration of a medication that the resident had refused. A third resident received their Parkinson's medication, carbidopa-levodopa, outside the prescribed administration window, which was confirmed as a medication error by a physician assistant. The facility's policy required medications to be administered within a two-hour window, but the medication was given 50 minutes late. Interviews with staff, including a physician assistant and the regional nurse consultant, confirmed the importance of adhering to prescribed medication administration times and locations, particularly for medications with specific timing requirements like Parkinson's medications.
Infection Control Deficiencies in Medication Administration
Penalty
Summary
The facility failed to adhere to proper infection prevention practices during medication administration and patient care. Observations revealed that an LPN did not perform hand hygiene before entering a resident's room, after administering eye drops, or before administering oral medications. The LPN also failed to clean a pulse oximeter before and after use on a resident. Another LPN was observed preparing medications without performing hand hygiene and entered a resident's room without doing so. Additionally, a staff member picked up a pill from the floor and handed it to an LPN, who disposed of it without performing hand hygiene before continuing to prepare medications. Interviews with the wound care nurse, who oversees the facility's infection control program, confirmed that hand hygiene should be performed before administering resident care and medications, especially eye drops, to prevent infection spread. The nurse also stated that vital signs monitoring equipment should be cleaned after each resident use. These observations and interviews highlight the facility's failure to implement appropriate infection prevention measures, as outlined by the CDC and other professional references.
Medication Storage and Management Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications in accordance with professional standards. Observations revealed that multi-dose medications, such as Anoro Ellipta inhalers, Latanoprost eye drops, and SoloStar insulin pens, were not labeled with the date they were opened. Additionally, a resident's used inhaler was improperly stored in a tissue within a medication cart. These lapses in labeling and storage practices were observed in two medication carts, indicating a systemic issue in medication management. The facility also failed to maintain secure access to medications, as evidenced by an LPN leaving a medication cart unattended with the keys in the lock, making the medications accessible to unauthorized individuals. Furthermore, the disposal of unused, wasted, or damaged medications was not conducted in a manner that prevented diversion or accidental exposure. Instances were noted where medications were improperly disposed of in trash cans instead of using the available drugbuster bottles designed for safe disposal. The medication storage room was found to be cluttered, with expired medications and those belonging to discharged residents left on the counter. The refrigerator in the storage room was observed to have a dried brown liquid on the bottom shelf, indicating a lack of cleanliness and organization. Interviews with staff revealed a lack of clarity regarding responsibilities for cleaning and medication disposal, contributing to the deficiencies observed in medication management and storage practices.
Failure in QAPI Program and Resident Care
Penalty
Summary
The facility failed to implement an effective Quality Assurance Performance Improvement (QAPI) program to identify and address compliance concerns related to quality of life and quality of care. The QAPI committee did not address issues such as medication administration errors and infection control, which were identified during a recertification survey. The facility's regulatory record showed repeat deficiencies, including a medication administration error rate above five percent and infection control issues, both cited at an E level scope and severity. Additionally, the facility failed to ensure pressure injuries were assessed and treated timely, leading to a resident developing a wound infection with sepsis, creating an immediate jeopardy situation with actual serious harm. Interviews revealed that the medical director was unaware of a resident's hospitalization due to infected wounds, indicating a lack of communication and oversight. The new nursing home administrator (NHA) had only participated in one QAPI meeting and was not aware of the identified concerns, such as pressure injuries and medication issues. The NHA was unable to locate any investigations or notes from the previous administrator, highlighting a gap in continuity and documentation. Despite submitting a QAPI plan of correction for medication errors, the NHA did not provide evidence of staff education or audits being conducted, further demonstrating the facility's failure to address and rectify the identified deficiencies.
Removal Plan
- Education to all nurses
- Audits for expired, discontinued or missing medications to be completed
Facility Fails to Prevent Theft of Resident's Electric Tricycle
Penalty
Summary
The facility failed to prevent the misappropriation of property for a resident whose electric tricycle was stolen from behind a locked gate. The resident, who was cognitively intact and dependent on supplemental oxygen, had been admitted to the facility and later discharged to another long-term care facility. The resident's inventory sheets did not list the electric tricycle, and a grievance was filed when the tricycle was not replaced or reimbursed by the facility. The facility's administrator stated that they were not liable for the loss, and corporate management did not authorize reimbursement for the tricycle, which was valued at approximately $4,000. Interviews with staff revealed that the previous nursing home administrator had agreed to store the tricycle in a nearby building due to its size. A police report was filed after the tricycle was stolen, but it was not recovered. The current administrator was unaware of the incident, and the facility lacked a policy for personal property responsibility. The resident was offered a few hundred dollars, which was not accepted, and requested an unused electric wheelchair from the facility as a replacement, which was not provided.
Premature PICC Line Removal and Missed Antibiotic Doses
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for a resident who required intravenous (IV) therapy. The resident, who was over 65 years old and had been diagnosed with acute osteomyelitis of the mandible and an inflammatory condition of the jaw, was prescribed a course of IV antibiotics through a peripherally inserted central catheter (PICC) line. However, the nursing staff removed the PICC line prematurely, before the completion of the prescribed antibiotic course, without a physician's order. The removal of the PICC line led to the resident missing three doses of the antibiotic, as documented in the medication administration record. The error was not reported to a physician until several days later, delaying the replacement of the PICC line and the continuation of the antibiotic therapy. The facility's policy did not include specific guidelines for PICC line care, contributing to the oversight. Interviews with staff revealed a lack of clarity regarding the necessity of a physician's order for PICC line removal and the importance of timely notification and replacement in case of an error. Additionally, the facility failed to adhere to the physician's orders for PICC line dressing changes, as the dressing was not changed every seven days as required. This oversight was noted in the medication administration record, with missed dressing changes on specific dates. Staff interviews highlighted the importance of regular dressing changes to prevent infection at the insertion site and the need for adherence to the antibiotic stewardship program to track and manage infections effectively.
Failure to Conduct Annual Performance Reviews for CNAs
Penalty
Summary
The facility failed to conduct a performance review for two certified nurse aides (CNAs) within the required 12-month period, as mandated by regulations. CNA #1, hired on February 28, 2023, and CNA #2, hired on November 29, 2022, did not have documented performance reviews completed within the past year. This deficiency was identified through record reviews and staff interviews. The human resources director confirmed that each department lead was responsible for conducting annual performance reviews, but acknowledged that reviews for CNA #1 and CNA #2 were not completed. The regional nurse consultant also confirmed the absence of performance reviews for these CNAs.
Failure to Honor Resident Preferences in Care and Scheduling
Penalty
Summary
The facility failed to honor the residents' rights to make choices about aspects of their lives, specifically for two residents. Resident #7, who was cognitively intact and had multiple medical conditions including a sacral pressure ulcer, was not provided assistance in scheduling a wound care appointment at his preferred in-network clinic. Instead, the facility arranged for him to attend an out-of-network clinic, resulting in a significant financial burden. The resident and his representative were not informed about the network status or financial implications of the clinic chosen by the facility. Despite the resident's request to attend an in-network clinic closer to the facility, the facility scheduled an appointment at a distant location, causing additional discomfort due to the long travel. Resident #2, who was also cognitively intact and diagnosed with Parkinson's disease, expressed a preference for three showers per week. However, the facility assigned shower days based on room numbers without consulting the resident's preferences. There was no documentation in the resident's electronic medical record or the shower binder to indicate the resident's shower preferences, and the staff followed a predetermined schedule without accommodating individual requests. Interviews with staff, including the wound care nurse and the regional nurse consultant, revealed a lack of communication and documentation regarding the residents' preferences and the financial aspects of care. The facility's policy on residents' rights was not adhered to, as staff failed to facilitate and support the residents' choices, leading to dissatisfaction and potential financial strain for the residents involved.
Failure to Revise Care Plan for Resident's Medication Refusals
Penalty
Summary
The facility failed to ensure that the comprehensive care plan for a resident was reviewed and revised in a timely manner to include necessary instructions for effective and personalized care. The resident, who had severe cognitive impairments and multiple diagnoses including Huntington's disease, dementia, and depression, frequently refused physician-ordered medications and treatments. Despite these refusals, the care plans did not document or address the resident's pattern of refusals, nor did they include person-centered interventions to manage these refusals. The resident's medication administration record revealed multiple instances where medications such as Aspercreme and Haloperidol were not administered due to the resident's refusal. Additionally, the treatment administration record showed that the resident often refused to be moved to her chair for meals, as requested by her family. There was no documentation in the resident's electronic medical record indicating that the facility attempted to address these repeated refusals or update the care plan accordingly. Interviews with facility staff, including an LPN, a primary care provider, and a regional nurse consultant, confirmed that the resident's refusals were known but not adequately addressed. The LPN and RNC acknowledged the resident's right to refuse care but emphasized the need for re-approaching the resident and seeking assistance from other nurses. However, the care plan did not reflect these strategies or any person-centered interventions to reduce the number of refusals, leading to a deficiency in the resident's care management.
Failure to Provide Scheduled Showers for Resident
Penalty
Summary
The facility failed to ensure that a resident, who was unable to perform activities of daily living independently, received the necessary services to maintain personal hygiene. The resident, who was under 65 years old and had multiple diagnoses including multiple sclerosis and severe cognitive impairments, was dependent on staff for showering and dressing. Despite the resident's preference for morning baths, as documented in her care plan, she reported not receiving a shower since her admission to the facility. Observations and interviews revealed that the resident's hair was greasy and her fingernails were unkempt, indicating a lack of personal hygiene care. The facility's records showed no documentation of the resident being offered a shower since her admission. A grievance was filed by the resident, but there was no documentation of any follow-up action to offer her a shower after the grievance was filed. Interviews with staff, including an LPN and a CNA, indicated that showers were scheduled based on room numbers rather than resident preferences. The staff were unaware if the resident had received a shower since her admission. The regional nurse consultant acknowledged the grievance and stated that the resident should have been offered a shower within 24 to 48 hours of admission, highlighting a failure in the facility's process to ensure timely and appropriate personal hygiene care for the resident.
Deficiency in Staff Training Program
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for its staff, specifically for two certified nurse aides (CNAs). The deficiency was identified through record reviews and staff interviews, revealing that the facility did not ensure that these CNAs received necessary training in areas such as abuse, dementia management, behavioral health management, infection control, communication, quality assurance and quality improvement (QAPI), compliance and ethics, and resident rights. Additionally, the facility did not provide documentation to confirm that these CNAs completed at least 12 hours of annual in-service training as required. Interviews with the human resources director (HRD) and the regional nurse consultant (RNC) further highlighted the issue. The HRD admitted that while training was supposed to be completed through an electronic learning management program, there was no documentation to prove that the CNAs had completed the required training in the past 12 months. The HRD also mentioned an annual skills clinic training and monthly staff meetings that included training, but again, there was no documentation to confirm attendance by the CNAs. The RNC acknowledged the difficulty in ensuring staff completed the required annual training, confirming that the CNAs did not complete the necessary training in the past year.
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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