Arvada Care And Rehabilitation Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Arvada, Colorado.
- Location
- 6121 W 60th Ave, Arvada, Colorado 80003
- CMS Provider Number
- 065321
- Inspections on file
- 20
- Latest survey
- January 15, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Arvada Care And Rehabilitation Center during CMS and state inspections, most recent first.
Surveyors found that the facility failed to maintain sanitary conditions in the main kitchen and to properly store and label food. Walls near food prep areas were splattered and unclean, dishwasher racks had embedded black residue and buildup, and "clean" pans and bins were stacked wet on the drying rack. Food debris and heavy grease were present around the stove, uncovered grease-filled coffee tins were stored under a kitchen sink, and dust and debris had accumulated along pipes, baseboards, and behind the ice machine. In food storage areas, a spoiled bag of cabbage and expired chocolate milk were found, contrary to professional standards and the facility’s own policies for cleaning, dating, and labeling food.
A deficiency was cited for not ensuring a resident's right to request, refuse, or discontinue treatment, participate in or refuse experimental research, and formulate an advance directive. The report does not provide further details about the specific circumstances or individuals involved.
The facility failed to develop and implement baseline care plans within 48 hours of admission for four residents, leading to deficiencies in providing effective and person-centered care. The care plans lacked specific details about skin concerns, assistance needed for ADLs, cognitive status, and initial discharge goals. Interviews with staff revealed that the MDS coordinator, with assistance from nursing staff, was responsible for completing the baseline care plans, which were incomplete and lacked personalization to the residents' specific needs.
The facility failed to maintain an effective infection control program, with deficiencies in Enhanced Barrier Precautions during wound care, inadequate cleaning of high-touch areas, and improper labeling and storage of personal hygiene items in shared bathrooms. A nurse did not wear a gown during wound care, and high-touch areas were not cleaned daily. Personal items in shared bathrooms were unlabeled, posing a risk of cross-contamination.
A resident requiring BiPAP therapy did not receive proper respiratory care as the facility failed to maintain, clean, and store the BiPAP equipment according to professional standards. The resident's mask was torn and improperly stored, and the facility's policy was not followed. Staff interviews revealed confusion over responsibilities, and the resident's insurance coverage complicated equipment replacement.
A resident with a history of spinal fusion and knee replacement experienced constant pain that was not effectively managed by the facility. Despite having a care plan, the resident frequently reported pain levels above his acceptable threshold and had to wait for extended periods for medication. The care plan did not address knee pain, and there was no follow-up or physician notification when pain levels were high. Staff interviews revealed inconsistent pain assessments and a lack of follow-up actions.
The facility failed to properly post information on filing complaints with the State Agency, as the posting was obscured, missing an email address, and inaccessible to residents in wheelchairs. Residents were unaware of the complaint process, and staff acknowledged the need for corrections.
A resident's DNR status was not documented in the EMR, leading to CPR and intubation against her wishes after a cardiac arrest. The advanced directive form was misplaced, and staff incorrectly informed EMTs to perform CPR. The resident was intubated and later passed away after the tube was removed at the family's request.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to store, prepare, distribute, and serve food under sanitary conditions for all residents receiving meals from the main kitchen. During an initial kitchen tour, surveyors observed multiple sanitation issues in the food preparation area, including walls throughout the kitchen, behind the handwashing station, and around the refrigerator with dime-sized brown and yellow streaks and splatters. The dishwasher plate racks were heavily soiled with black embedded residue that could not be wiped or scraped off, and several racks had gummy blackish buildup of unknown matter in the drainage crevices. The drying rack contained multiple food storage bins and pans stacked on top of each other, trapping moisture between the stacked items on the clean drying rack, contrary to requirements for proper air-drying. Additional observations showed food debris and heavy grease accumulation around the range stove and burner brackets, as well as several coffee tins containing grease left uncovered and stored under a kitchen sink in the food preparation area. Debris and small piles of dust had accumulated along ceiling pipes, along baseboards, and on the sides and behind the ice machine. These conditions conflicted with professional standards and the facility’s own kitchen cleaning policy, which required cleaning before, during, and after food preparation, and mandated that each user properly clean and sanitize the kitchen after their shift and ensure floors were swept and cleaned at the end of the shift. Surveyors also found failures related to proper labeling and storage of perishable foods. In the dry storage and refrigerated food areas, they observed a bag of cabbage with browning and pooling liquid inside the bag, indicating spoilage, and chocolate milk stored in the refrigerator that was labeled with an expiration date that had already passed. These findings were inconsistent with state retail food regulations and the facility’s food storage policy, which required all products to be dated when received and when opened, adherence to use-by or expiration dates, and labeling of foods removed from their original containers with the common name of the food.
Failure to Honor Resident Rights Regarding Treatment and Advance Directives
Penalty
Summary
A deficiency was identified regarding the failure to honor a resident's right to request, refuse, or discontinue treatment, to participate in or refuse experimental research, and to formulate an advance directive. The report notes that the facility did not ensure these resident rights were upheld, but does not provide specific details about the actions or inactions of staff, the events that occurred, or the medical history or condition of any resident involved. No further factual observations or resident-specific information are included in the report.
Deficiencies in Baseline Care Plans for New Admissions
Penalty
Summary
The facility failed to develop and implement baseline care plans within 48 hours of admission for four residents, leading to deficiencies in providing effective and person-centered care. Resident #9's baseline care plan lacked specific details about skin concerns, assistance needed for activities of daily living (ADLs), cognitive status, and initial discharge goals. Similarly, Resident #24's care plan did not include interventions for surgical wound care or address the resident's initial discharge goal, despite the resident being cognitively intact and having acute/chronic pain and a surgical wound. Resident #201's baseline care plan also omitted necessary information regarding surgical wound care and the resident's cognitive status, as well as the initial discharge goal. This resident required moderate to maximum assistance with mobility and had moderate cognitive impairment. Additionally, Resident #39's care plan failed to document specific diagnoses related to cognitive impairments and ADL self-care performance deficits. The plan did not specify the number of staff needed for assistance with transfers or address catheter care, which was crucial given the resident's severe cognitive impairments and dependence on care for ADLs. Interviews with facility staff revealed that the MDS coordinator, with assistance from nursing staff, was responsible for completing the baseline care plans. However, the plans were incomplete and lacked personalization to the residents' specific needs, leading to deficiencies in care planning. The social services director and regional social services director confirmed that the areas they completed were included in the comprehensive care plan, but the baseline care plans remained insufficient in addressing the residents' immediate needs upon admission.
Infection Control and Hygiene Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. One significant issue was the failure to adhere to Enhanced Barrier Precautions (EBP) during wound care. A registered nurse did not wear a gown while providing wound care to a resident with wounds, despite the presence of an EBP sign and available personal protective equipment (PPE) in the room. The nurse misunderstood the requirements for EBP, believing it was only necessary for residents with certain medical devices, not wounds. This misunderstanding was confirmed during interviews with the nurse and the Director of Nursing (DON), who acknowledged that EBP should include gown and glove use during wound care. Another deficiency was observed in the housekeeping practices within the facility. The housekeeper did not clean and sanitize high-touch areas such as door knobs, light switches, and call lights in resident rooms. These areas are critical for infection control as they are frequently touched and can harbor pathogens. The DON and the maintenance director both confirmed that high-touch areas should be cleaned daily, but there was a lack of specific guidance in the cleaning checklists, indicating a gap in the facility's cleaning protocols. Additionally, the facility failed to ensure that residents' personal hygiene items in shared bathrooms were labeled and stored in a sanitary manner. Observations revealed unlabeled items such as toothbrushes, toothpaste, and bedpans in shared bathrooms, which could lead to cross-contamination among residents. The DON explained that labeling was typically done by certified nurses aides or admissions staff, but acknowledged that the current practice was insufficient, as many items were not labeled, and there was inadequate storage space in the bathrooms.
Failure to Maintain and Clean BiPAP Equipment
Penalty
Summary
The facility failed to provide adequate respiratory care for a resident who required the use of a BiPAP machine. The resident, who was over 65 years old and had a history of Parkinson's disease, asthma, acute respiratory failure, and other conditions, reported that his BiPAP mask was not being cleaned by the staff. Observations revealed that the BiPAP machine was stained, and the mask was torn and improperly stored on the floor, contrary to the facility's policy and professional standards of practice. The facility's policy required the BiPAP equipment to be cleaned and stored according to the manufacturer's instructions, which were not provided during the survey. The resident's care plan included orders to apply the BiPAP every night, change the distilled water, and clean the mask nightly. However, the resident's mask was found on the floor, and the area under the bed was unclean, indicating a lack of adherence to these orders. The care plan was updated during the survey to reflect the resident's preference for storing the mask on the floor, but staff were instructed to encourage alternative storage. Interviews with staff revealed a lack of clarity and responsibility regarding the cleaning and maintenance of the BiPAP equipment. The Director of Nursing acknowledged the resident's mask had been replaced previously but was unaware of its current condition. The resident's insurance coverage for a new mask was also a complicating factor, as it only allowed for periodic replacements. The facility's contracted respiratory services vendor did not clean or replace personal equipment, further complicating the situation. The manufacturing instructions for the BiPAP machine were requested but not provided, leaving a gap in the facility's compliance with its own policy.
Inadequate Pain Management for Resident
Penalty
Summary
The facility failed to provide effective pain management for a resident, identified as Resident #201, who was admitted with a history of spinal fusion, spinal stenosis, and a knee replacement. The resident experienced constant pain that affected his daily activities and sleep. Despite having a care plan that included both pharmacological and non-pharmacological interventions, the facility did not adequately manage the resident's pain, as evidenced by multiple instances where his pain levels exceeded his acceptable threshold of 3 on a numeric scale of 1-10. Observations and interviews revealed that Resident #201 frequently complained of pain and had to wait for extended periods before receiving pain medication. On one occasion, the resident waited nearly an hour for pain relief after expressing his discomfort. The resident also reported that his pain was not being controlled effectively and that he was not aware of any non-pharmacological interventions being used to alleviate his pain. The care plan did not address the resident's knee pain, and there was no follow-up or notification to a physician when the resident's pain levels were consistently above his acceptable threshold. Interviews with staff indicated a lack of consistent pain assessments and follow-up actions. The Director of Nursing acknowledged that pain assessments should occur regularly and with any change in condition, such as the resident's fall, but there was no evidence of such assessments being conducted. Additionally, the resident's medical record showed that he had not been seen by the medical director during his stay, further highlighting the facility's failure to manage the resident's pain effectively.
Inadequate Posting of State Agency Complaint Information
Penalty
Summary
The facility failed to adequately post information on how residents can file a complaint with the State Agency. Observations revealed that the posting was located in the facility lobby but was obscured by a potted plant, making it difficult for residents to see. Additionally, the posting was missing the State Agency email address, and the information was placed above the eyeline for residents in wheelchairs and written in a small font, making it inaccessible and unreadable for some residents. Interviews with residents indicated that they were unaware of how to file a complaint with the State Agency and did not know where the information was posted. Residents expressed difficulty in reading the information due to its small size and inaccessible placement. Staff interviews revealed that the social services director was initially unsure of the required elements for the posting and acknowledged the missing information. The nursing home administrator was aware of the need for corrections to the postings, including the missing email address, font size, and location, to ensure residents could easily access and read the information.
Failure to Document and Communicate DNR Status
Penalty
Summary
The facility failed to ensure that a resident's advanced directive, indicating a Do Not Resuscitate (DNR) status, was properly documented and communicated. Upon admission, a Licensed Practical Nurse (LPN) interviewed the resident and filled out the advanced directive form, which was signed by the resident's family and a nurse practitioner. However, the LPN did not record the DNR status in the resident's electronic medical records (EMR) as required. Seven days after admission, the resident experienced a cardiac arrest. The nursing staff was unable to locate the advanced directive form and, lacking documentation in the EMR, incorrectly informed emergency medical technicians (EMTs) that the resident was to receive cardiopulmonary resuscitation (CPR). Consequently, the EMTs performed CPR and intubated the resident, contrary to her DNR wishes, and transported her to a hospital. The hospital records confirmed the resident's DNR status, but the intubation had already occurred. The resident's family, upon learning of the intubation, agreed to wait 24 to 48 hours to see if she would recover. However, after 24 hours, the family requested the removal of the intubation tube due to the resident's suffering, and she passed away shortly after. The facility's failure to document and communicate the resident's DNR status resulted in unnecessary medical intervention and suffering for the resident and her family.
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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