Bear Creek Senior Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Colorado Springs, Colorado.
- Location
- 1685 S 21st St, Colorado Springs, Colorado 80904
- CMS Provider Number
- 065373
- Inspections on file
- 17
- Latest survey
- February 11, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Bear Creek Senior Living during CMS and state inspections, most recent first.
Surveyors identified multiple infection control deficiencies, including improper hand hygiene, PPE use, and room disinfection. An RN administered a subcutaneous injection to a resident without performing hand hygiene between handling the med cart and the injection and did so without gloves, then later administered an oral medication that had fallen onto the med cart surface. During tracheostomy care for a resident, the same RN did not change gloves between removing a soiled inner cannula and inserting a clean one and did not use a gown or mask. In a separate observation, two CNAs and an RN provided high-contact care, including dressing, transferring, toileting, and wound care, to a resident with a Foley catheter and a buttock wound while only wearing gloves and not donning EBP gowns. Housekeeping staff were also observed spraying disinfectants on toilets, sinks, grab bars, and bedside tables and immediately wiping them dry, failing to meet required chemical dwell times and not fully disinfecting high-touch surfaces.
A facility failed to provide a written discharge notice to a resident, their representative, and the State LTC Ombudsman, as required. The resident, who had multiple medical conditions and was cognitively intact, was not readmitted after hospitalization due to the facility's claim of inability to meet their needs. The resident's representative was verbally informed but did not receive a written notice or information on appeal rights, leaving them unaware of how to appeal the discharge.
A facility failed to allow a resident to return after hospitalization, citing medication refusals as the reason. The resident, who had multiple medical conditions and was cognitively intact, was not provided with a discharge letter or appeal rights, violating facility policy. The decision was made by the IDT, but lacked proper documentation and communication with the resident's representative.
The facility failed to maintain an effective infection control program by not adequately monitoring water temperatures to prevent Legionella growth and not offering the COVID-19 vaccine to a resident. Water temperatures were often within the favorable range for Legionella, and there was no immediate follow-up monitoring. Additionally, a resident over 65 was not offered the COVID-19 vaccine, and their vaccination status was not documented, indicating lapses in the facility's vaccination tracking process.
Three residents in the facility experienced significant medication errors. One resident did not receive prescribed antibiotics for a UTI and an inhaler for COPD due to unavailability and lack of physician notification. Another resident missed doses of a nasal spray, and a third resident did not receive pain medication, with no documentation of physician notification. The facility's medication dispensing machine was not effectively used to prevent these errors.
A facility failed to ensure a resident with COPD had a clear physician's order for oxygen therapy, leading to confusion about whether the oxygen was to be used continuously or intermittently. Staff interviews revealed uncertainty about the resident's oxygen needs, and the deficiency was noted during a survey when it was found that the order had not been clarified.
A facility failed to offer a pneumococcal vaccine to a resident over 65 with no cognitive impairment. The resident's EMR lacked documentation of prior vaccinations, and staff interviews revealed that the ADON and DON missed reviewing the resident's immunization history upon admission. The facility did not have a comprehensive system to track and document resident immunization information, leading to this oversight.
Infection Control, EBP, and Environmental Disinfection Deficiencies
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, including proper hand hygiene, appropriate use of PPE, hygienic room cleaning, and adherence to chemical dwell times. Facility policies stated that hand hygiene is the primary means to prevent spread of healthcare-associated infections and is required before resident contact, before aseptic tasks, after contact with blood or body fluids, after touching a resident or their environment, and immediately after glove removal. Despite this, a registered nurse (RN) prepared and administered a subcutaneous enoxaparin injection to a resident without performing hand hygiene between handling the medication cart and administering the injection, and without donning gloves while breaking the resident’s skin. The RN only performed hand hygiene after exiting the room and after touching the medication cart computer. In another instance, while preparing famotidine for a different resident, the RN allowed a tablet that had fallen onto the top of the medication cart to be administered to the resident instead of discarding it. Additional hand hygiene and aseptic technique failures were observed during tracheostomy care for a resident with a tracheostomy. The RN performed hand hygiene and donned clean gloves, but did not change gloves after removing the old inner tracheostomy cannula and before inserting the clean inner cannula. In interviews, the RN stated he did not know whether gloves were required for subcutaneous or intramuscular injections and reported he typically only wore gloves when manipulating an IV catheter. He also stated he did not know whether gloves should be changed between handling the soiled inner tracheostomy cannula and inserting the clean cannula, and that he had never considered the risk. The DON confirmed that hand hygiene should occur before dispensing and administering medications and after exiting the room, that gloves should be worn when breaking the skin for injections, that dropped pills should be discarded rather than administered, and that gloves should be changed after working with a dirty area such as a used tracheostomy cannula before moving to a clean area. The facility also failed to implement Enhanced Barrier Precautions (EBP) for residents with indwelling devices and wounds during high-contact care activities. A resident with a tracheostomy reported that staff performing tracheostomy care wore gloves but never wore a yellow gown. During observed tracheostomy care for this resident, the RN performed hand hygiene and donned gloves but did not don a mask or yellow isolation gown, despite facility policy and CDC guidance indicating gown and gloves for device care such as tracheostomy care. In another observation, two CNAs and an RN provided high-contact care to a resident with a Foley catheter and a wound on the buttocks, including dressing, transferring with a sit-to-stand device, toileting, cleaning the resident’s bottom, and applying cream to the wound. They wore gloves but did not don EBP such as gowns during these high-contact activities. In interviews, a CNA stated she did not know of any special precautions for residents with tracheostomies, believed no residents were on EBP, and did not think special PPE was needed for dressing or toileting such residents. The RN involved in tracheostomy care stated he did not know what EBP were. The infection preventionist stated that residents with indwelling lines or skin breakdown that increased infection risk would qualify for EBP and that EBP had been implemented in the past, but signage had been replaced during COVID-19 outbreaks and not brought back. The DON stated that residents with additional lines such as catheters or tracheostomies or skin breakdown would be expected to be on EBP and that there were several residents on EBP, but she was unclear about whether transferring required gowns under EBP. She also noted that EBP orders should be in place and care planned, and that door signs sometimes get switched and not replaced. The facility further failed to follow manufacturer-recommended dwell times for disinfectant chemicals and to properly disinfect high-touch surfaces in resident rooms. Product information for NABC Concentrate required surfaces to remain wet for ten minutes, and Clean by 4D required treated surfaces to remain wet for a specified period for sanitization. Facility policy required following manufacturers’ instructions and cleaning horizontal surfaces daily and personal-use items at least twice weekly with disinfectant solution. During observations of two housekeepers cleaning resident rooms, both sprayed NABC Concentrate on toilets, sinks, counters, grab bars, and other bathroom surfaces and immediately wiped them dry, rather than allowing the required contact time. One housekeeper sprayed a rag with NABC to wipe a bedside table and used Clean by 4D on a grab bar, and the other used Clean by 4D on a side table, but in all instances the products were wiped off immediately. In interviews, the environmental services director stated that the dwell time for Clean by 4D was two minutes and for NABC Concentrate was ten minutes, and that housekeepers were trained to spray surfaces first and let the chemicals sit while they completed other tasks such as trash removal and sweeping. She acknowledged that staff sometimes get in a hurry. She also stated that high-touch surfaces expected to be disinfected included light switches, door knobs, doors around the knobs, furniture and handles, bedside tables and legs, lamps, call lights, and chair arms. The infection preventionist stated that high-touch surfaces such as remotes, call lights, bedside tables, door knobs, phones, and bed rails should be sanitized daily and that chemical dwell times should be followed to clean off the spread of germs.
Failure to Provide Written Discharge Notice and Appeal Rights
Penalty
Summary
The facility failed to provide a written discharge notice to a resident, their representative, and the State Long-Term Care Ombudsman at least 30 days before the resident's discharge. The facility did not issue a written notice that included the reason for the discharge, the effective date, the location to which the resident was being transferred, and the resident's appeal rights. Additionally, the facility did not send a copy of the discharge notice to the ombudsman, as required by their policy. The resident involved was over 65 years old and had multiple medical conditions, including alcoholic cirrhosis of the liver, type 2 diabetes with complications, and major depressive disorder, among others. The resident was cognitively intact and required supervision for most activities of daily living. Despite these needs, the facility decided not to readmit the resident after a hospitalization, citing an inability to meet the resident's needs and the resident's refusal to allow interventions for safety. Interviews revealed that the resident's representative was verbally informed of the discharge decision but did not receive a written notice or information on appeal rights. The facility's failure to document the discharge notice and notify the ombudsman was confirmed by the assistant director of nursing. The lack of proper documentation and notification led to the resident and their representative being unaware of the appeal process, which they expressed a desire to pursue.
Failure to Permit Resident Return After Hospitalization
Penalty
Summary
The facility failed to permit a resident to return after a hospitalization, which was a violation of their policy regarding facility-initiated transfers and discharges. The policy states that residents who are sent to an acute care setting, such as a hospital, are expected to return to the facility unless specific criteria are met. In this case, the facility did not allow the resident to return, citing an inability to meet her needs due to her refusal to take medications, which was not aligned with the policy requirements for discharge. The resident in question was over 65 years old and had multiple medical conditions, including alcoholic cirrhosis of the liver, type 2 diabetes with complications, and major depressive disorder, among others. She was cognitively intact and required supervision for most activities of daily living. The resident had a history of refusing medications, which led to a change in her mental status and subsequent hospitalization. Despite this, the facility's policy required that residents be allowed to return unless their needs could not be met or the health and safety of others were at risk, which was not adequately documented in this case. Interviews with facility staff revealed that the decision to not allow the resident's return was made by the interdisciplinary team due to her medication refusals. However, there was no documentation of a facility-initiated discharge letter or notification of appeal rights provided to the resident or her representative. This lack of communication and documentation further contributed to the deficiency, as the resident's representative was not given the opportunity to appeal the decision, which is a requirement under the facility's policy.
Infection Control and Vaccination Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection control program, specifically in monitoring water for Legionella and offering COVID-19 vaccinations to residents. The facility did not ensure that water temperatures were maintained outside the favorable range for Legionella growth, which is between 77 to 113 degrees Fahrenheit. The maintenance director (MTD) was unaware that the hot water temperatures did not meet the required control measure temperature for hot water storage or supply, which should be between 130 to 135 degrees Fahrenheit without a thermostatic mixing valve. The water temperature logs showed several instances where the temperatures were within the favorable range for Legionella growth, and there was no additional monitoring until the annual water analysis was completed. The facility's water management program was not effectively implemented, as the infection preventionist (IP) was not a member of the water management team, and there was no immediate follow-up monitoring when water temperatures were out of range. The director of nursing (DON) acknowledged that the water temperatures were not always in the range to prevent Legionella growth and that waiting for laboratory analysis could delay necessary follow-up actions. The facility's policy required weekly checks of cold water temperatures and annual Legionella culture tests, but the records indicated that these measures were not consistently followed. Additionally, the facility failed to offer the COVID-19 vaccine to a resident who was admitted over the age of 65. The resident's electronic medical record (EMR) did not indicate whether they had received any COVID-19 vaccinations prior to admission, and there was no documentation that the resident was educated, offered, or refused the vaccine since their admission. The assistant director of nursing (ADON) and the DON shared the responsibility of tracking resident vaccination status, but they were unable to find documentation regarding the resident's COVID-19 vaccination status, indicating a lapse in the facility's vaccination tracking and documentation process.
Medication Errors Affect Three Residents
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting three residents. Resident #18 did not receive the prescribed antibiotics for a urinary tract infection upon admission from the hospital. The initial order for Amoxicillin was not entered into the computerized physician orders, resulting in the resident missing seven doses over several days. Additionally, the resident's inhaler for COPD was not available for administration for multiple days, and there was no documentation indicating that the physician was notified of these missed doses. Resident #6 experienced a lack of availability of a prescribed nasal spray, which was intended to relieve respiratory symptoms. The resident reported feeling miserable without the medication, and there was no documentation of the physician being notified about the unavailability of the nasal spray. The medication was noted as being on order from the pharmacy, but there was no follow-up documented to determine when it would be delivered. Resident #188 did not receive prescribed pain medication due to its unavailability. The resident missed multiple doses over several days, and there was no documentation that the physician was informed of these missed doses. The facility's automated medication dispensing machine, which could have been used to access urgent medications, was not utilized effectively to prevent these medication errors.
Deficiency in Oxygen Therapy Documentation
Penalty
Summary
The facility failed to ensure that a resident receiving oxygen therapy had a clear and specific physician's order regarding the use of supplemental oxygen. The deficiency was identified for a resident with chronic obstructive pulmonary disorder (COPD), who was observed using an oxygen concentrator set at 2 liters per minute (LPM) but reported only using oxygen at night. The physician's order did not specify whether the oxygen was to be used continuously or intermittently, leading to confusion about the resident's oxygen therapy needs. Interviews with staff, including a registered nurse and the director of nursing, revealed that the physician's order lacked documentation on the specific use of oxygen, and there was uncertainty about whether the resident required continuous oxygen. The facility's oxygen care plan indicated continuous use, but this was not reflected in the physician's order. The deficiency was noted during a survey when it was discovered that the order had not been clarified, resulting in a lack of adherence to professional standards of practice for oxygen therapy.
Failure to Offer Pneumococcal Vaccine to Resident
Penalty
Summary
The facility failed to develop and implement policies and procedures related to pneumococcal vaccines for one of the residents reviewed for vaccinations. Specifically, the facility did not ensure that a resident, who was over the age of 65 and had no cognitive impairment, was offered the pneumococcal vaccine. The resident's electronic medical record did not indicate whether she had received any pneumococcal vaccinations prior to her admission to the facility, and there was no documentation that she was offered the vaccine upon admission. Interviews with the assistant director of nursing (ADON) and the director of nursing (DON) revealed that they shared the responsibility of tracking resident vaccination status. However, they admitted to missing the review of the resident's immunization history upon admission, which led to the oversight. The ADON stated that the facility did not have a system in place to track and document resident immunization information comprehensively, which contributed to the failure to offer the pneumococcal vaccine to the resident.
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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