Coal Creek Post Acute & Assisted Living
Inspection history, citations, penalties and survey trends for this long-term care facility in Lafayette, Colorado.
- Location
- 329 Exempla Cir, Lafayette, Colorado 80026
- CMS Provider Number
- 065414
- Inspections on file
- 22
- Latest survey
- September 3, 2025
- Citations (last 12 mo.)
- 14
Citation history
Health deficiencies cited at Coal Creek Post Acute & Assisted Living during CMS and state inspections, most recent first.
Staff failed to follow sanitary food handling practices by using the same gloves to touch both ready-to-eat foods and non-food items without changing gloves or performing hand hygiene, and by wiping food residue from gloves onto food contact surfaces. Additionally, mold was observed on the floor of the walk-in refrigerator and on baking sheets used for food storage, with the mold on the floor persisting over several days despite staff awareness.
Several residents who were cognitively intact and dependent on staff for care reported being spoken to rudely or inappropriately by nursing staff, including being called derogatory names and having their concerns dismissed. In some cases, grievances were filed regarding disrespectful communication and improper care, but the facility's records did not show that the staff's inappropriate behavior was addressed. Staff also discussed residents in areas where conversations could be overheard, violating residents' rights to dignity and privacy.
Staff failed to consistently wear required gowns and gloves during high-contact care activities for residents on enhanced barrier precautions, including those with wounds, indwelling catheters, and surgical sites. Despite clear signage and existing protocols, several CNAs and a physical therapy assistant provided direct care without proper PPE, and interviews revealed confusion and lack of knowledge about EBP requirements among staff.
A resident's medical records were inaccurately completed, with documentation indicating that pain reassessment and indwelling catheter care had been performed when, in fact, these actions did not occur. Observation and resident interview confirmed that the nurse did not return to reassess pain or provide catheter care after administering as-needed pain medication, despite records showing otherwise.
Two residents, one cognitively intact and one with severe cognitive impairment, were not offered the COVID-19 vaccine as required, and there was no documentation in their medical records indicating that the vaccine was offered or administered. Staff interviews confirmed the absence of documentation for both residents.
A resident at high risk for falls was not provided with a fall prevention plan or adequate supervision, resulting in a fall and head injury. Despite being assessed as a high fall risk, the resident's care plan did not include necessary interventions. The resident fell after reportedly being denied assistance by a CNA, leading to a head laceration requiring emergency care. The facility's investigation was incomplete, lacking interviews with key staff present during the incident.
The facility failed to administer medications on time for two residents, leading to delays beyond the allowed window. A resident with Alzheimer's and hypertension received medications nearly two hours late, while another with osteomyelitis and diabetes experienced similar delays. The issue arose due to a nurse's absence, as confirmed by the DON and RCR.
A resident with Parkinson's disease did not receive their prescribed Carbidopa-Levodopa medication at three scheduled times due to it being out of stock. The nursing staff failed to audit the medication cart and reorder the medication in time, and did not order it as STAT when it was found missing. There was no documentation of notifying the physician or monitoring the resident for symptoms, leading to a significant deficiency in care.
The facility failed to maintain resident dignity and respect, as evidenced by incidents involving three residents. One resident was neglected when requesting bathroom assistance, leading to his departure from the facility. Another resident, with Alzheimer's, was often found in poor hygiene despite communicated care preferences, prompting her family to remove her from the facility. A third resident filed a grievance after a CNA refused to assist with changing a soiled brief, using inappropriate language. These incidents highlight ongoing issues with staff treatment and grievance handling.
Failure to Maintain Sanitary Food Handling and Storage Practices
Penalty
Summary
The facility failed to ensure that food was prepared, distributed, and served under sanitary conditions in the main kitchen. During lunch meal service, kitchen staff were observed handling ready-to-eat foods with gloved hands that had also been used to touch non-food items such as meal tickets, serving utensils, and equipment handles. Staff did not change gloves or perform hand hygiene between tasks, and gloved hands were used to touch both food and potentially contaminated surfaces. Additionally, one staff member wiped food residue from a glove onto the inner rim of a steam table bin containing food, further compromising food safety. Observations in the main kitchen's walk-in refrigerator revealed a persistent patch of green-grey mold on the floor near the freezer door, which remained present over several days despite staff awareness. Baking sheets used to hold cheese products were found with small spots of mold along their edges and corners. Although the baking sheets were eventually cleaned, the mold on the refrigerator floor was not addressed in a timely manner, and staff interviews indicated that deep cleaning of the refrigerator had been delayed due to staffing shortages and equipment issues. Facility policies required the use of single-use gloves for one task only, with gloves to be discarded after each use and hand hygiene performed between glove changes. Policies also mandated that food be stored in clean, dry locations and that all kitchen surfaces and equipment be kept clean and in good repair. Despite these policies, staff practices and the condition of the kitchen environment did not meet these standards, resulting in the deficiencies cited.
Failure to Ensure Resident Dignity and Respectful Communication
Penalty
Summary
The facility failed to ensure that residents were treated with dignity and respect, as required by policy and federal regulations. Multiple residents who were cognitively intact and dependent on staff for various activities of daily living reported or were observed to have experienced disrespectful or inappropriate communication from staff. One resident, who was unable to reach her call light, used her cell phone to request assistance and was spoken to rudely by a registered nurse, who told her to stop calling. The resident was unaware of her right to file a grievance and did not report the incident to facility leadership. Another resident reported that a registered nurse spoke loudly in the hallway, referring to residents as "drug addicts," and was rude and dismissive when administering medication. This resident reported the incident to the DON, but was unsure of the outcome. Additional grievances reviewed included a resident who experienced an argument with a nurse regarding IV line care, resulting in the resident developing blisters after the use of chlorhexidine, and another resident who was spoken to inappropriately by a CNA during a transfer, being told that other staff would not help because she was "too difficult to work with." The facility's grievance records did not indicate that the inappropriate communication by staff was addressed in the resolutions provided. Staff interviews confirmed awareness of some, but not all, of the allegations, and indicated that investigations were ongoing. The incidents demonstrate a pattern of staff failing to communicate respectfully with residents and discussing residents in areas where conversations could be overheard, in violation of residents' rights to dignity and privacy.
Failure to Ensure Proper PPE Use for Residents on Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain and follow its infection prevention and control program, specifically regarding the use of personal protective equipment (PPE) for residents on enhanced barrier precautions (EBP). Surveyors observed multiple instances where staff did not wear the required gowns and gloves during high-contact care activities for residents with wounds, indwelling devices, or recent surgeries. For example, during direct care activities such as transferring, catheter care, clothing changes, and colostomy care, several staff members either wore only gloves or did not wear any PPE, despite clear signage on residents' doors indicating the need for both gowns and gloves. Residents involved in these deficiencies included individuals with indwelling urinary catheters, surgical wounds with staples, and multiple wounds with devices such as colostomies and intravenous lines. Staff members, including CNAs, a physical therapy assistant, and an unidentified nursing staff member, were observed providing direct care without adhering to the required PPE protocols. In some cases, staff expressed uncertainty or lack of knowledge about the necessity of wearing gowns in addition to gloves, or believed PPE was only needed for certain tasks, despite the residents' high risk for infection due to their medical conditions. Interviews with staff, including RNs, CNAs, the LPN, the DON, and the infection preventionist, revealed gaps in understanding and communication regarding EBP requirements. Some staff were unsure about the specific PPE needed for residents on EBP, while others acknowledged they should have worn gowns but failed to do so. The infection preventionist and DON confirmed that education on EBP and PPE use was provided, but the observed lapses indicated inconsistent adherence to infection control protocols during resident care activities.
Inaccurate Documentation of Pain Reassessment and Catheter Care
Penalty
Summary
The facility failed to maintain accurate medical records for one resident, specifically regarding pain reassessment and indwelling catheter care. During a continuous observation period, it was noted that the resident's medication administration record (MAR) and treatment administration record (TAR) were incomplete at the start of the observation. Although the records were later marked as completed for both pain reassessment and catheter care, direct observation confirmed that the nurse did not return to the resident's room to perform a pain reassessment or provide catheter care after the initial administration of as-needed pain medication. The resident confirmed in an interview that no catheter care was provided that morning and that pain reassessment was not consistently performed after receiving pain medication. A review of the progress notes indicated documentation of a pain reassessment that, according to both observation and the resident's account, did not actually occur. The director of nursing acknowledged that the time care was documented in the TAR did not necessarily reflect when the care was provided and that staff were encouraged to document as accurately as possible. However, the evidence showed that documentation was completed for care and assessments that were not actually performed, resulting in inaccurate medical records for the resident.
Failure to Offer and Document COVID-19 Vaccination for Two Residents
Penalty
Summary
The facility failed to develop and implement policies and procedures related to COVID-19 immunizations for two of five residents reviewed for immunizations. Specifically, the facility did not offer the COVID-19 vaccine to two residents, as required by CDC guidelines. One resident, under 65 years old with a history of traumatic brain injury and multiple fractures, was cognitively intact and did not recall being offered the COVID-19 vaccine. Review of his electronic medical record confirmed there was no documentation that the vaccine was offered or administered. Another resident, over 65 years old with diagnoses including femur fracture, joint replacement, anemia, dementia, and generalized weakness, had severe cognitive impairment and was dependent on staff for most activities of daily living. There was no documentation in her medical record that the COVID-19 vaccine was offered or administered. Staff interviews confirmed that there was no record of either resident being offered or declining the vaccine, and the DON stated it was the admitting nurse's responsibility to document such offers and refusals.
Failure to Implement Fall Prevention Plan for High-Risk Resident
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident who was at high risk for falls. Upon admission, the resident was assessed and identified as a high fall risk due to her medical conditions, including a compression fracture, diabetes, and difficulty walking. Despite this assessment, the baseline care plan did not reflect the resident's fall risk, nor did it include person-centered interventions to prevent falls. On the day following her admission, the resident sustained a fall resulting in a head laceration that required emergency department treatment. The fall occurred after the resident reportedly asked a CNA for assistance to the bathroom but was told to manage on her own. The resident attempted to use the bathroom independently, resulting in a fall. The facility's investigation into the incident was incomplete, lacking interviews with key staff present during the incident. The CNA involved was suspended and later dismissed for not responding to the facility's calls. The investigation did not substantiate neglect, as there was no conclusive evidence that the CNA refused assistance. The facility's failure to implement a fall prevention plan and provide adequate supervision contributed to the resident's fall and injury.
Medication Administration Delays for Two Residents
Penalty
Summary
The facility failed to ensure that professional standards of practice were followed during medication administration for two residents. Specifically, Resident #9 and Resident #8 did not receive their medications as scheduled according to the physician's orders. For Resident #9, the medications were scheduled for 8 a.m., but were administered at 9:50 a.m., which is one hour and 50 minutes past the scheduled time and 50 minutes after the allowed medication administration window. Resident #9, who is over 65 years old, has diagnoses including Alzheimer's dementia and hypertension, and was receiving an antidepressant, opioid, and hypoglycemic medications. Similarly, Resident #8, who is also over 65 years old and has diagnoses including osteomyelitis and type 2 diabetes, received medications late. The B-complex, Finasteride, and Aspirin were scheduled for 8:00 a.m. but were administered at 10:06 a.m., two hours and six minutes past the scheduled time and one hour after the medication administration window. Additionally, the lactobacillus, quetiapine, and omeprazole were scheduled for 9:00 a.m. but were administered one hour and six minutes past the scheduled time. The delay in medication administration was attributed to a morning nurse calling off and not coming to work, as confirmed by the Director of Nursing and the Regional Clinical Resource.
Failure to Administer Parkinson's Medication as Prescribed
Penalty
Summary
The facility failed to ensure that a resident with Parkinson's disease was free from significant medication errors. The resident was prescribed Carbidopa-Levodopa to be administered four times a day at specific times. However, on a particular day, the resident did not receive the medication at three scheduled times due to the medication being out of stock. The medication administration record indicated the absence of the medication, and nursing progress notes confirmed that the pharmacy was contacted but did not deliver the medication as expected. The nursing staff did not audit the medication cart adequately to reorder the medication before it ran out. Additionally, once the medication was found to be missing, the staff failed to order it as STAT, which would have expedited its delivery. There was also no documentation that the resident's physician was notified about the missed doses, nor was there any record of monitoring the resident for symptoms related to missing the medication. Interviews with the nursing staff and administration revealed that there were expectations for auditing medication carts and reordering medications, which were not met in this instance. The staff acknowledged the importance of administering Parkinson's medication as prescribed and the potential consequences of missed doses. However, the necessary steps to prevent and address the medication error were not taken, leading to a significant deficiency in the resident's care.
Failure to Maintain Resident Dignity and Respect
Penalty
Summary
The facility failed to promote and maintain resident dignity by not providing care in a dignified, respectful, and individualized manner for three residents. Resident #1, who was alert and oriented, requested assistance to use the bathroom but was told by a CNA to use his brief instead. This led to the resident feeling neglected and ultimately leaving the facility, calling the police, and being taken to the hospital. The facility's investigation confirmed that the CNA did not respond to the resident in a dignified and respectful manner. Resident #5, diagnosed with Alzheimer's disease, was dependent on staff for daily living activities and had specific care preferences, such as being up before lunch and attending church services. Despite these preferences being communicated, the resident was often found in poor hygiene, wearing the same clothes for days, and left in soiled conditions. The resident's representative voiced concerns multiple times, but the facility failed to address these issues adequately, leading to the resident's family deciding to remove her from the facility. Resident #6, who had intact cognition, filed a grievance after a CNA refused to assist her with changing a soiled brief, using inappropriate language. The facility's investigation revealed that this CNA had previous complaints from other residents, leading to her termination. Interviews with other residents and a frequent visitor highlighted ongoing issues with staff not treating residents respectfully and taking a long time to address grievances, indicating a broader problem with the facility's approach to resident care.
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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