Good Samaritan Society -- Loveland Village
Inspection history, citations, penalties and survey trends for this long-term care facility in Loveland, Colorado.
- Location
- 2101 S Garfield Ave, Loveland, Colorado 80537
- CMS Provider Number
- 065139
- Inspections on file
- 18
- Latest survey
- April 2, 2026
- Citations (last 12 mo.)
- 15
Citation history
Health deficiencies cited at Good Samaritan Society -- Loveland Village during CMS and state inspections, most recent first.
A resident with dementia, dysphagia, and anxiety, who required significant assistance with ADLs and mobility, experienced increasing leg and hip pain, functional decline, and remained in bed after a suspected fall. Nursing and hospice notes documented escalating pain, new PRN morphine orders, non-verbal pain behaviors, and staff pre-medicating with morphine before care. CNAs and an LPN reported the resident’s increased pain, weakness, and reduced mobility to nursing staff. Although facility policy required communication with family or a healthcare proxy during a change in condition, and the DON stated that the hospice nurse spoke with the resident’s representative, the EMR lacked documentation that the representative was notified of the resident’s increased pain or that treatment decisions related to this change in condition were discussed with the resident or her representative.
A resident with dementia, dysphagia, anxiety, and severe cognitive impairment experienced increasing leg and hip pain, outward rotation of a leg, non-verbal signs of pain with movement, and a marked decline in mobility, including no longer getting out of bed. Nursing and hospice notes documented escalating pain, new morphine use, and pre-medication before care, and CNAs reported that the resident screamed in pain and required more assistance after a potential fall. Despite facility policy requiring provider notification for changes in condition and staff reports of pain and functional decline, there was no documentation that the physician was notified of the resident’s increased pain and reduced mobility, resulting in a deficiency for failure to notify the provider of a change in condition.
A resident with intact cognition and a history of schizoaffective disorder approached a table in a common area where two other residents were seated, including a resident with mild cognitive impairment and documented behavioral issues such as poor impulse control, verbal and physical aggression, and a habit of grabbing women’s hands as they walked by. After a brief verbal exchange about space at the table, the aggressive resident grabbed and forcefully squeezed the other resident’s hand, causing significant pain, bruising, numbness in several fingers, and pressure from a ring digging into the skin. Another resident witness reported that the aggressive resident appeared very angry, twisted the victim’s hand with both hands, and looked like he wanted to hurt her. Staff and residents described the aggressive resident as possessive of his preferred seating area and objects, and as someone who routinely grabbed women’s hands in the common area, yet the incident occurred unwitnessed by staff, resulting in the facility’s failure to keep the victim free from physical abuse by another resident.
Facility staff failed to report an injury of unknown origin as a potential abuse/neglect event to the abuse coordinator and State Survey and Certification Agency, contrary to facility policy and state law. A resident with severe cognitive impairment, dementia, and functional dependence developed significant leg and hip pain, outward rotation of a leg, and increased pain with movement after staff heard about a potential fall. Nursing and hospice documentation showed escalating pain, new opioid orders, and the resident remaining in bed with pain during care, while CNAs and an LPN reported the resident’s pain and functional decline to nursing staff. Despite these findings and the facility’s stated procedures for investigating and reporting such incidents, no report of the injury of unknown origin was submitted to the State Agency.
A resident with severe cognitive impairments and a history of falls experienced seven falls over two months due to inadequate supervision and inconsistent implementation of care-planned interventions. The facility failed to ensure the resident's bed was in a low position and did not consistently assist with transfers, contributing to repeated falls and a hip fracture. Despite the resident's memory deficits, the facility relied on ineffective verbal reminders, leading to the resident's decline and placement on hospice services.
Two residents were sexually abused by a CNA in the facility. One resident, who was cognitively impaired, was found in a compromising position with the CNA, who later confirmed the abuse. Another resident, who was visually impaired, reported that the CNA put something in her hand, which she identified as his penis. The facility's policy on abuse and neglect was not effectively implemented, leading to a failure to protect the residents and a delay in reporting the incidents.
A resident known to be at risk for falls sustained a left femur fracture after the facility failed to ensure her floor alarm was properly reset and turned on. Staff were aware of the need to reset the alarm but did not ensure it was in the on position, leading to the fall.
The facility had a medication error rate of 7.7%, with errors including a CNA-Med failing to check vital signs before administering Nebivolol and an RN crushing Metoprolol Succinate ER tablets against manufacturer guidelines.
Failure to Notify Resident Representative of Change in Condition and Increased Pain
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition, specifically increased pain and functional decline. Facility policy for Interact-Change in Condition Evaluation required staff to review the medical record, consult with interdisciplinary staff and family members or healthcare proxies as needed, and clarify advance directives when appropriate. Despite this policy, there was no documentation in the electronic medical record (EMR) that the resident or her representative was informed of the resident’s increased pain or that treatment decisions were reviewed with them. The resident involved was over 65 years old, had diagnoses including unspecified dementia, dysphagia, and anxiety, and was documented on the MDS as having severe cognitive impairment with a BIMS score of 5/15. She required maximal assistance with toileting and dressing and moderate assistance with mobility. Nursing notes documented that she complained of right leg pain on one date and later was yelling out, had a furrowed brow, and complained of left hip pain, for which PRN Tylenol and aspercreme with lidocaine were administered. Hospice notes showed that as-needed morphine was added to her plan of care and that the hospice nurse spoke with the resident’s daughter, and later that a new morphine order was placed after the facility nurse notified hospice of increased left hip and groin pain. Subsequent hospice documentation described outward rotation of the right leg, non-verbal signs of pain with inward rotation, pain with care and rolling in bed, and that staff were pre-medicating with morphine prior to care. Interviews with staff further described the change in the resident’s condition. An LPN reported that around the beginning of February the resident stopped getting out of bed and complained of pain in her left side, despite previously ambulating with one-person assistance and a walker. CNAs reported hearing about a potential fall and observed that after this incident the resident heavily favored one side, had weakness, screamed out in pain, complained of hip and leg pain, grimaced frequently, and was no longer getting out of bed, with pain limiting her ability to sit up. They stated they reported the pain to the nurse. The DON stated that standard steps after a fall included assessing the resident, notifying the provider, resident representative, hospice if applicable, and management, and that in this case the hospice nurse spoke to the representative when there was an increase in pain and morphine was needed. However, the resident’s EMR did not contain documentation that the resident’s representative was notified of the increased pain or that the facility discussed the change in condition and related treatment decisions with the resident or her representative.
Failure to Notify Physician of Resident’s Change in Condition and Increased Pain
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of a change in condition, specifically an increase in pain and decreased mobility. Facility policy, as outlined in the Interact-Change in Condition Evaluation procedure, required staff to review the resident’s record, gather information from interdisciplinary staff and others, and notify the provider of changes in condition as indicated. Despite this policy, there was no documentation that the resident’s physician was notified when the resident experienced increased pain and functional decline. The resident involved was over 65 years old, admitted with diagnoses including unspecified dementia, dysphagia, and anxiety, and had severe cognitive impairment with a BIMS score of 5/15. She required maximal assistance with toileting and dressing and moderate assistance with mobility. Nursing notes documented that she complained of right leg pain on one date and later was yelling out, had a furrowed brow, and complained of left hip pain, for which PRN Tylenol and aspercreme with lidocaine were administered. Hospice notes documented an increase in left hip pain radiating to the groin, a new morphine order, outward rotation of the right leg, non-verbal signs of pain with inward rotation, and that she had not been out of bed for about a week, with staff pre-medicating with morphine prior to care. Interviews with staff further described the change in the resident’s condition. An LPN reported that around the beginning of February the resident stopped getting out of bed and complained of pain in her left side, but the EMR did not show documentation that the physician was notified that the resident was not getting out of bed as often due to increased pain. CNAs reported that the resident had previously walked with assistance but, after a potential fall, heavily favored one side, had weakness, screamed out in pain, and complained of hip and leg pain, and that they reported this pain to the nurse. The DON stated that standard steps after a fall included assessing the resident and notifying the provider, among other actions, and said she mentioned the potential fall to the provider; however, there was no documentation that the physician was notified of the resident’s increased pain, constituting the cited failure to notify the provider of a change in condition.
Failure to Protect Resident From Physical Abuse by Another Resident in Common Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from physical abuse by another resident. The facility’s Abuse and Neglect policy states that residents must be free from abuse by anyone, including other residents. Despite this, a physical altercation occurred in a common area when one resident approached a table where two other residents were seated. According to the victim, the assailant shook his fists at her, told her there was not enough room, and then grabbed and forcefully squeezed her hands for about two minutes after she challenged him to "go ahead and try it." A witness reported that the assailant grabbed the victim’s left hand, twisted it with both hands, appeared very angry, and looked like he wanted to hurt her, describing the interaction as the assailant taking things too far and trying to show off his strength. The victim was an older adult with schizoaffective disorder (bipolar type), anxiety, and depressive episodes, but was documented as cognitively intact with a BIMS score of 15/15 and independent in ADLs and mobility. She reported immediate left hand pain rated 7/10, described as pinched nerve pain with shocks, and later reported that three fingers went numb and took a couple of weeks to regain feeling. She also stated that a ring on one finger dug into her hand during the squeezing. Subsequent assessments documented bruising on the backs of both hands and ongoing tingling in three fingers. The victim reported that she had tried to tell her nurse about the incident but was told the nurse already knew from a CNA and was not allowed to report it directly, and she later told the social services worker she wanted to file a restraining order against the assailant. The assailant was an older resident with mild cognitive impairment (BIMS 11/15) and a documented history of behavior symptoms, including poor impulse control, verbal and physical aggression, antagonistic behaviors toward roommates and peers, and the need for staff to intervene to protect the rights and safety of others. Staff and another resident reported that he habitually grabbed mostly women’s hands as they walked by and held on until they had to shake their hands free. Staff also described him as possessive of items and space, including a preferred spot in the common area next to a small table, and noted that he became upset when he perceived others encroaching on what he believed was his. The assailant himself stated that he did not get along with the victim, considered her obnoxious, and admitted that he squeezed her hands because he wanted her to know he was in control. These known behaviors and triggers, combined with his established pattern of grabbing women’s hands in the common area, preceded and contributed to the physical abuse incident in which the victim was not kept free from abuse by another resident. Additional information from resident and staff interviews further described the environment and interpersonal dynamics leading up to the incident. A witness resident stated that the victim approached the table to talk with him, that a few words were exchanged, and that the assailant then grabbed and squeezed the victim’s hand hard enough to cause injury, with the ring digging into her hand. He also confirmed that the assailant had a habit of grabbing women’s hands as they passed by his usual seating area. Nursing staff and CNAs corroborated that the assailant was possessive of his preferred spot and objects, and that he liked to grab women’s hands. The interdisciplinary team note characterized the event as a potential abuse incident in which the victim sat too close to the assailant, who then squeezed her hand. Despite the facility’s policy and the assailant’s documented behavioral history and triggers, the victim was not protected from physical abuse by this resident in the common area. The victim’s mental health care plan, initiated shortly after the incident, documented that she had poor self-awareness and boundaries and could be intrusive with others, which could lead to frustration among peers. Interventions included monitoring interactions with peers and assisting in redirecting and de-escalating as needed. The assailant’s care plan, in place prior to the incident and later revised, documented behavior symptoms such as verbal and physical aggression, argumentative behavior, and the need for staff to monitor his interactions with peers, redirect, de-escalate, and separate him from peers as needed, as well as to intervene to protect the safety of others. Despite these identified needs and risks, the incident occurred in a common area without staff witnessing the altercation, and the victim sustained bruising and reported significant pain and numbness in her hand and fingers as a result of the assailant’s actions.
Failure to Report Injury of Unknown Origin as Potential Abuse/Neglect
Penalty
Summary
Facility staff failed to report an alleged violation of potential abuse/neglect, specifically an injury of unknown origin, to the facility’s abuse coordinator and the State Survey and Certification Agency as required by facility policy and state law. The facility’s Abuse and Neglect policy states that all alleged or suspected abuse/neglect events, including injuries of unknown origin, must be promptly reported and investigated, with designated agencies, including the State Survey and Certification Agency, notified in accordance with state law. The policy further requires that results of all investigations be reported to the administrator and to the state survey and certification agency within five working days of the event. Review of the State Agency reporting portal showed no report submitted by the facility regarding the resident’s injury of unknown origin. The resident involved was an individual over age 65 with diagnoses including unspecified dementia, dysphagia, and anxiety, and had severe cognitive impairment with a BIMS score of 5/15. The resident required maximal assistance with toileting and dressing and moderate assistance with mobility. Nursing documentation showed that on one date the resident complained of right leg pain, and on a later date the resident was yelling out, had a furrowed brow, and complained of left hip pain, for which PRN Tylenol and topical aspercreme with lidocaine were administered. Hospice notes documented increased pain in the left hip radiating to the groin, a new order for morphine, and later a noticeable outward rotation of the right leg with non-verbal signs of pain on inward rotation. Hospice documentation also indicated the resident had not been out of bed for about a week, had pain with cares and rolling in bed, and that staff were pre-medicating with morphine prior to care. Interviews with staff indicated awareness of a potential fall and subsequent pain, but no corresponding report of an injury of unknown origin to the State Agency. An LPN reported that around the beginning of February the resident stopped getting out of bed and complained of pain in her left side. CNAs described the resident as confused but ambulatory with a walker and one-person assistance prior to the incident, and reported hearing about a potential fall. After this potential fall, CNAs observed the resident heavily favoring one side, experiencing significant pain in the hip and leg, grimacing, and being unable to get out of bed, and they stated they notified the nurse when the resident was in pain. Despite these observations and the facility’s stated investigative and reporting process as described by the DON, nurse manager, and NHA, the injury of unknown origin associated with the resident’s pain and functional decline was not reported to the facility’s abuse coordinator or to the State Survey and Certification Agency.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and timely interventions to prevent multiple falls for a resident known to be at high risk for falls. The resident, who had severe cognitive impairments and a history of falls, experienced seven falls over a period of less than two months. These falls were often related to the resident's attempts to self-transfer in and out of bed, particularly around meal times, and were compounded by the resident's incontinence and memory deficits. Despite being aware of the resident's routine and risk factors, the facility did not consistently implement care-planned fall interventions, such as ensuring the bed was in a low position and using a pool noodle for safety. The resident's care plan included various interventions to mitigate fall risks, such as reminders to use a call light, ensuring appropriate footwear, and monitoring for changes in gait and cognition. However, these interventions were not effectively implemented or updated in response to the resident's repeated falls. For instance, the resident was found without the recommended gripper socks or with the pool noodle improperly placed, and staff failed to consistently assist with transfers before and after meals. The facility's failure to adapt and enforce these interventions contributed to the resident's continued falls, one of which resulted in a hip fracture. The facility's documentation and incident reports revealed inconsistencies in the timing and assessment of falls, as well as a lack of timely review by the interdisciplinary team. The resident's falls were often unwitnessed, and the root causes were not adequately addressed. Despite the resident's significant memory deficit and impulsivity, the facility continued to rely on verbal reminders and education, which were ineffective given the resident's cognitive impairments. This lack of proactive and consistent intervention ultimately led to the resident's decline and the decision to place the resident on hospice services.
Failure to Protect Residents from Sexual Abuse by CNA
Penalty
Summary
The facility failed to protect two residents from sexual abuse by a certified nurse aide (CNA). Resident #2, who was cognitively impaired and physically dependent, was sexually abused by CNA #1. The incident was discovered when another CNA entered the room and found CNA #1 in a compromising position at the resident's bedside. The resident was lying in bed fully clothed, and CNA #1 was positioned with his right knee on the bed and his left leg on the floor, facing the resident at the level of her face. When the other CNA entered, CNA #1 jumped off the bed, adjusted his pants, and pulled his shirt down. The resident later confirmed the abuse during an interview. Resident #3, who was cognitively intact but visually impaired, reported that she was also sexually abused by CNA #1 before his suspension. She stated that CNA #1 put something in her hand, which she identified as his penis. This incident was reported to the police, and the facility was informed by the local police and adult protective services about CNA #1's confession to the police regarding the abuse of Resident #3. The facility's policy on abuse and neglect was not effectively implemented, as evidenced by the failure to protect the residents from abuse and the delay in reporting the incidents. The facility's investigation revealed that CNA #1 had been working in the facility since April 2024 and had completed abuse and neglect education before beginning orientation. However, there were no indications that he would engage in sexually abusive behavior, and he was considered a lazy worker by the facility staff.
Removal Plan
- CNA #1 was suspended immediately after the incident was reported and terminated.
- CNA #1 was reported to the appropriate governing agencies, and complaints were filed on his license.
- The facility began education on neglect and abuse to the nursing care staff, including all direct care staff.
- 75% of the direct care staff training was completed, and the remaining staff training was completed.
- Facility-wide education on abuse and neglect was conducted.
- The facility expanded their interview sample and initiated a facility-wide education on abuse and neglect.
Failure to Ensure Proper Functioning of Fall Prevention Alarm
Penalty
Summary
The facility failed to ensure that a floor alarm, which was a care-planned fall intervention for a resident known to be at risk for falls, was properly reset and turned on. This failure led to the resident sustaining a fall that resulted in a fracture of her left femur. The incident occurred when the floor alarm was found to be in the off position at the time of the fall, and staff were not alerted to the resident's movements in her room. Staff interviews confirmed that they were aware of the need to reset the alarm by switching it to the off position and then returning it to the on position, but it was unclear when the alarm was last reset and why it was in the off position at the time of the fall. The resident involved, an 81-year-old with a history of muscle weakness, dementia with behaviors, and previous falls, was moderately cognitively impaired and used a manual wheelchair. She required assistance for most activities of daily living and had been using the floor alarm as an effective fall prevention measure. On the day of the fall, the resident was found sitting on the floor between her bed and the sink area, having attempted to walk towards her door. Initially, she denied pain or injury, but subsequent x-rays revealed a left femur fracture, leading to her transfer to the emergency room. Interviews with staff, including an LPN and a CNA, indicated that they were familiar with the alarm system and had received recent re-education on its use. However, the investigation revealed that the alarm was not properly reset, which directly contributed to the resident's fall. The DON and NHA confirmed that the alarm had been effective in preventing falls for this resident in the past, but the failure to ensure it was turned on at the time of the incident resulted in the deficiency.
Removal Plan
- The facility interviewed all staff on duty who were involved in care for the resident on the day of fall and a few days prior to the fall.
- Inspection of the floor alarm device determined the alarm device was in an off position at the time of the fall and therefore did not alert the staff about the resident's movement in the room.
- All interviewed staff reported that the alarm was functioning well and they heard the sound of it during their shift.
- Staff was aware that in order to reset the alarm after it was triggered, it was necessary to switch it to the off position and return it to an on position.
- It was unclear when the alarm was reset for the last time and why it was in the off position at the time of the fall.
- The last interaction with the resident was reported around 6:30 p.m., about 30 minutes prior to the fall, when a staff member assisted the resident with care.
- All direct care staff who were involved in Resident #58's care and had access to the alarm device were educated on how to reset it and to make sure it was turned on.
- The device was to be checked at the beginning of every shift and on an as needed basis.
- Staff were to ensure it was in the on position after the reset.
- A log was initiated to ensure every shift checked the alarm.
- The interdisciplinary team (IDT) met to review the fall for the Resident #58.
- Medications, care routines, non-pharmacological interventions and resident preferences were reviewed.
- The IDT recommended adding the following interventions and continuing to monitor: Bariatric bed for extended sleep surface, improve lighting in the room, and add an air mattress.
- The facility completed an audit and identified other residents in the building who were at risk for falls.
- Thirteen identified residents were reviewed for appropriate fall interventions and care plans were updated to ensure the accuracy of the interventions.
- Nursing leadership re-educated the nursing staff in regards to reviewing the care plan and Kardex (tool utilized by staff to provide comprehensive care of the residents) as well as the importance of following and implementing interventions outlined in these documents in an effort to reduce the risk of falls for facility residents.
- Audits were initiated to verify fall prevention interventions outlined in the care plans for residents identified to be at risk of falls were in place accordingly via direct observations when rounding as well as via interviews with staff.
- The director of nursing (DON) was responsible for completing the audits weekly for the next four weeks, one a month for the next two months and quarterly for the next three quarters.
- A monthly Report Out, summarizing the findings of the audits, was to be completed and provided to the Quality Assurance Performance Improvement (QAPI) Committee.
- The QAPI Report Out was to be reviewed by the QAPI Committee for compliance and trends and to make additional recommendations as needed for continued improvement.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure the medication error rate was not five percent or greater, resulting in a medication error rate of 7.7%. Specifically, two errors were identified out of 26 opportunities for error. One error involved a certified nurse aide with medication aide authority (CNA-Med) who administered Nebivolol to a resident without checking the resident's blood pressure or heart rate, as required by the physician's order. The CNA-Med stated that the medication administration record (MAR) did not display the necessary heart icon or further instructions to check vital signs before administering the medication. Another error involved a registered nurse (RN) who administered Metoprolol Succinate extended-release tablets to a resident by crushing the medication and mixing it with applesauce, contrary to the manufacturer's recommendations that the medication should be swallowed whole and not chewed or crushed. The RN had checked the resident's vital signs before administering the medication, which were within normal limits, but failed to follow the proper administration guidelines for the extended-release medication. Interviews with the director of nursing (DON) and unit manager (UM) revealed that the medication administration process had lapses, including the failure to properly enter medication orders into the electronic medical record (EMR) and the lack of adherence to physician's orders. The DON and UM acknowledged the importance of following physician's orders and the potential impact of not doing so on resident safety and medication efficacy. They also noted that education had been provided to staff regarding the proper administration of extended-release medications and the need to check vital signs when required by physician's orders.
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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