Kiowa Hills Rehabilitation And Nursing, Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Colorado Springs, Colorado.
- Location
- 924 W Kiowa St, Colorado Springs, Colorado 80905
- CMS Provider Number
- 065175
- Inspections on file
- 23
- Latest survey
- December 10, 2025
- Citations (last 12 mo.)
- 8
Citation history
Health deficiencies cited at Kiowa Hills Rehabilitation And Nursing, Llc during CMS and state inspections, most recent first.
A resident with hemiplegia and other medical conditions did not consistently receive restorative ambulation therapy as recommended by PT. The RNA responsible for providing these services was frequently reassigned to other duties, and the DON was unaware of the required therapy frequency. As a result, the resident received fewer therapy sessions than prescribed, contrary to the PT recommendations.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Staff did not follow menu extensions or recipes during meal preparation, resulting in residents receiving incorrect portion sizes and food items. A resident on a pureed diet was served items not specified in the menu, and residents on regular diets received only half of the required sandwich portion. The dietary manager admitted to not using recipes and noted a lack of training among dietary aides regarding proper portion sizes.
Surveyors observed that food and drink served to residents were not palatable, attractive, or at a safe and appetizing temperature, resulting in a deficiency.
Two residents with cognitive and physical impairments were subjected to physical abuse by another resident with a history of behavioral disturbances. In both cases, the assailant resident physically grabbed the victims, with staff intervening immediately. The incidents were substantiated through staff and resident interviews and record review, confirming that the facility did not prevent the abuse as required by policy.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet needs.
A deficiency occurred when a resident did not receive treatment and care in accordance with physician orders and their documented preferences and goals, resulting in care that was not individualized as required.
A resident at high risk for falls experienced a fall with a major injury due to the facility's failure to ensure a safe environment and adequate supervision. Despite care plan instructions to keep the call light within reach, it was frequently found out of reach, preventing the resident from calling for assistance. Staff failed to update the care plan with new interventions after the fall, and observations showed consistent non-compliance with safety measures.
The facility failed to maintain sanitary conditions in food preparation and storage areas. Dietary aides did not change gloves between tasks, leading to potential cross-contamination. Food items were found unlabeled, undated, or expired, and cleanliness was not maintained, with debris and pests observed in kitchen areas. Additionally, frozen meats were not thawed safely, as they were not fully submerged under running water.
The facility failed to maintain an effective infection control program, with staff not adhering to PPE protocols, failing to offer updated COVID-19 vaccinations, and not following proper hand hygiene during meal delivery. Additionally, wound care practices were inadequate, and glucometers were not disinfected after use, leading to potential cross-contamination.
The facility failed to conduct regular care conferences for three residents, preventing them from participating in their person-centered care plans. Despite the facility's policy requiring resident involvement, there was a lack of documentation and missed meetings over several months. Staff interviews revealed scheduling errors contributed to this deficiency.
The facility failed to maintain a comfortable temperature range in four out of five neighborhoods, with temperatures falling below the required 71 to 81 degrees Fahrenheit. Residents reported feeling cold, and some were visibly shivering. Despite complaints and temporary measures like extra blankets, the heating issues persisted due to incomplete repairs and lack of funding from previous ownership.
The facility failed to administer medications timely for two residents, leading to missed doses of crucial medications for managing conditions like neuropathy and respiratory failure. Additionally, due to a shortage of lancets, staff used insulin syringes for blood glucose testing, causing increased pain for four residents. The DON confirmed the inappropriate practices and lack of documentation regarding missed medication doses.
The facility failed to employ a qualified activities director, resulting in an inadequate activities program that did not meet residents' needs. A resident reported limited and repetitive activities, while the AD lacked necessary qualifications and training. The NHA acknowledged insufficient supervision and communication regarding the activities program.
The facility failed to properly store and label medications, with expired medications found in medication carts and storage rooms, and over-the-counter medications lacking resident labels. Observations revealed expired activon honey, phos-nak supplements, cetirizine, latanaprost, buproprion, amlodipine, and citalapram. Additionally, Genteal tears and saline nasal spray were not labeled with resident names. Interviews indicated a lack of awareness regarding medication disposal and storage protocols.
A resident with no cognitive impairment was denied beverages of choice and appropriate clothing, leading to undignified treatment. Despite no fluid restrictions, staff failed to offer alternatives when the dining room was closed. The resident was observed in a wheelchair wearing only an incontinent brief, and the care plan included inappropriate conditions for receiving beverages. Staff interviews confirmed the need for updated care plans and access to clothing.
A resident with a history of trauma preferred female aides for bathing, but the facility failed to consistently honor this preference. Despite a grievance resolution, the care plan and EMR did not reflect her choice, leading to missed showers and a male aide assisting her on one occasion. Staff interviews revealed a lack of documentation and communication regarding her preferences.
A resident reported missing personal items, including a blanket and socks, to several staff members, but the facility failed to document or follow up on the grievances as required by their policy. Despite the resident's representative informing staff, no grievance form was completed, and the facility did not provide documentation of any investigation or resolution.
A resident in a LTC facility was not provided with meaningful activities or one-to-one staff visits as per their care plan. Despite being cognitively intact and independent, the resident reported limited and repetitive activities, mainly Bingo, and inaccuracies in the activities calendar. The activity director, new to the role and lacking proper training, was unaware of the residents' needs, contributing to the deficiency.
A facility failed to ensure proper hospice service coordination for a resident, lacking a physician's order and updated care plan. The resident, with multiple health issues, reported not seeing a hospice nurse for weeks. The facility did not maintain accessible hospice notes or consistent communication, despite the hospice agency's scheduled visits.
Failure to Provide Consistent Restorative Therapy as Recommended
Penalty
Summary
A resident under the age of 65 with diagnoses including hemiplegia, hemiparesis, major depressive disorder, and type 2 diabetes mellitus did not consistently receive restorative therapy services as recommended by the physical therapy department. The resident was cognitively intact and required varying levels of assistance with activities of daily living. Physical therapy discharge notes recommended a restorative ambulation program five times per week for six weeks to maintain the resident's current level of function, with an excellent prognosis if staff support was consistent. However, restorative nursing notes showed the resident only received therapy on 13 out of 22 possible occasions during the review period. Interviews with the restorative nursing aide (RNA) and the director of nursing (DON) revealed that the RNA was frequently pulled from providing restorative therapy to assist with other duties, such as accompanying residents to outside appointments and working the floor. The RNA confirmed he was unable to provide restorative services according to the resident's plan, and the DON was unaware of the specific frequency required for the resident's restorative program. Both acknowledged that the resident did not receive restorative services as scheduled, resulting in a failure to follow the physical therapy recommendations.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Follow Menu Extensions and Recipes for Resident Meals
Penalty
Summary
The facility failed to ensure that recipes and menu extensions were followed to meet residents' nutritional needs during meal preparation and service. Observations during a dinner meal revealed that residents on regular diets were served only half of a baked Italian sub sandwich instead of the two halves specified in the menu extensions. Additionally, a resident prescribed a pureed diet was served pureed barley soup and a pureed hamburger patty, rather than the required pureed Italian grinder sub and pureed potato salad. The menu extensions also indicated that a pureed brownie should have been served for dessert, but the resident received a pureed chocolate chip cookie and ice cream instead. Record review confirmed that the menu extensions detailed specific portion sizes and food items for both regular and pureed diets, which were not adhered to during meal service. Staff interviews revealed that the dietary manager did not use or follow recipes, was unable to locate them in the dining manager RD program, and acknowledged that dietary aides were not properly trained on portion sizes. The nursing home administrator confirmed that recipes should be followed and recognized the potential concerns related to not doing so, including issues with allergies, safety, and nutritional values.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. Surveyors observed that the food and beverages did not meet these standards during their review. The deficiency was identified based on direct observation of the meals served to residents.
Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, resulting in substantiated incidents of abuse. In the first incident, a resident with a history of cognitive impairment and behavioral symptoms, including aggression and confusion, entered another resident's room without permission and physically grabbed her by the hair. This event was witnessed by staff, who intervened immediately. The victim, who also had moderate cognitive impairment and required some assistance with activities of daily living, did not recall the incident in detail and reported no injury, but staff and the facility's investigation confirmed the physical contact occurred. In a separate incident the following day, the same resident with behavioral disturbances approached another resident near the nurses' station and grabbed her arm. This incident was directly observed by a CNA, who intervened to separate the residents. The victim in this case had significant physical and cognitive impairments, including hemiplegia and dependence on staff for most activities of daily living. She reported no pain or fear as a result of the incident and continued her routine without issue. Both incidents were substantiated by the facility's internal investigations, which included staff and resident interviews, record reviews, and direct observations. The reports indicated that the assailant resident had a documented history of behavioral symptoms and was known to respond to external stimuli with physical contact. The facility's policies required immediate response and increased supervision in such cases, but the incidents occurred nonetheless, resulting in physical abuse of two residents.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs. No further details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when treatment and care were not provided in accordance with physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was individualized and aligned with the documented directives and wishes of the resident, as required by regulation.
Failure to Ensure Safe Environment and Supervision Leads to Resident Fall
Penalty
Summary
The facility failed to ensure a safe environment and adequate supervision for a resident at high risk for falls, leading to a fall with a major injury. The resident, who had a history of falls and a recent femur fracture, was observed multiple times with the call light out of reach, contrary to the care plan instructions. The care plan required staff to keep the call light within reach and to anticipate and meet the resident's needs, but these interventions were not consistently implemented. Observations during the survey revealed that the resident's call light was frequently placed out of sight and reach, either on the floor or under the pillow, despite staff acknowledging the importance of keeping it accessible. On several occasions, staff members, including CNAs and an RN, failed to ensure the call light was within reach, even after entering the resident's room. This lack of adherence to the care plan contributed to the resident's inability to call for assistance, ultimately resulting in a fall while attempting to walk to the sink. The resident's fall care plan was not updated with new interventions following the fall with a fracture, indicating a failure to reassess and modify the care plan to prevent future incidents. Interviews with staff, including the DON, confirmed that the call light placement was inadequate and that the resident required staff assistance for safe transfers. The facility's policy emphasized the importance of implementing and monitoring interventions to reduce accident risks, but these measures were not effectively carried out for this resident.
Sanitation and Food Safety Deficiencies in Kitchen Operations
Penalty
Summary
The facility failed to ensure that food was prepared, distributed, and served under sanitary conditions in both the main and satellite kitchens, as well as in one of the nourishment refrigerators. Observations revealed that dietary aides did not change gloves between tasks, leading to potential cross-contamination of ready-to-eat foods. For instance, a dietary aide used the same pair of gloves to handle lettuce, touch faucet heads, and prepare salads, while another aide used the same gloves to handle meal tickets, serving utensils, and cookies. The dietary manager confirmed that gloves should be single-use and changed between tasks, which was not adhered to during the lunch service. The facility also failed to store food items safely and appropriately. During inspections, several food items in the refrigerators were found to be unlabeled, undated, or past their expiration dates, including cottage cheese, hot dogs, and various containers of fruits and meats. Additionally, a container of sugar was found uncovered with debris in it. The dietary manager acknowledged that items should be labeled and dated, and that the nourishment refrigerators were part of the kitchen's responsibility, which was not being properly managed. Furthermore, the facility did not maintain cleanliness in the kitchen and food service areas. Observations noted debris on the deli meat slicer, soiled floors, and missing tiles in the main kitchen, which had been an issue for several months. Ants were also observed in the satellite kitchen, indicating a pest problem. The dietary manager admitted that deep cleaning was only performed once a month and that the staff did not consistently use cleaning checklists. Additionally, frozen meats were not thawed in a safe manner, as they were not fully submerged under running water, and the packaging was not removed, contrary to the facility's policy and professional standards.
Infection Control Deficiencies in PPE, Vaccination, and Hygiene Practices
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by multiple deficiencies observed during the survey. Staff did not adhere to the required personal protective equipment (PPE) protocols when entering rooms with transmission-based precautions. Specifically, a certified nurse aide and a registered nurse entered rooms without wearing the necessary eye protection, and the isolation cart outside the room lacked the required supplies. The assistant director of nursing, who also acted as the infection preventionist, acknowledged the oversight and indicated that in-the-moment training was provided to staff. The facility also failed to offer updated COVID-19 vaccinations to residents and did not document consent or declination for the 2024-2025 season. The electronic medical records for several residents did not reflect their current vaccination status, and the assistant director of nursing admitted to not having offered the vaccines. The regional clinical resource confirmed that the vaccines were available but had not been administered, and the immunization records were not up to date. Additionally, staff did not follow proper hand hygiene practices during meal delivery, as observed with two certified nurse aides who failed to perform hand hygiene between delivering meal trays to residents. Furthermore, during wound care for a resident, a registered nurse did not change gloves between treating different wound sites, nor did she use a clean barrier under the resident, leading to potential cross-contamination. Lastly, glucometers were not disinfected after each use, as observed with a registered nurse who failed to clean the devices before returning them to their cases, despite each resident having their own glucometer. The assistant director of nursing acknowledged these lapses in infection control practices and indicated that staff education was provided regularly.
Failure to Conduct Regular Care Conferences
Penalty
Summary
The facility failed to ensure that residents had the opportunity to participate in the development and implementation of their person-centered care plans. This deficiency was identified for three residents out of a sample of 33. The facility's policy requires that residents and their representatives be invited to care conferences to discuss and review care plans. However, the facility did not conduct regular care conferences for the involved residents, nor did they maintain adequate documentation of such meetings. Resident #5, who has multiple diagnoses including schizoaffective disorder and diabetes, was not documented to have attended a care conference between July 2024 and January 2025. Although a care conference was held in January 2025, there was no record of any meetings in the interim period. Similarly, Resident #14, who has a history of stroke and diabetes, had no documented care conferences between August 2024 and January 2025. The resident's representative confirmed that they had not been invited to any meetings since the initial one in the summer of 2024. Resident #38, who suffers from dementia and other conditions, also lacked documentation of care conferences since July 2024. The resident's representative stated that they had not been contacted for a meeting in several months. Staff interviews revealed that the social services director was using an incorrect schedule for care conferences, resulting in missed meetings for some residents. The facility's failure to adhere to its policy and maintain proper documentation led to the deficiency in resident participation in care planning.
Facility Fails to Maintain Adequate Heating
Penalty
Summary
The facility failed to maintain a comfortable air temperature range in four out of five neighborhoods, as required by their Quality of Life-Homelike Environment policy. This policy mandates that temperatures should be maintained between 71 to 81 degrees Fahrenheit. Observations and interviews revealed that the ambient temperatures in various areas of the facility were below the required range, with some areas as low as 62.9 degrees Fahrenheit. Residents reported feeling cold, and some were visibly shivering, indicating that the environment was not comfortable or homelike. Interviews with residents and their representatives highlighted ongoing issues with the heating system. Several residents reported that their rooms were cold, and some mentioned that the heating had been inadequate for an extended period. Despite complaints to the maintenance supervisor, the issues persisted, and residents were provided with temporary solutions such as extra blankets. The maintenance supervisor acknowledged the problems and stated that the facility had been experiencing heating issues since before September 2024. The facility's maintenance records showed attempts to address the heating problems, including cleaning and flushing supply lines, adjusting sensors, and recommending repairs. However, some recommended repairs, such as thermostat replacement and pipe blockage repair, were not completed. The maintenance supervisor noted that previous facility ownership did not provide funds for necessary repairs, contributing to the ongoing deficiency in maintaining a comfortable environment for residents.
Medication Administration and Blood Glucose Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure that residents received medications in a timely manner according to physician's orders, affecting two residents. One resident, who was moderately cognitively impaired and had a history of cerebral palsy, quadriplegia, and neuropathy, did not receive prescribed doses of gabapentin and baclofen on multiple occasions due to the medications being on order. The facility's staff did not document any contact with the resident's provider regarding the missed doses, and the Director of Nursing (DON) confirmed the absence of such documentation. The DON acknowledged that the medications were crucial for managing the resident's nerve pain and muscle spasms, and that inconsistent administration could reduce their effectiveness. Another resident, who was cognitively intact and had chronic respiratory failure and anxiety disorder, also missed doses of prescribed medications, including buspirone and Advair, due to them being on order. The facility's staff failed to document any communication with the resident's provider about the missed doses. The DON verified the missed doses and expressed confusion over the documentation, as some doses were marked as administered despite the medications being unavailable. The resident's conditions required consistent medication administration to manage anxiety and respiratory issues. Additionally, the facility failed to use appropriate devices for blood glucose monitoring for four residents. Due to a shortage of lancets, the facility resorted to using insulin syringes with needles to obtain blood samples, which was more painful for the residents. The Assistant Director of Nursing (ADON) directed this practice, and the DON confirmed it was inappropriate. Residents reported increased pain from the needle method, and the Medical Director noted that while it caused more discomfort, there were no long-term consequences. The facility's supply management issues led to the use of inappropriate devices for blood glucose testing.
Unqualified Activities Director Leads to Inadequate Resident Engagement
Penalty
Summary
The facility failed to ensure that the activities program was directed by a qualified professional, as required by the National Certification Council of Activity Professionals (NCCAP). The activities director (AD) lacked the necessary qualifications and experience for the role, having assumed the position without prior experience or training. The AD was not aware of the certification requirements and had not been provided with a mentor or adequate supervision. The previous AD also lacked certification and experience, having transitioned from the maintenance department to the activities role. A resident expressed dissatisfaction with the limited and repetitive activities available, indicating that the facility's activities program did not meet the residents' needs or interests. The resident reported spending the day with nothing to do, highlighting the inadequacy of the activities provided. The initial activities calendar was heavily reliant on a single activity, coffee and news, which constituted half of the scheduled activities for the month. Interviews with facility staff revealed a lack of communication and oversight regarding the activities program. The nursing home administrator (NHA) acknowledged that the consultant responsible for supervising the AD was not aware of the new hire and that monthly supervision was insufficient for an inexperienced AD. The AD had not been informed of the role's requirements, and the consultant had not been contacted to provide necessary training and support.
Improper Storage and Labeling of Medications
Penalty
Summary
The facility failed to ensure that medications and biologicals were properly stored and labeled according to professional standards. During observations, expired medications were found in both the medication carts and the medication storage room. Specifically, seven tubes of activon medical grade honey and a box of phos-nak dietary supplements were found with expiration dates that had already passed. Additionally, a bottle of cetirizine, latanaprost eye drops, buproprion, amlodipine, and citalapram were found with expired dates on the medication cart in the 100 hallway. Furthermore, over-the-counter medications intended for single resident use were not labeled with the resident's name. In the 600 hallway medication cart, a box of Genteal tears and a bottle of saline nasal spray were found without pharmacy labels or resident names. Interviews with RN #1 and the DON revealed a lack of awareness regarding the proper disposal of expired medications and the appropriate duration for using opened medications like latanaprost. The DON acknowledged that the medication carts and storage room should be checked weekly, but was unsure why expired medications were still present.
Resident Denied Dignified Care and Personal Choices
Penalty
Summary
The facility failed to ensure that a resident was treated with respect and dignity, as evidenced by the lack of provision of beverages and appropriate clothing upon request. The resident, who was under 65 years old and had a BIMS score of 15, indicating no cognitive impairment, was denied a beverage of choice when the dining room was closed, and staff did not offer an alternative. Additionally, the resident was observed sitting in a wheelchair wearing only an incontinent brief and was not provided with clothing despite requesting to get dressed. The resident's medical records indicated no fluid restrictions, contradicting a staff member's claim that the resident was on such a restriction. The resident's care plan included inappropriate conditions for receiving beverages, such as keeping his room clean and using the bathroom appropriately. The facility's failure to update the care plan and provide necessary clothing further contributed to the resident's undignified treatment. Interviews with staff and other residents corroborated the resident's claims of unfair treatment. The Social Services Director acknowledged the need for an updated care plan and the availability of donated clothing, while the Nursing Home Administrator confirmed that residents should not be restricted in their choices by a Power of Attorney and should not be required to wear hospital gowns if they wish to dress in regular clothing.
Failure to Honor Resident's Preference for Female Shower Aides
Penalty
Summary
The facility failed to honor a resident's preference for assistance with bathing from female shower aides. The resident, who was cognitively intact and dependent on staff for bathing, expressed a preference for female aides due to a history of trauma and sexual assault. Despite this, the facility did not consistently accommodate her preference, resulting in missed showers when male aides were assigned. The resident's care plan and electronic medical record (EMR) did not reflect her preference for female aides, even though a grievance was filed and resolved with the agreement that only female staff would assist her. The care plan inaccurately stated that the resident had no preference for male or female caregivers, contradicting the resident's expressed wishes and the grievance resolution. Interviews with staff revealed a lack of documentation and communication regarding the resident's preferences. Certified nurse aides (CNAs) and the director of nursing (DON) were unaware of the specific preference for female aides, and the shower book used by staff did not include information on aide preferences. This lack of documentation and communication led to the facility's failure to consistently honor the resident's choice, as evidenced by a male aide assisting the resident with a shower on one occasion.
Failure to Resolve Resident Grievances Promptly
Penalty
Summary
The facility failed to ensure prompt resolution of grievances for a resident who reported missing personal items. The resident, who had no cognitive impairment and required assistance with mobility and personal hygiene, reported a missing blanket and socks to several staff members, including a CNA, a nurse, and the social services director (SSD). Despite these reports, the facility did not document or follow up on the grievances as required by their policy. The policy mandates that grievances be investigated and a report submitted to the administrator within five working days, with findings communicated to the resident. However, no grievance form was completed for the current missing items, and the facility was unable to provide documentation of any investigation or resolution. Interviews with the resident and their representative revealed that the blanket had gone missing before and was found after five weeks, but was missing again. The representative reported the missing items to staff, and the SSD acknowledged being informed about the missing socks only on the day of the survey. The SSD mentioned that the facility would replace the socks if not found, but no grievance form had been completed. The nursing home administrator (NHA) stated that any staff member could report missing items and that a form should be filled out and submitted to the NHA. The facility planned to re-educate staff on the grievance reporting process, but this was not part of the deficiency itself.
Failure to Provide Meaningful Activities for Resident
Penalty
Summary
The facility failed to provide an ongoing program of activities tailored to meet the needs and interests of Resident #16, who was one of three residents reviewed for activities. Resident #16, a 77-year-old with diagnoses including diabetes, heart disease, dementia, and epilepsy, was cognitively intact and independent in daily activities. The resident expressed a strong interest in keeping up with the news, participating in favorite activities, and going outside for fresh air, but did not prioritize group or religious activities. Despite these preferences, the resident reported a lack of meaningful activities and one-to-one staff visits as outlined in his individualized care plan. Observations and interviews revealed that Resident #16 often sat in his room with no TV, music, or reading materials, and reported that the facility's activities were limited and repetitive, mainly consisting of Bingo. The resident also noted that the activities calendar was often inaccurate, with scheduled activities frequently changed or canceled. Despite having a care plan that included independent leisure pursuits and participation in group activities, there was no documentation of activity participation for December 2024 or January 2025, except for a few Bingo sessions in November 2024. Interviews with the activity director (AD) and other staff highlighted a lack of organization and oversight in the activities program. The AD, who had recently assumed the role without proper training or mentorship, was unaware of the residents' needs and the requirements for an activity director in a nursing facility. The AD admitted to not knowing who created the initial January 2025 activities calendar and had to revise it after discovering inaccuracies. The nursing home administrator acknowledged the AD's lack of training and mentorship, which contributed to the deficiency in meeting Resident #16's activity needs.
Deficiency in Hospice Service Coordination
Penalty
Summary
The facility failed to ensure that hospice services provided to a resident met professional standards and principles. Specifically, the facility did not obtain a physician's order for hospice care for a resident who was receiving hospice services. Additionally, the facility did not ensure that the hospice agency's notes were easily accessible to the facility staff, nor did it maintain consistent communication and documentation of hospice care visits and updates. The resident involved was under 65 years old and had multiple diagnoses, including diabetes, respiratory failure, heart failure, and kidney cancer, among others. The resident was cognitively intact and dependent on staff for daily activities. Despite being enrolled in hospice services, the resident reported not having seen a hospice nurse for four to five weeks, indicating a lapse in the expected frequency of hospice visits. The facility's records did not include a physician's order for hospice care, and the hospice care plan had not been updated since a previous hospice agency managed the resident's care. The new hospice agency had been providing services since November, but there was no active physician's order until the survey. The hospice clinical supervisor confirmed that the resident was scheduled for regular visits, but the facility lacked a communication binder and had issues with receiving documentation from the hospice agency.
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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