La Villa Grande Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Junction, Colorado.
- Location
- 2501 Little Bookcliff Dr, Grand Junction, Colorado 81501
- CMS Provider Number
- 065253
- Inspections on file
- 22
- Latest survey
- December 18, 2025
- Citations (last 12 mo.)
- 1 (1 serious)
Citation history
Health deficiencies cited at La Villa Grande Care Center during CMS and state inspections, most recent first.
A resident with multiple chronic conditions was given warfarin twice daily instead of the prescribed once daily due to a failure to discontinue a previous order and inaccurate documentation of INR results. This led to the resident receiving excessive doses of the anticoagulant over several days, with staff not updating the MAR with current INR values or completing scheduled INR testing.
A resident with dementia, mobility issues, and a history of falls experienced three unwitnessed early morning falls within a week, two resulting in injuries, due to the facility's failure to provide adequate supervision, timely physical therapy evaluation, and effective fall prevention interventions. The facility did not identify a pattern in the falls or promptly address contributing factors such as high blood pressure and UTI, leading to repeated incidents and injury.
Several residents were prescribed and, in some cases, administered psychotropic medications such as antipsychotics and antianxiety drugs without proper documentation of clinical indications, targeted behaviors, or physician rationale. In multiple instances, PRN medications were continued beyond recommended timeframes without evidence of need, and behavior monitoring was not consistently documented, leading to inappropriate use of these medications.
The facility did not consistently serve food at safe and appetizing temperatures, with multiple residents reporting that meals were often lukewarm or unpalatable. Surveyors observed delays in tray delivery and found that hot foods were served below required temperatures and cold foods above required temperatures, resulting in poor food quality and dissatisfaction among residents.
Staff did not consistently perform hand hygiene when assisting residents with meals, including after touching potentially contaminated items, and did not use appropriate PPE or follow enhanced barrier precautions for residents with catheters or pressure ulcers. Staff interviews revealed gaps in knowledge and inconsistent access to hand hygiene supplies, and observations showed that required PPE was not available in rooms where it was needed.
A resident was allowed to self-administer a chewable tablet at bedside without a documented assessment or physician's order, contrary to facility policy. Nursing staff permitted the practice based on their judgment, but the required interdisciplinary assessment and care plan update were not completed or documented.
The facility did not provide or post the required State Survey Agency (SSA) contact information, including phone number, address, and email, in an accessible manner. During interviews, several residents reported not knowing how to contact the SSA, and a walk-through confirmed the absence of this information. The NHA acknowledged that the information was not posted.
Multiple incidents occurred where residents with severe cognitive impairments and behavioral histories engaged in physical altercations, including one resident throwing water at another, a resident being kicked after entering another's room, and a resident slapping another following verbal provocation. These events were witnessed by staff and substantiated, but care plans did not always reflect risk for abuse or update interventions after incidents.
A resident with limited mobility and multiple diagnoses was not consistently assisted to ambulate to the dining room as required by the walk-to-dine program, despite clear indications in the Kardex and a green symbol on the wheelchair. Staff routinely transported the resident by wheelchair, and interviews revealed confusion about program participation and inadequate communication following discharge from PT. The care plan was not updated to reflect the ambulation intervention.
A facility failed to keep its medication error rate below 5%, with two errors observed out of 26 opportunities. An RN administered an eye drop formulation instead of the prescribed gel and documented a Calcium Carbonate tablet as given even though a resident declined it and kept it at bedside for self-administration without proper assessment or physician order.
The facility failed to maintain sanitary conditions in the kitchen, with issues in food storage and handling. Observations included dented cans, moldy and undated produce, and improper hand hygiene during meal preparation. Staff interviews revealed a lack of routine checks for food freshness and labeling, contributing to the deficiencies.
The facility failed to manage fluid intake for a resident with chronic kidney disease, leading to fluid overload and hospitalization. Additionally, another resident with diabetes did not receive proper education on dietary adherence, and her care plan was not updated to reflect her refusals. Staff interviews revealed confusion about fluid restriction orders and a lack of communication regarding dietary non-adherence.
Significant Medication Error in Warfarin Administration and Monitoring
Penalty
Summary
A significant medication error occurred when a resident with a history of hypertension, kidney disease, diabetes, stroke, and left-sided paralysis was administered warfarin, a blood-thinning medication, twice daily instead of the prescribed once daily at bedtime. The resident was admitted from the hospital with orders for warfarin and regular INR (international normalized ratio) monitoring to manage stroke risk. The initial physician's order specified warfarin 1 mg in the morning, with daily INR monitoring for dose adjustments. After an INR result was communicated to the physician, a new verbal order was given for warfarin 1.5 mg to be administered once daily in the evening, along with instructions to document the most recent INR and schedule the next INR test. However, the verbal order did not include discontinuation of the previous morning dose, resulting in the resident receiving both the morning and evening doses of warfarin from August 28 to September 9. During this period, facility nurses failed to update the medication administration record (MAR) with the most recent INR result from August 26, instead repeatedly documenting an outdated hospital INR result from August 22. The scheduled INR test for August 29 was not completed, and the error in warfarin administration continued until a subsequent INR test on September 10 revealed an elevated level of 4.5. The facility's medication administration policy required medications to be given as prescribed and for staff to contact the prescriber if a dosage appeared inappropriate or excessive. The anticoagulation protocol also required the use of a warfarin flow sheet to track dosage and response. Despite these policies, the failure to discontinue the prior warfarin order, lack of accurate INR documentation, and omission of scheduled INR testing led to the resident receiving excessive doses of warfarin over a prolonged period.
Failure to Provide Adequate Supervision and Timely Interventions for Fall Prevention
Penalty
Summary
The facility failed to ensure adequate supervision and timely interventions to prevent accidents for a resident with a high risk of falls. The resident, who had diagnoses including dementia, a history of falls, gait abnormalities, weakness, and insomnia, was admitted with significant cognitive impairment and required partial to moderate assistance with activities of daily living. Despite a physician's recommendation for a physical therapy (PT) evaluation and a transition to a walker without wheels for safety, the resident continued to use a four-wheel walker, and the PT evaluation was not conducted until nearly two weeks later. Within a short period, the resident experienced three unwitnessed falls, all occurring in the early morning hours when she got out of bed independently. Two of these falls resulted in injuries, including facial bruising and a head laceration requiring hospital treatment and stitches. The facility did not identify a pattern in the timing or circumstances of the falls, nor did they implement targeted interventions to address the repeated early morning incidents. Additionally, the resident's medical records indicated that she developed high blood pressure and a urinary tract infection (UTI) during this period, both of which increased her risk for falls, but these factors were not promptly identified or addressed in the fall prevention plan. The facility's fall protocol required staff to investigate causes of falls within 24 hours and to monitor and adjust interventions as needed. However, the resident's care plan and post-fall investigations did not reflect timely or effective changes in response to the repeated incidents. The resident continued to use unsafe equipment, was not provided with recommended therapy services in a timely manner, and did not receive increased supervision or specific interventions during the high-risk early morning hours. Staff interviews confirmed gaps in communication, delayed implementation of interventions, and a lack of recognition of the fall pattern.
Failure to Justify and Document Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that psychotropic medications, including antipsychotics and antianxiety drugs, were only prescribed and administered when clinically justified and properly documented. Multiple residents were prescribed PRN (as needed) psychotropic medications without clear documentation of a diagnosed specific condition or indication for use, as required by facility policy. In several cases, there was no evidence in the medical records or progress notes that residents exhibited behaviors or symptoms warranting the use of these medications, and behavior monitoring was either not documented or not transcribed onto the appropriate records. For example, one resident with chronic kidney disease and bipolar disorder was prescribed PRN olanzapine and lorazepam for agitation and anxiety, but there was no documentation of any episodes of agitation, anxiety, or related behaviors prior to the prescription. Staff interviews confirmed that the resident had not displayed aggressive or anxious behaviors, and there was no place in the electronic medical record to document such behaviors if they occurred. Similarly, another resident with severe dementia and psychotic disturbance was continued on a high dose of olanzapine despite only one documented episode of verbal aggression and paranoid delusions over several months. The rationale for continuing the medication at a higher-than-recommended dose was based on a single poor interaction with family, without ongoing documentation of targeted behaviors. Additionally, two other residents were prescribed PRN antianxiety medications for extended periods beyond the 14-day limit without proper physician rationale or evidence of anxiety. In one case, the only rationale provided for extending a PRN diazepam order was the resident's hospice status, which was later discontinued without updating the medication order or rationale. In another case, a resident was prescribed PRN lorazepam for anxiety or shortness of breath, but neither the resident nor their family reported a history of anxiety, and there was no documentation of anxiety or use of the medication. The facility's failure to document clinical indications, monitor behaviors, and ensure appropriate prescribing practices led to the deficiency.
Failure to Serve Palatable and Appropriately Tempered Food
Penalty
Summary
The facility failed to consistently serve food that was palatable, attractive, and at appropriate temperatures, as required by its own policy. The policy specified that hot food should be held at 135 degrees Fahrenheit or above and cold food at 41 degrees or below until served. However, observations and interviews revealed that food was often served lukewarm or cold, and residents reported dissatisfaction with the taste and temperature of their meals. Multiple residents stated that hot food was not always warm, meat was dry and tasteless, and food sometimes did not taste good. Resident council minutes from two consecutive months also documented complaints about meals being lukewarm or not hot enough, especially for those receiving room tray service. Surveyors observed delays in meal tray delivery, with carts sitting in the hallway for several minutes before trays were distributed. During one observation, a meal cart sat for six minutes before delivery began, and in another, the cart door was left open while waiting for an alternate meal to be prepared, further compromising food temperature. A test tray evaluated by surveyors after all trays were delivered showed that all hot food items were served at temperatures well below the required 135 degrees Fahrenheit, and a cold dessert was served above the required 41 degrees, resulting in unpalatable food temperatures and poor food quality. Staff interviews confirmed awareness of the issues, with the dietary manager acknowledging resident complaints about food temperature and quality, and noting that delays in tray delivery contributed to the problem. The director of nursing stated that timely delivery of trays was necessary to maintain appropriate food temperatures. The registered dietitian also noted that food not served warm would not be as appetizing. These findings demonstrate a failure to ensure that food was consistently served at safe and appetizing temperatures, as required by facility policy.
Failure to Ensure Consistent Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
Staff failed to consistently perform hand hygiene when providing meal assistance to residents. During a lunch meal observation, a CNA used alcohol-based hand rub (ABHR) before assisting residents but subsequently touched her nose, picked up a pen from the floor, and continued to assist residents without reapplying ABHR. The CNA also picked up an ABHR cap from the floor and then assisted a resident with her beverage without performing hand hygiene. Another CNA provided meal assistance to two residents without performing hand hygiene between assisting each resident. Both CNAs acknowledged in interviews that hand hygiene should be performed before and between assisting residents, but one CNA reported not having ABHR available due to supply shortages. The facility's infection prevention and control program policy requires staff to adhere to hand hygiene practices to prevent the spread of infections. However, observations revealed that staff did not consistently follow these practices, particularly during meal assistance. Staff interviews indicated gaps in knowledge and inconsistent access to hand hygiene supplies, with one CNA stating her ABHR was in her backpack and the supply cabinet was empty. The infection preventionist (IP) and director of nursing (DON) confirmed that hand hygiene training was provided at hire and during outbreaks, but could not specify when the last training occurred, and the clinical consultant could not find recent training records related to hand hygiene during meal assistance. Additionally, the facility failed to ensure the use of enhanced barrier precautions (EBP) and appropriate personal protective equipment (PPE) for residents with conditions such as urinary catheters and pressure ulcers. Multiple observations showed that rooms of residents requiring EBP lacked PPE supplies, and staff did not don PPE when providing direct care. Staff interviews revealed a lack of awareness regarding EBP requirements, with some staff believing only gloves were necessary for residents with catheters or pressure ulcers. The infection preventionist stated that residents with these conditions should be on EBP and that staff should use gloves and gowns, but this was not consistently implemented.
Failure to Assess Resident for Self-Administration of Medication
Penalty
Summary
The facility failed to ensure that a proper assessment was conducted to determine if a resident was clinically appropriate to self-administer medications. According to facility policy, the interdisciplinary team is required to assess each resident's cognitive and physical abilities before allowing self-administration of medications, and this decision must be documented in the medical record and care plan. In the case reviewed, a resident over the age of 65 with diagnoses including GERD and osteoporosis, and who was cognitively intact but required moderate assistance with some activities of daily living, was observed to have a medication cup with a chewable tablet left at the bedside at her request. Nursing staff allowed the resident to keep the medication at her bedside and self-administer it, but there was no documentation of a formal assessment or a physician's order permitting self-administration. Interviews with nursing staff revealed that while some staff felt it was safe for the resident to self-administer the medication, they could not recall if a formal assessment had been completed. The DON confirmed that policy requires a self-administration assessment, physician notification, and care plan update, but acknowledged that no such assessment had been completed for this resident. Review of the electronic medical record confirmed the absence of documentation for a self-administration assessment or a physician's order for the resident to self-administer the medication.
Failure to Post State Survey Agency Contact Information
Penalty
Summary
The facility failed to ensure that residents received notices both orally and in writing, including a written description of their legal rights, in a format and language they could understand. During a group interview with five interviewable residents, all stated they were unaware they could contact the State Survey Agency (SSA) and did not know where to find the SSA's contact information. Observations during a facility walk-through confirmed that the required SSA contact information, including phone number, address, and email address, was not posted in any accessible location. The nursing home administrator also confirmed that the necessary contact information was not posted within the facility.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect residents from abuse, specifically physical abuse and altercations between residents, as evidenced by multiple incidents involving three residents with severe cognitive impairments and behavioral histories. In one incident, two residents with dementia and histories of agitation and aggression engaged in an altercation at a lunch table, where one resident threw water at the other. Both residents had documented behavioral care plans, but the care plan for the resident who was the victim did not indicate a risk for abuse or prior victimization. The incident was witnessed by a CNA, and both residents were subsequently monitored, but the event itself was substantiated as it occurred. Another incident involved a resident entering another resident's room and physically kicking her after being asked to leave. The assailant had a documented history of wandering, intrusiveness, and physical aggression, with care plan interventions focused on redirection and monitoring. However, after the physical altercation, the care plan did not reflect new interventions specific to the incident. The event was witnessed by a CNA, and the victim was checked for injury, but the documentation did not indicate a comprehensive assessment for injury at the time of the incident. A further altercation occurred when one resident verbally provoked another, resulting in the provoked resident slapping the other in the face. Both residents had severe cognitive impairments and behavioral symptoms, with care plans addressing their aggression and agitation. The incident was witnessed by both an RN and a CNA, and the residents were separated. The documentation confirmed that neither resident recalled the incident, but the physical contact was substantiated. These events demonstrate that the facility did not prevent or adequately address resident-to-resident physical abuse, as required by policy.
Failure to Provide Consistent Ambulation Services for Resident on Walk-to-Dine Program
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with limited range of motion consistently received appropriate restorative nursing services to maintain ambulation, as outlined in the facility's policy. The resident, who had diagnoses including functional quadriplegia, history of falls, altered mental status, and fibromyalgia, was dependent on staff for several activities of daily living and required moderate assistance with transfers and repositioning. Despite being identified for the walk-to-dine program, which was intended to help maintain mobility by assisting the resident to ambulate to the dining room, staff routinely transported the resident by wheelchair without offering ambulation assistance. Observations showed that staff did not offer to ambulate the resident to the dining room, instead wheeling her in a wheelchair. The resident reported that she was only assisted to walk to the dining room once in the past two weeks, despite a green card on her wheelchair indicating participation in the walk-to-dine program. The resident expressed concern about losing her ability to ambulate due to the lack of consistent participation in the program. The Kardex instructed staff to offer ambulation assistance for every meal, but the resident's care plan was not updated to reflect this intervention. Interviews with staff revealed confusion about the meaning of the green walking man symbol and uncertainty regarding which residents were on the walk-to-dine program. The director of rehabilitation confirmed that the program was intended to maintain residents' physical abilities and that staff should have been educated about the resident's participation. However, there was no clear documentation or communication in the electronic medical record to confirm that staff were informed about the resident's status in the program after discharge from physical therapy.
Medication Error Rate Exceeds Acceptable Threshold Due to Administration and Documentation Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, with a calculated error rate of 7.69% based on two errors out of 26 observed opportunities. During medication administration, a registered nurse (RN) administered Genteal moisturizing eye drops instead of the Genteal moisturizing gel as ordered by the physician for a resident with dry eyes. The nurse did not clarify the discrepancy with the physician before administering the medication, despite the order specifying the gel formulation. Additionally, the same RN attempted to administer a scheduled dose of Calcium Carbonate chewable tablet to the resident, who declined to take it and requested to keep it at her bedside for later self-administration. The RN left the medication at the bedside and documented it as administered in the medication administration record (MAR), even though the resident had not taken it. The resident had not been assessed or authorized by a physician for self-administration of medications. Interviews with staff confirmed that the nurse should have clarified the medication order and should not have documented the medication as administered without witnessing its consumption.
Sanitation and Food Handling Deficiencies in Kitchen
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner, as observed in the kitchen. Specifically, the facility did not ensure the safe and appropriate storage of food items in the refrigerators and pantry. Observations revealed a can of corn with a large and deep dent on the side, which was stocked on the can goods rack in the dry storage room. In the walk-in refrigerator, multiple containers of undated strawberries were found, with four containers containing moldy strawberries. Additionally, pre-bowled berries, a tub of lettuce, and a tub of cheese were not labeled or dated, and some of these items were served during the lunch meal service. The facility also failed to ensure that ready-to-eat foods were handled in a sanitary manner to prevent cross-contamination. During the lunch meal service, a cook was observed touching her head and continuing to plate meals without performing hand hygiene. Another cook donned a glove without washing hands beforehand, handled meal tickets with the gloved hand, and then used the same glove to place hamburger patties on a skillet. These actions were contrary to the professional standards outlined in the Colorado Retail Food Establishment Regulations and the facility's own policies. Interviews with staff, including the dietary manager and cooks, revealed a lack of routine checks for produce freshness and proper labeling. The dietary manager acknowledged the risks associated with dented cans and moldy produce, emphasizing the need for proper labeling and dating of food items. The infection preventionist confirmed that hand hygiene training was provided, but the observed practices during the meal service indicated non-compliance with these standards.
Deficiencies in Fluid Management and Dietary Education
Penalty
Summary
The facility failed to ensure services provided met professional standards of practice for two residents. For one resident with chronic kidney disease and other health issues, the facility did not effectively monitor and manage fluid intake, leading to fluid overload and hospitalization. Despite a physician's order for a fluid restriction, the resident's fluid intake exceeded the prescribed limits on multiple occasions. The facility's documentation did not reflect any interventions to address the resident's significant weight gain, and the fluid restriction orders were misinterpreted as per shift rather than per day, resulting in excessive fluid intake. Another resident, who had type two diabetes and other health conditions, did not receive adequate education regarding the risks of not adhering to her diabetic diet. The resident frequently refused to comply with her dietary recommendations, and there was no documentation of education provided to her about the importance of diet adherence. The resident's care plan was not updated to reflect her refusals to follow the recommended diet, and the facility did not document any discussions with the resident about her dietary choices during care conferences. Interviews with staff revealed a lack of clarity and communication regarding dietary and fluid restriction orders. The registered dietitian was not informed of the resident's non-adherence to the diet, and there was confusion among staff about the interpretation of fluid restriction orders. The facility's policies on hydration and care planning were not effectively implemented, contributing to the deficiencies in care for the residents.
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.
Trusted data from CMS and state health departments
Every citation, penalty and Plan of Correction is sourced from public CMS records (latest release June 24, 2026) and official state health department websites — never guesswork.
Trusted by long-term care providers and associations.
