Life Care Center Of Westminster
Inspection history, citations, penalties and survey trends for this long-term care facility in Westminster, Colorado.
- Location
- 7751 Zenobia Ct, Westminster, Colorado 80030
- CMS Provider Number
- 065358
- Inspections on file
- 21
- Latest survey
- March 19, 2026
- Citations (last 12 mo.)
- 1
Citation history
Health deficiencies cited at Life Care Center Of Westminster during CMS and state inspections, most recent first.
A resident with a history of falls, fractures, and significant mobility impairment experienced an unwitnessed fall from bed, which had been left in a high position despite care-plan interventions requiring it to be kept low with a fall mat. An RN found the resident on the floor, initiated neuro checks, and documented elevated BP readings and pain but did not complete or document a thorough head-to-toe assessment before moving the resident back to bed, and did not promptly notify the MD, hospice, or the resident’s representative. Hospice was contacted several hours later due to rising BP and severe pain; a hospice RN then assessed the resident, notified the on-call MD, and obtained an order to transfer the resident to the hospital, where imaging revealed multiple fractures and a scalp contusion. Staff interviews and facility policy confirmed that standard practice required immediate RN assessment prior to moving a fallen resident, timely MD and family notification, and adherence to fall-prevention interventions, all of which were not followed in this case.
A resident at risk for pressure injuries developed an unstageable pressure ulcer on the left heel after staff failed to implement and document appropriate heel protection and offloading interventions. Despite the presence of risk factors and early signs of skin breakdown, the care plan was not updated, and heel protection devices were not used while the resident was in bed or a wheelchair. Staff interviews revealed gaps in awareness and execution of pressure injury prevention protocols.
The facility's medication error rate was found to be 13%, exceeding the acceptable threshold, due to multiple instances where LPNs were unable to locate and administer prescribed medications, including both prescription and over-the-counter drugs, and in some cases failed to notify the physician. The DON confirmed there was no formal system for tracking medication availability, contributing to these errors.
Residents repeatedly reported insufficient CNA coverage, long call light wait times, and lack of hot water for showers during resident council meetings and interviews. Despite these ongoing grievances, facility leadership did not implement effective solutions, and documentation showed persistent issues with missed showers, delayed assistance, and inadequate monitoring of call light response times, particularly during evenings and weekends. Staff interviews confirmed that short staffing and reliance on agency personnel contributed to unresolved resident concerns.
Three residents were found to be receiving psychotropic medications without proper clinical justification, mood and behavior monitoring, or documentation of target behaviors. One resident was on three antidepressants with no documented rationale, while two others lacked specific care plans and tracking for their psychotropic medication use. Staff interviews confirmed the absence of required monitoring and documentation practices.
The facility did not provide or document required annual abuse prevention and reporting training for multiple staff, including CNAs, an RN, and an LPN. Review of records and staff interviews confirmed that mandated education on abuse, neglect, exploitation, and reporting procedures was not completed as required by facility policy.
Two residents did not consistently receive showers according to their expressed preferences and care plans, with one resident missing showers on preferred days for family visits and another missing scheduled weekly showers due to equipment issues and lack of rescheduling. Staff were unaware of specific resident requests and documentation errors contributed to the deficiency.
A resident with multiple chronic conditions reported concerns about the care and communication provided by a CNA, including infrequent changes and perceived rudeness. The resident voiced these concerns to several staff members and submitted a formal grievance, but there was no documented follow-up or resolution for several months. Staff interviews confirmed awareness of the complaint but indicated that no action was taken until the day of the survey interview, contrary to the facility's grievance policy requiring prompt resolution.
A resident with multiple chronic conditions was not consistently given prescribed medications, including pain medication, inhalers, and supplements, due to repeated unavailability in the facility. Staff interviews revealed there was no formal system to track or ensure the availability of over-the-counter medications, and communication about shortages only occurred after medications were already missing. The pharmacy confirmed timely refills, but the DON and PCP were not fully aware of the missed doses, and documentation did not consistently show physician notification.
A resident with moderate cognitive impairment and depression received antipsychotic medication without adequate documentation of diagnosis or indication in the EMR. For four consecutive months, pharmacy consultation reports recommended updates and monitoring, but the DON did not distribute these recommendations to physicians, resulting in no physician review or documentation of actions taken.
The facility did not ensure that two residents on long-term prophylactic antibiotics had documented physician rationale, specified duration, or ongoing monitoring and reassessment of their antibiotic use. Staff interviews confirmed a lack of specific monitoring or care planning for chronic antibiotic therapy, and the required documentation was missing from the medical records.
The facility failed to honor the beverage preferences of three residents, specifically their choice to have soda with dinner. Despite being cognitively intact and requiring assistance with daily activities, residents reported feeling disregarded and upset by the restriction, which only allowed soda during lunch. Staff interviews revealed inconsistencies in the availability of soda, with the food service director claiming it was available on beverage carts, while the nursing home administrator cited concerns about hoarding as a reason for the restriction.
The facility failed to ensure timely responses to residents' call lights, affecting their right to a dignified existence. Two residents reported feeling neglected due to long wait times for assistance, with delays ranging from 30 minutes to three hours. Observations showed staff, including the NHA and DON, did not promptly address activated call lights, with delays of up to 14 minutes. A CNA expressed concerns about inadequate staffing levels, and the NHA acknowledged the expectation for a 15-minute response time.
A resident with cerebral palsy, requiring a mechanical lift for transfers, was improperly transferred by an agency CNA who ignored the care plan and attempted a stand and pivot transfer. This resulted in the resident sustaining an acute fracture of the left femur. The facility's investigation confirmed the neglect, and the agency CNA was prohibited from returning.
Failure to Assess, Notify, and Respond Appropriately After Unwitnessed Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards following an unwitnessed fall. A cognitively intact resident with a history of falls, prior fractures (including a right humerus fracture), osteoarthritis, muscle weakness, and difficulty walking was admitted with orders and care plan interventions that included keeping the bed in the lowest position, use of a high-impact fall mat, and a lipped mattress. The resident required maximal assistance with transfers and used a wheelchair. On the night of the incident, the resident was found on the floor on her left side in a somewhat fetal position, partially on and partially off the fall mat, with the bed raised in a high position. RN #1, who heard a loud sound and discovered the resident on the floor, documented an initial assessment that included vital signs showing elevated blood pressure and initiation of neurological monitoring. However, there was no documentation that RN #1 completed a thorough head-to-toe assessment before the resident was moved back to bed, despite facility policy requiring a nurse evaluation to determine presence of injury prior to moving a resident who has fallen. The record lacked evidence of a full assessment of injuries at the time of the fall, even though the resident later was found to have multiple fractures and a scalp contusion. Staff interviews, including from the DON and other nurses, confirmed that standard practice and policy required a complete RN assessment before moving a resident after a fall. Following the fall, RN #1 did not notify the physician, the resident’s representative, or hospice at the time of the incident, despite facility policy and staff statements that the physician and responsible party should be notified immediately after the assessment. The resident’s blood pressure continued to rise over several hours, and she complained of pain, yet the first notification was to hospice at 6:00 a.m., approximately three hours after the fall. The hospice RN arrived around 6:30 a.m., found the resident arousable to verbal stimuli with tense features, facial grimacing, and reporting severe pain, and then notified the on-call physician, who ordered transfer to the hospital. Hospital imaging revealed a left parietotemporal scalp contusion, an acute nondisplaced C7 vertebral fracture, multiple displaced fractures of at least the first six left ribs, a left scapula fracture, and a left clavicle fracture. The facility also failed to ensure the resident’s bed was maintained at a safe, low height as care-planned, and the transfer to the hospital did not occur until after hospice assessment and physician notification several hours post-fall. The resident’s representative reported that the resident lay in bed for three hours in severe pain without medical attention and that the family and physician were not notified by facility staff, but rather by hospice. Documentation showed that the facility did not contact the resident’s representative until later that afternoon, after the hospital had already identified multiple fractures and the resident was being admitted to intensive or trauma care. Staff interviews, including from CNAs, an LPN, an RN, and the DON, consistently described that facility practice required immediate RN assessment before moving a resident, prompt vital signs and neurological checks, and immediate notification of the physician and responsible party after a fall, particularly if there was pain or potential major injury. In this case, the facility failed to accurately and timely assess the resident after the fall, failed to promptly notify the physician and responsible party, did not ensure the bed was at the lowest and safest height, and did not ensure timely transfer to the hospital after an unwitnessed fall that resulted in major injury and pain. The facility’s own fall care plan and incident policy emphasized prevention of avoidable accidents, completion of a nurse evaluation prior to moving a resident who has fallen, and documentation of injury status and notifications. Despite these requirements, the EMR lacked a full head-to-toe assessment at the time of the fall, and the DON acknowledged that RN #1, an agency nurse, failed to document the fall appropriately, complete an accurate assessment, and notify the physician and the resident’s representative. The hospice RN confirmed that RN #1 did not notify the physician or the resident’s representative and that hospice was contacted due to the resident’s increased pain and rising blood pressure. These actions and omissions collectively led to the cited deficiency for failure to provide treatment and care in accordance with professional standards and the resident’s care plan following the fall.
Failure to Implement Heel Protection Leads to Unstageable Pressure Ulcer
Penalty
Summary
A resident was admitted for long-term care and identified as being at risk for developing pressure injuries, with no wounds present upon admission. Despite this risk, the facility failed to implement and document appropriate preventative measures, particularly for heel protection, after a slightly darkened area was first noted on the resident's left inner heel. There was no evidence in the medical record that the area was monitored or that interventions were put in place to prevent further skin breakdown between the initial finding and the development of an open wound. On a later date, the resident developed a new open area on the left inner heel, which progressed to an unstageable pressure ulcer as documented by both nursing staff and a wound care physician. Observations revealed that the resident did not have heel protection devices in place while in bed or in a wheelchair, and both heels were seen resting directly on hard surfaces. The care plan was not updated to include interventions for heel protection, and there were no physician's orders for pressure-relieving devices or heel offloading before or after the wound developed. Interviews with nursing staff indicated a lack of awareness and implementation of heel offloading interventions, with some staff unaware of the wound's origin or the need for specific protective measures. The wound care physician confirmed that the injury could have been prevented with timely offloading and repositioning. The director of nursing acknowledged that high-risk residents should have soft pressure-relieving devices and regular monitoring, but these measures were not documented or observed in practice for this resident.
Medication Error Rate Exceeds Acceptable Threshold Due to Missed Doses and Tracking Failures
Penalty
Summary
The facility failed to maintain a medication error rate below five percent, resulting in a calculated error rate of 13% with four errors out of 29 observed opportunities. During medication administration, staff were unable to locate prescribed medications, including Vitamin A and cranberry tablets for one resident, and amlodipine for another resident. In these instances, the medications were not administered as ordered, and in some cases, the physician was not notified of the missed doses. Additionally, an LPN mistakenly prepared simethicone instead of sodium bicarbonate for a resident, but recognized the error before administration. Interviews with staff revealed a lack of a formal system to track the availability of over-the-counter medications, and inconsistent communication regarding medication supply. The DON stated reliance on unit managers, central supply, and floor nurses to ensure medication availability, but acknowledged the absence of a structured process. The observed failures to administer medications as prescribed and to notify physicians as required contributed directly to the elevated medication error rate.
Failure to Resolve Resident Council Grievances Regarding Staffing and Shower Conditions
Penalty
Summary
The facility failed to promptly resolve grievances raised by the resident council regarding insufficient floor staff, long call light wait times, and lack of hot water for showers. Multiple residents, including the resident council president and vice president, reported repeated issues during interviews and resident council meetings. Residents described frequent staff shortages, especially on evenings and weekends, resulting in long waits for assistance with activities of daily living (ADLs), pain medication, and showers. Several residents also noted that agency staff were unfamiliar with their care needs, and that the facility no longer felt like a home. Resident council meeting minutes over several months documented ongoing concerns about missed or delayed showers, cold water in the shower rooms, and inadequate CNA coverage, particularly on weekends. Despite these concerns being raised repeatedly, the meeting minutes did not indicate specific actions taken to ensure residents received scheduled showers or that the hot water issue was resolved. The facility leadership acknowledged the problems and stated that efforts were being made to hire more staff and address the water issue, but the same concerns persisted in subsequent meetings. Call light observation logs revealed that monitoring was not conducted during evening, night, or weekend shifts, and documented wait times ranged from one to over 50 minutes. Staff interviews confirmed that staffing shortages led to delayed responses to call lights and unmet resident care needs. Maintenance staff were only recently made aware of the hot water issue, despite residents having reported it for several months. The DON and NHA both acknowledged ongoing staffing challenges and the reliance on agency staff, which contributed to the unresolved grievances.
Failure to Justify and Monitor Psychotropic Medication Use
Penalty
Summary
The facility failed to ensure that residents were as free from unnecessary psychotropic medications as possible, as evidenced by the lack of appropriate clinical justification, monitoring, and documentation for the use of such medications in three out of five residents reviewed. For one resident, there was no documented physician rationale for the concurrent use of three antidepressant medications, despite the resident experiencing significant drowsiness and sleeping up to sixteen hours per day. The physician could not recall if a rationale for the use of multiple antidepressants was documented, and the medical record did not provide justification for the continued use of trazodone in the context of excessive sleep. Two other residents were found to be receiving psychotropic medications, including antidepressants and antipsychotics, without proper mood and behavior monitoring or documentation of target behaviors to justify the use of these medications. Their care plans did not specify which behaviors or symptoms were being targeted by the medications, and there was no mood or behavior tracking documented in their treatment administration records. Additionally, one resident was prescribed an antipsychotic without a documented diagnosis or adequate indication for its use in the medical record. Staff interviews confirmed that the facility did not have a system in place for mood or behavior tracking related to psychotropic medication diagnoses, and only tracked medication side effects. The social services assistant, pharmacy consultant, and DON all acknowledged the absence of specific mood and behavior care plans and tracking, which are necessary to evaluate the effectiveness and ongoing need for psychotropic medications. The facility's own policy required documentation of adequate indications for medication use and proper monitoring, which was not followed in these cases.
Failure to Provide Required Annual Abuse Prevention Training to Staff
Penalty
Summary
The facility failed to provide required annual training to staff on abuse identification, prevention, and reporting, as well as education on neglect, exploitation, and misappropriation of resident property. Record review revealed that five staff members, including three certified nurse aides, one registered nurse, and one licensed practical nurse, did not have documentation of having completed the mandated annual abuse training within the past 12 months. The facility's policy requires all employees to receive orientation and ongoing training on abuse prevention and reporting, including bi-annual in-service training, but there was no evidence that this was completed for the staff reviewed. Interviews with the nursing home administrator (NHA) and director of nursing (DON) confirmed the lack of documentation for the required training. The NHA, who had been in the role for three months, was unable to locate records of abuse in-service training for the identified staff. The DON, who assumed responsibility for staff education after the previous staffing coordinator resigned, also could not confirm that the training had been completed. This lack of training and documentation directly led to the deficiency cited by surveyors.
Failure to Honor Resident Shower Preferences and Care Plans
Penalty
Summary
The facility failed to honor and facilitate resident choices regarding shower schedules for two residents out of a sample of four, as required by their care plans and expressed preferences. One resident, who was cognitively intact and independent in activities of daily living but required supervision for showers, consistently requested showers on Saturdays and Wednesday mornings to accommodate family visits and personal appointments. Despite these requests, the resident continued to receive showers on Mondays and Thursdays, and on one occasion, did not receive a shower at all after waiting the entire day. Documentation inconsistencies were also noted, with staff marking a shower as given when it was not provided. Another resident, also cognitively intact but fully dependent on staff for all activities of daily living due to end-stage multiple sclerosis and quadriplegia, was scheduled for one shower per week on Sundays. The resident reported that if a Sunday shower was missed, it was not rescheduled, resulting in missed opportunities for personal hygiene. On at least two occasions, the resident did not receive a shower as scheduled, including one instance where the preferred shower chair was unavailable and alternative options were declined by the resident. Staff interviews revealed a lack of awareness regarding the residents' specific preferences and missed showers. The DON stated that the facility attempted to honor shower requests as staffing allowed but was not aware of the residents' specific needs or the missed showers. Documentation errors and communication gaps contributed to the failure to provide showers according to resident choice and care plans.
Failure to Promptly Resolve Resident Grievance Regarding CNA Care
Penalty
Summary
The facility failed to promptly resolve a grievance raised by a resident regarding the care provided by a certified nurse aide (CNA). The resident, who was cognitively intact and required significant assistance with activities of daily living due to multiple chronic conditions, reported that the CNA only changed her twice per eight-hour shift, did not communicate with her, and was perceived as rude. The resident expressed her concerns to multiple staff members, including leaving a message for the nursing home administrator (NHA), but did not receive feedback or resolution. A Concern and Comments form was completed by the resident, documenting her issues with the CNA and indicating that the concern was reported to an LPN. However, the form did not show any actions taken to address or resolve the grievance. Staff interviews confirmed that the resident had voiced her concerns as early as January, but no follow-up occurred until months later. The LPN acknowledged that the facility did not follow up with the resident about her concerns until the day of the survey interview, at which point the CNA was removed from the resident's care team. Additional staff interviews revealed that other nurses were aware of the resident's concerns for several months but were not aware of any actions taken or resolutions provided. The NHA stated he was not aware of the grievance until recently and had not received any messages from the resident. Despite the facility's grievance policy requiring prompt efforts to resolve complaints, the documentation and interviews demonstrated a lack of timely response and resolution for the resident's grievance.
Failure to Administer Medications as Ordered Due to Lack of Availability and Tracking
Penalty
Summary
A deficiency occurred when a resident with multiple chronic conditions, including COPD, morbid obesity, asthma, atrial fibrillation, heart failure, anxiety, depression, chronic kidney disease, insomnia, and sleep apnea, was not consistently administered prescribed medications as ordered by the physician during April 2025. The resident, who was cognitively intact, reported that staff frequently failed to provide both prescription and over-the-counter medications, including her antidepressant, pain medication, and inhalers. Review of the medication administration record confirmed that several medications were missed on multiple dates throughout the month, and progress notes indicated these omissions were due to medication unavailability. Staff interviews revealed a lack of a formal system to track and ensure the availability of over-the-counter medications, with communication about shortages occurring only after medications were already missing. The central supply coordinator and unit manager both acknowledged the absence of a tracking system, and the DON stated she relied on staff communication to maintain medication availability. The pharmacy manager confirmed that all medications were refilled as ordered and could not explain the lapses, while the primary care physician was not fully aware of the missed doses. Documentation did not consistently show that the physician was notified when medications were not administered.
Failure to Ensure Timely Physician Review of Pharmacist Drug Regimen Recommendations
Penalty
Summary
The facility failed to ensure that a physician reviewed and documented actions taken in response to monthly pharmacist recommendations regarding a resident's drug regimen. Over a period of four months, pharmacy consultation reports repeatedly identified that a resident was receiving an antipsychotic medication without adequate documentation of diagnosis or indication for use in the electronic medical record (EMR). Each monthly report recommended updating the EMR with a specific diagnosis, a list of symptoms or target behaviors, evidence that other causes and medications had been considered, documentation of individualized non-pharmacological interventions, and orders for ongoing monitoring. Despite these repeated recommendations, there was no evidence in the resident's record that the physician had reviewed the pharmacist's findings or documented any actions taken to address the identified irregularities. The pharmacy consultation reports for January, February, March, and April all lacked a physician's signature or any indication of review or follow-up. The resident in question had moderate cognitive impairment, mild depression, and was receiving both antidepressant and antipsychotic medications, with care plans in place to monitor for adverse reactions and behavioral symptoms. Interviews with the Director of Nursing (DON) revealed that although she received the pharmacist's recommendations each month, she had not distributed them to the physicians for the past four months due to being behind on other tasks. As a result, the required physician review and documentation of actions taken in response to the pharmacist's recommendations did not occur, leading to the deficiency.
Failure to Monitor and Document Long-Term Antibiotic Use
Penalty
Summary
The facility failed to develop and implement an effective antibiotic stewardship program that promotes the appropriate use of antibiotics and includes a system of monitoring to improve resident outcomes and reduce antibiotic resistance. Specifically, for two residents, the facility did not ensure that a physician's rationale for the use of long-term antibiotics was documented, nor was there evidence of ongoing monitoring or reassessment of the continued need for these antibiotics. The facility's own policy required documentation of dose, duration, and indication for each antibiotic, as well as regular reassessment and care planning, but these steps were not followed. For one resident with a history of chronic urinary tract infections and multiple physical impairments, the medical record showed a long-term order for Macrobid as prophylaxis, but the order lacked a specified duration and did not include the physician's rationale for ongoing use. There was also no documentation of monitoring or reassessment of the antibiotic's appropriateness, and the resident's care plan did not address the long-term antibiotic use. Similarly, another resident with a prosthetic knee and multiple comorbidities was prescribed doxycycline prophylactically, but again, the order lacked a duration, rationale, and evidence of monitoring or care planning related to the antibiotic. Interviews with staff revealed a lack of specific monitoring or documentation for residents on long-term antibiotics. The DON acknowledged that while initial assessments and short-term monitoring were performed, there was no ongoing monitoring or monthly reassessment for residents on chronic antibiotics, nor was there documentation of physician justification for continued use. The medical director confirmed that all residents on long-term antibiotics should have an indication, diagnosis, and ongoing monitoring, but this was not reflected in the records for the two affected residents.
Facility Fails to Honor Resident Beverage Preferences
Penalty
Summary
The facility failed to honor the beverage preferences of three residents, specifically their choice to have soda with their dinner. The facility's policy on resident rights emphasizes the importance of self-determination and accommodating resident preferences unless it poses a safety risk. However, residents reported that they were unable to have soda with their dinner, which was a preference they valued. This restriction made them feel disregarded and upset, as they were only allowed to have soda during lunch and had to save it for dinner if they wanted it at that time. Resident #1, who is cognitively intact and requires maximum assistance with daily activities, expressed sadness over the inability to have soda with dinner, feeling that her preferences were not respected. Similarly, Resident #2, also cognitively intact and requiring significant assistance, felt upset and infantilized by the restriction. Resident #3, who is cognitively intact and requires assistance with toileting and showering, expressed anger over the inability to have soda at dinner, feeling that her autonomy was being undermined. Staff interviews revealed a lack of clarity and consistency regarding the availability of soda. The food service director mentioned that soda was available on beverage carts, but residents reported otherwise. The nursing home administrator acknowledged that soda was not easily accessible and cited concerns about residents hoarding soda as a reason for the restriction. The activities director was unaware of how residents could access soda after the kitchen closed, indicating a gap in communication and policy implementation regarding resident preferences.
Delayed Response to Call Lights Compromises Resident Dignity
Penalty
Summary
The facility failed to ensure residents' call lights were answered in a timely manner, compromising the residents' right to a dignified existence. Interviews and observations revealed that two residents experienced significant delays in receiving assistance after activating their call lights. One resident reported feeling neglected due to long wait times for help, while another resident experienced delays ranging from 30 minutes to three hours. These delays in response made the residents feel uncared for and neglected. Observations conducted on specific dates showed multiple instances where staff members, including the Nursing Home Administrator (NHA) and Director of Nursing (DON), did not respond promptly to activated call lights. In several cases, staff members walked past activated call lights without providing assistance, and call lights remained unanswered for extended periods, ranging from 11 to 14 minutes. Despite the presence of staff members at the nurses' station, including the DON, call lights were not promptly addressed, indicating a systemic issue in responding to residents' needs. Interviews with staff members, including a Certified Nurse Aide (CNA), highlighted concerns about inadequate staffing levels to meet residents' needs in a timely manner. The NHA acknowledged the expectation for staff to respond to call lights within 15 minutes but noted that not all staff might be able to assist residents depending on their needs. The NHA also mentioned that staff members would receive verbal warnings if they were observed walking past call lights without checking on residents.
Neglect Leads to Resident Injury Due to Improper Transfer
Penalty
Summary
The facility failed to protect a resident from neglect, resulting in a serious injury. The resident, who had a history of falls and was dependent on staff for transfers, required the assistance of two staff members and a mechanical lift for safe transfers due to her diagnosis of cerebral palsy. Despite this, an agency CNA attempted to transfer the resident without the mechanical lift, opting instead for a stand and pivot transfer, which was against the resident's care plan. During the unauthorized transfer, the resident's left leg bent under her wheelchair, and she reported hearing popping sounds, indicating an injury. The resident experienced significant pain, and an x-ray initially showed no fractures. However, a subsequent CT scan revealed an acute fracture of the left femur, confirming the resident's injury due to the improper transfer method used by the agency CNA. Interviews with facility staff, including CNAs and the DON, confirmed that the agency CNA did not follow the care plan, which required the use of a mechanical lift with two staff members. The facility's investigation substantiated the neglect allegation, and the agency CNA was barred from returning to the facility. The incident highlighted a failure to adhere to established transfer protocols, resulting in harm to the resident.
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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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