Mountain View Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Colorado Springs, Colorado.
- Location
- 835 Tenderfoot Hill Rd, Colorado Springs, Colorado 80906
- CMS Provider Number
- 065147
- Inspections on file
- 33
- Latest survey
- April 1, 2026
- Citations (last 12 mo.)
- 25
Citation history
Health deficiencies cited at Mountain View Post Acute during CMS and state inspections, most recent first.
A resident with a history of trauma and recent bilateral amputations was in the activities room with others when another resident, who had a behavior care plan for verbal aggression and mood disorder, began talking loudly. After being told to calm down, the verbally aggressive resident responded with racial and sexual orientation insults and struck the other resident in the face with an open hand, while no staff were present in the room. A witness reported that it took a long time for staff to arrive and that the resident who was hit had already left by the time staff came. The aggressive resident’s prior care plan called for monitoring behaviors and intervening before agitation escalated, yet the incident was not documented in that resident’s progress notes, even though facility leadership later substantiated the event as abuse.
Surveyors found that multiple rooms lacked clean washcloths, had broken or missing towel racks, and were not properly cleaned. One resident's room had a broken window seal that allowed ants to enter, and a main shower room had a hazardous, dangling light fixture with exposed wires. Staff interviews confirmed that towels were only provided upon request and that maintenance issues were not promptly addressed.
Two residents with severe cognitive impairment and behavioral disturbances engaged in a physical altercation in a common area, resulting in a skin tear to one resident. Despite documented care plans and staff awareness of their aggressive behaviors, the facility did not effectively prevent the incident, constituting a failure to protect residents from abuse.
Housekeeping staff did not consistently follow infection control protocols, including proper hand hygiene and glove changes between tasks, and failed to disinfect high-touch surfaces and reusable cleaning equipment. These lapses led to recontamination of cleaned areas and improper handling of resident personal items, contrary to CDC guidelines and facility policy.
The facility's call light system was not fully functional, with alarms only audible at the nurse's station and visual indicators obstructed by the building layout. Multiple residents experienced long waits for assistance, including urgent medical needs, due to staff being unable to hear or see call light alerts when away from the nurse's station. Staff confirmed the system did not indicate which resident had called first or how long calls had been active, resulting in delayed responses to resident care needs.
A resident with multiple chronic conditions did not receive medications, including Baclofen, Eliquis, and Gabapentin, within the prescribed time frames on numerous occasions. Most late administrations were by an LPN, with some doses given hours late or in close succession, disrupting consistent therapeutic management. Staff cited high resident acuity and workflow challenges as contributing factors, and the DON was unaware of the frequency of late doses until an audit was performed.
A resident with mental disorders and psychosocial adjustment difficulties did not receive appropriate treatment and services in the facility. Despite having a care plan, the resident's distress and aggressive behaviors were not effectively managed or documented. The facility failed to provide necessary psychiatric or psychological support, and the resident was not reviewed in psychoactive drug meetings. Staff interventions were limited, and there was a lack of follow-up from social services.
The facility failed to maintain a system for reconciling and destroying controlled substances, resulting in a large inventory of medications awaiting destruction. The DON admitted to not having a system in place for tracking discontinued medications, and the NHA was unaware of the issue. The facility's pharmacist had not completed reconciliation monitoring.
A resident with cognitive intactness and multiple health conditions, including diabetes and benign prostatic hyperplasia, experienced a significant delay in receiving incontinence care, waiting nearly three hours for assistance. The resident frequently faced long wait times for care, particularly on weekends, and expressed frustration over the issue. Staff interviews revealed inconsistencies in the frequency of incontinence checks, with some staff indicating checks should occur every two hours, while others noted variability based on the resident's needs. The facility's policy required timely assistance for residents unable to perform ADLs independently, but adherence to this policy was lacking.
A facility failed to provide proper treatment and medication administration for three residents. One resident did not receive wound care as ordered, another had issues with surgical site care, and a third faced medication shortages affecting pain management. Staff interviews revealed documentation and communication issues contributing to these deficiencies.
The facility failed to implement Enhanced Barrier Precautions (EBP) effectively, as observed when a CNA did not perform hand hygiene or wear PPE before providing care to a resident with a chronic wound. Staff interviews revealed inconsistent understanding and application of EBP protocols, with some staff not wearing PPE during required interactions. The infection preventionist noted ongoing training efforts, but adherence failures persisted, compromising infection control standards.
Failure to Prevent Resident-to-Resident Physical Abuse in Unsupervised Activities Room
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident in the activities room. On the evening in question, one resident with a history of trauma and recent bilateral above-knee amputations was in the activities room with other residents when another resident, who had a behavior care plan for verbal aggression, began talking loudly. The first resident told him to calm down or stop talking, which led to the second resident responding with racial and sexual orientation insults and then striking the first resident in the face with an open hand. The first resident reported that he grabbed the other resident’s shirt during the confrontation and then turned around and left the room. At the time of the incident, there were no staff members present in the activities room. A witness resident confirmed that the verbally aggressive resident was talking too much and too loudly, that the other resident told him to calm down, and that the verbally aggressive resident overreacted, insulted him, and hit him in the face. The witness also stated that there were no staff in the room and that it took a long time for staff to arrive, by which time the resident who had been struck had already left the room. The assistant director of nursing later learned of the altercation only after hearing someone scream for a nurse and then went to check on the residents. The resident who committed the physical act of abuse had documented diagnoses including depression and an unspecified mood (affective) disorder, and an existing behavior care plan initiated months earlier for a history and potential for verbal aggression such as cursing and yelling at staff. That care plan called for analyzing triggers, monitoring behaviors, and intervening before agitation escalated. Following the incident, a psychosocial and behavioral care plan was initiated for this resident that described risks for striking out, grabbing others, being combative, verbally aggressive, and using derogatory words, including those related to sexual orientation, toward others. However, review of this resident’s progress notes revealed no documentation of the incident between the two residents, despite the facility’s regional nurse consultant stating that the incident was substantiated as abuse by the facility.
Failure to Maintain Clean, Homelike Environment and Timely Repairs
Penalty
Summary
Surveyors observed that the facility failed to maintain a comfortable and homelike environment for residents across three of four units. Multiple resident rooms were found with broken towel racks, missing towels, and in some cases, only one towel rack for two occupants. A broken window seal in one room allowed ants to enter during rain, and a trash bag was left on the floor outside a bathroom. Additionally, one resident room was noted to be dirty, with a hazy and muted tile floor. In the main shower room, a light fixture was found dangling from the ceiling with exposed wires and cracked drywall, leaving the internal electrical box exposed. Interviews with residents and staff confirmed these deficiencies. A resident reported that the broken window seal allowed ants into the room and that towels were only provided upon request, with no towel rack available for some time. Certified nurse aides stated that all nursing staff were responsible for room cleanliness and towel provision, but towels were only given to residents who asked. The maintenance director was unaware of the extent of broken or missing towel racks and indicated that work orders for repairs were to be initiated by nursing staff. The assistant director of nursing confirmed that every resident's room should have a towel rack and that nursing staff were responsible for providing towels.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect two residents from physical abuse by each other, resulting in a substantiated incident of resident-to-resident physical aggression. Both residents involved were severely cognitively impaired, with documented histories of behavioral disturbances, including physical aggression and verbal outbursts. On the date of the incident, a certified nurse aide (CNA) witnessed the two residents facing each other and making hand-to-hand, swatting gestures that resulted in physical contact. The CNA immediately intervened by separating the residents and notifying the nurse on duty. Although no injuries were initially reported, a subsequent assessment revealed that one resident had sustained a skin tear on the back of her left hand. Record reviews indicated that both residents had care plans addressing their behavioral issues, including interventions such as providing activities of interest, removing them from high-traffic areas, and ensuring they were kept apart from residents with whom they had previous altercations. Despite these interventions being documented, the incident occurred in a common area, suggesting that the measures in place were not effectively implemented at the time of the altercation. Staff interviews confirmed that both residents were known to exhibit aggressive behaviors and required close monitoring to prevent such incidents. Observations and staff accounts further revealed that both residents were prone to agitation and could be triggered by loud environments or interactions with each other. Staff described using redirection techniques and attempting to keep the residents separated, but the altercation still occurred. The facility's policy required protections against abuse, including resident-to-resident altercations, but the failure to prevent this incident constituted a deficiency in safeguarding residents from abuse.
Failure to Maintain Infection Control Program and Proper Cleaning Procedures
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observations of housekeeping staff not following proper cleaning and hand hygiene procedures. During cleaning of resident rooms, housekeeping staff were observed donning new gloves without performing hand hygiene, handling both clean and dirty items without changing gloves or sanitizing hands, and neglecting to disinfect high-touch surfaces such as call lights, door knobs, and grab bars. Additionally, staff placed contaminated items, such as trash cans, on already cleaned surfaces, leading to potential recontamination. Specific cleaning lapses included not disinfecting reusable cleaning equipment like toilet brushes after use, failing to clean side rails in resident bathrooms, and not sweeping the entire floor prior to mopping. Housekeeping staff also used the same gloves to handle both dirty cleaning rags and resident personal items, such as a juice cup, without changing gloves or performing hand hygiene in between tasks. These actions were inconsistent with both CDC guidelines and the facility's own policies on cleaning, disinfecting, and hand hygiene. Interviews with housekeeping staff and facility leadership confirmed awareness of the correct procedures, but staff admitted to forgetting or skipping steps such as cleaning high-touch areas and performing hand hygiene between glove changes. The infection preventionist and maintenance director both stated that gloves should be changed and hand hygiene performed between tasks, and that high-touch areas must be disinfected daily. Despite this, observed practices did not align with these expectations, resulting in a failure to prevent the development and transmission of infections within the facility.
Deficient Call Light System Leads to Delayed Resident Assistance
Penalty
Summary
The facility failed to ensure that the call light system was functioning properly throughout the building, resulting in staff being unable to hear or see call light alerts when away from the centralized nurse's station. Observations revealed that the audible alarm for the call light system was only present at the nurse's station and was not audible down the hallways. The visual indicators for activated call lights were also obstructed by the building's layout, making it difficult for staff to identify which rooms required assistance and in what order. The call light system did not provide information on how long a call had been active or which resident had called first. Multiple residents reported significant delays in staff response to call lights, with some waiting up to two hours for assistance with pain management, toileting, or urgent medical needs. One resident described an incident where her roommate experienced difficulty breathing and had already activated the call light, but staff did not respond until additional efforts were made to attract attention. Another resident recounted waiting over an hour for help after an incontinence episode, and a respiratory therapist documented an instance where a resident in need of immediate medical attention was not attended to because the call light alarm was not heard. Internal audits and grievance records confirmed a pattern of delayed call light responses, with documented response times ranging from one minute to over an hour and multiple grievances filed regarding long waits for care. Staff interviews corroborated these findings, with CNAs and LPNs stating that the call light alarms were difficult to hear or see from various locations in the facility, and that the system did not indicate which resident had been waiting the longest. The facility's policy required call lights to be accessible and to relay alerts directly to staff or a centralized location, but the current system did not meet these requirements due to technological and structural limitations.
Failure to Administer Medications Timely and as Prescribed
Penalty
Summary
The facility failed to ensure that a resident received medications in a timely manner as prescribed, in accordance with professional standards of practice and the resident's comprehensive care plan. The resident, who was over 65 years old and had multiple diagnoses including COPD, respiratory failure, atrial flutter, heart failure, and atrioventricular block, was cognitively intact but dependent on staff for most activities of daily living. The resident reported concerns about not receiving morning medications at the scheduled time, sometimes receiving them as late as noon, and was not informed of any changes to medication times. A review of the medication administration audit revealed that over a two-week period, the resident received a significant number of late medication doses. Specifically, 102 medications were administered late, with the majority given by one LPN. Medications such as Baclofen, Eliquis, and Gabapentin were repeatedly administered outside the prescribed time windows, sometimes several hours late. On multiple occasions, all scheduled morning medications were given more than an hour past the administration window, and in some cases, doses were given in close succession rather than at evenly spaced intervals as recommended by professional guidelines. This inconsistent timing did not support optimal therapeutic effects or consistent management of the resident's conditions. Staff interviews indicated that medication administration was delayed due to high resident acuity, staff needing to assist with care tasks, and challenges in managing the medication cart assignments. The facility had recently changed the medication administration schedule to a three-hour window to accommodate resident preferences and staff workflow, but staff were still expected to administer medications within this window. The DON was unaware of the extent of late medication administration until an audit was conducted at the request of surveyors. Additionally, there were concerns that some medications may have been administered on time but documented later, which is not consistent with professional nursing practice.
Failure to Provide Adequate Psychosocial Support for Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with mental disorders and psychosocial adjustment difficulties. The resident, a 69-year-old male, was admitted with diagnoses including anxiety, head injury, dementia, depression, and epilepsy. Despite having a care plan that included non-pharmacological interventions and behavioral and psychological services, the facility did not adequately monitor or assess the resident's emotional and psychosocial needs. The resident displayed behaviors such as delusions, paranoia, and aggression, which were not effectively managed or documented by the staff. The facility's records revealed multiple instances where the resident exhibited distress and aggressive behaviors, including pacing, hallucinations, and attempts to leave the facility. Staff interventions were limited to redirection and reassurance, and there was a lack of follow-up from the social services director regarding the resident's repeated behaviors. Additionally, the facility did not document any psychological or psychiatric evaluations or behavior health provider notes, and the resident was not reviewed in the psychoactive drug meetings despite being on psychoactive medications. Interviews with staff indicated that the resident's behaviors were known, but the interventions were not personalized or effectively communicated to the floor staff. The social services department failed to send referrals for behavioral health counseling, and the resident was not evaluated by a psychiatrist. The facility began seeking alternative placement for the resident due to his aggressive behaviors, but without providing the necessary psychiatric or psychological support, it could not be confirmed that the facility was unable to meet the resident's needs.
Failure to Reconcile and Destroy Controlled Substances
Penalty
Summary
The facility failed to maintain a system of records and disposition for controlled drugs, leading to an inability to accurately reconcile these substances. The facility's policy, revised in November 2022, mandates compliance with laws and regulations regarding the handling, storage, disposal, and documentation of controlled medications. However, during an observation on September 5, 2024, it was found that the inventory of discharged or discontinued controlled substances awaiting destruction was stored in a locked file cabinet in the Director of Nursing's (DON) office. The medications dated from March 2024 to September 2024, indicating a lack of timely reconciliation and destruction. Interviews with the DON and the Nursing Home Administrator (NHA) revealed that there was no system in place to document the tracking of medications after they were discontinued and taken into custody for destruction. The DON admitted to not having destroyed any items since taking her position in February 2024 and acknowledged the absence of a reconciliation system for discontinued medications. The NHA was unaware of the large inventory awaiting destruction and noted that the facility's pharmacist had not completed reconciliation monitoring of controlled substance destruction.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care for a resident, identified as Resident #11, who was unable to perform activities of daily living independently. The resident, who was cognitively intact and required assistance with toileting hygiene, was observed sitting in his own feces for an extended period. During an observation period, the resident waited two hours and 45 minutes for assistance after activating the call light, which was turned off by a CNA who did not return to provide care. Resident #11, who had diagnoses including type 2 diabetes with diabetic neuropathy and benign prostatic hyperplasia, expressed frustration over the long wait times for incontinence care, stating it was a frequent issue, especially on weekends. The resident's care plan did not include specific interventions for bowel incontinence, despite being incontinent of both bowel and bladder. Interviews with staff revealed inconsistencies in the frequency of incontinence checks, with some staff indicating checks should occur every two hours, while others noted variability based on the resident's needs. The facility's policy required that residents unable to perform ADLs independently receive necessary services to maintain personal hygiene. However, interviews with staff, including CNAs and the DON, highlighted a lack of adherence to this policy, with reports of residents being left without care for extended periods. The DON acknowledged that care plans generally did not specify timeframes for incontinence checks, contributing to the deficiency in providing timely care for Resident #11.
Deficiencies in Treatment and Medication Administration
Penalty
Summary
The facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for three residents. For Resident #2, the facility did not follow physician's orders for skin and wound care. The resident, who was at risk for skin breakdown due to multiple health conditions, had specific orders for cleansing and applying barrier cream to the peri-area and elevating and offloading the right heel. These treatments were not administered as ordered on several occasions, as documented in the medication administration record (MAR). Resident #12 also did not receive wound care as ordered by the physician. The resident had a history of skin issues and was at risk for pressure ulcer development. Despite having specific orders for surgical site care, the treatments were not administered as documented in the MAR. Interviews with staff revealed a lack of awareness of the physician's orders and issues with documentation, contributing to the failure in providing the necessary care. Resident #7 experienced issues with medication administration, specifically with methadone for pain management. The resident reported that the pharmacy did not keep the medication in stock, leading to missed doses and inadequate pain control. The MAR indicated missed doses, but there were no corresponding nursing notes explaining the reasons for these omissions. Staff interviews highlighted a lack of a systematic approach to medication ordering and documentation, which contributed to the deficiency in medication administration.
Inconsistent EBP Implementation in Infection Control
Penalty
Summary
The facility failed to maintain an effective infection control program, specifically in the implementation of Enhanced Barrier Precautions (EBP) for a resident with a chronic wound. The Centers for Disease Control and Prevention (CDC) guidelines and the facility's own policy require the use of personal protective equipment (PPE), including gowns and gloves, during high-contact resident care activities to prevent the transmission of multidrug-resistant organisms (MDROs). However, observations revealed that a certified nursing aide (CNA) did not perform hand hygiene or don the necessary PPE before entering the room of a resident on EBP to perform incontinence care. The deficiency was further highlighted through staff interviews, which indicated a lack of understanding and adherence to EBP protocols. The CNA involved admitted to not seeing the EBP sign and was unsure of its implications, leading to her failure to wear the required PPE. Other staff members, including licensed practical nurses (LPNs) and registered nurses (RNs), provided varying interpretations of when PPE should be used, indicating inconsistency in the application of EBP guidelines. This inconsistency was evident as some staff did not wear PPE during interactions that required it, such as checking or changing briefs for residents with wounds or indwelling devices. The infection preventionist (IP) acknowledged the issue, noting that she conducted rounds and audits to monitor compliance with EBP but had observed failures in adherence. Despite initial training and ongoing spot-training efforts, the staff's inconsistent application of EBP protocols contributed to the facility's failure to maintain a safe and sanitary environment, as required by infection control standards.
Latest citations in Colorado
A resident with severe dementia, hallucinations, delusions, and chronic pain, who was independent with mobility and at risk for wandering, was struck in the face by another cognitively impaired resident known to exhibit verbal and physical aggression and to be highly protective of her room. An RN heard a commotion, saw the victim outside the aggressor’s room, and attempted to intervene but witnessed the aggressor hit the victim before reaching them, resulting in a lip laceration and bruise. The aggressor’s care plan noted use of a doorway stop sign or closed door and the need to redirect others away from her room, but she often refused these measures. At the time of the incident, only one CNA and one nurse were on the memory care unit due to an unfilled CNA call-in, and staff reported it was difficult to manage when two CNAs were not present. The facility investigation substantiated the event as abuse and identified that both residents may have had increased pain contributing to agitation before the altercation.
A resident with severe cognitive impairment and multiple chronic conditions intentionally slid from a wheelchair to sit on the floor and refused assistance to return to the chair. An LPN directed two CNAs to place a blanket under the resident and drag the resident across the floor, onto an elevator, and to another floor, rather than allowing the resident to remain seated on the floor as requested. The resident later reported trying to resist and stated dislike of the experience. Documentation by the LPN omitted how the resident was actually moved between floors, despite care plan goals for dignity and autonomy and a facility policy requiring residents be treated with dignity and respect and that their choices and preferences be honored.
Surveyors found that staff repeatedly failed to follow hand hygiene and Enhanced Barrier Precautions (EBP) requirements. CNAs and an LPN provided direct care, including incontinence care, use of a mechanical lift sling, and gastric tube feeding, without performing hand hygiene before or after care and without using required gowns for residents on EBP. One CNA handled a soiled lift sling, touched his hair and face, used a touchscreen to document care, and then assisted another resident without cleaning his hands. Another CNA entered an EBP room wearing only gloves, not a gown, and did not perform hand hygiene after removing gloves. An LPN handled a feeding tube and provided care to residents on EBP without hand hygiene or gown use. A resident’s representative reported seeing staff work with a feeding tube without gloves or a gown, while staff interviews and facility policy described correct practices that were not followed in practice.
A resident with severe cognitive impairment and multiple serious diagnoses had a physician-appointed health care proxy who reported that the facility did not inform her when the resident’s condition changed or when an antibiotic was started, and that her calls were not returned for days. Another representative for the same resident stated that calls went to a general voicemail and were rarely or very slowly returned. Grievance records documented repeated concerns about delayed communication, lack of notification about new medications, and difficulty reaching staff. Other residents’ representatives similarly reported that calls to check on residents or report suspected verbal abuse went to voicemail and were returned late or not at all, while staff acknowledged that calls often went to voicemail and that several calls from representatives were missed or delayed.
The facility failed to investigate an allegation of verbal abuse and threats between two cognitively impaired roommates after a family member, who was on the phone with one resident, reported hearing the other resident yelling loudly and making threats. The resident’s representative could not reach staff by phone and contacted EMS, which responded to the facility, yet no investigation or documentation of the altercation, alleged threats, or EMS involvement was found in either resident’s record. Staff acknowledged loud yelling and arguing and initiated a room change, but the RN did not fully inform the DON, the SSD—who was not present—dismissed the event as a simple argument, and the NHA did not treat or report it as abuse, contrary to facility policies requiring identification, investigation, and reporting of possible verbal or mental abuse by other residents.
Unsafe food handling and kitchen sanitation practices were observed in the dining room and main kitchen. Staff handled ready-to-eat foods with bare hands, failed to wash hands between tasks and after bathroom use, and touched food, dishes, and meal tickets while plating and serving meals. The facility also kept moldy croissants in dry storage, used a pencil to prop up a hood drip pan, and allowed a dietary aide with artificial nails and multiple bracelets to serve residents.
The facility failed to maintain and document safe food temperatures during meal service, resulting in cold foods being held and served within the temperature danger zone and incomplete temperature logs on multiple days. During a lunch service observation, various forms of chicken salad were held at 45–55°F, yet plates were assembled and sent out, and a resident reported that meals delivered to the room were always cold and often not eaten. Staff interviews showed inconsistent understanding of required hot and cold holding temperatures and confirmed that temperature logs were sometimes not completed as required.
Failure to Honor Residents’ Choice of Attending Physician: Three cognitively intact residents said they were not allowed to choose their own attending physician and were required to see the facility MD instead. EMR and admission agreement review showed no documentation that they were offered a choice of physician, despite one resident wanting to continue with a community PCP. The NHA stated residents could choose their attending physician, but also said the facility had only one physician available for residents to choose from.
Psychotropic Medication Documentation and PRN Behavior Monitoring Deficiencies Survey review found that several residents had psychotropic medications ordered without documented physician rationale, resident-specific target behaviors, or individualized non-pharmacological interventions. Generic behavior-monitoring orders were used instead of approaches tied to each resident’s history, interests, and identified behaviors, and one resident’s PRN antipsychotic was administered multiple times without documentation of attempted non-pharmacological interventions before use. The EMR also showed notes of stability or no unwanted behaviors for some residents, yet the records still lacked rationale supporting continued psychotropic treatment.
Failure to Address Suicidal Ideation and Individualized Psychosocial Needs: The facility did not adequately address suicidal statements, trauma-related needs, or individualized behavioral interventions for multiple residents. One resident with dementia, anxiety, and PTSD made a suicidal threat, but the record did not show ongoing safety monitoring or documented follow-up. Another resident with PTSD, depression, and a history of trauma and suicide attempts had ongoing depressive symptoms, but the care plan and orders did not reflect the PASRR-identified need for therapeutic support, psychiatric oversight, coping skills, or a safety plan. A third resident with autism and mood disturbance had inappropriate sexual behavior toward the DON, but the care plan was not updated with person-centered interventions specific to that behavior.
Failure to Prevent Resident-to-Resident Physical Abuse on Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. On the date of the incident, an RN heard a commotion in the hallway outside the alleged assailant’s room and observed that resident strike another resident, causing the victim’s lip to bleed. The RN had seen both residents near the medication cart a few minutes earlier without concern and attempted to intervene when she saw the victim standing outside the assailant’s room, but was unable to reach them before the strike occurred. The two residents were then separated, and frequent checks were initiated. The victim was a younger-than-65 resident with vascular dementia (severe, with agitation), Alzheimer’s disease, Lewy body disease, bipolar disorder, and chronic pain. Her MDS showed short- and long-term memory problems, hallucinations, delusions, and physical and verbal behaviors toward others, with moderately impaired cognition and impaired decision-making. She was independent with mobility and had a care plan for wandering and dementia that identified her as pleasantly confused and easily redirected, with interventions to identify wandering patterns, offer diversions, and assess for pain or toileting needs when agitated. Documentation on the day of the incident noted her involvement in a resident-to-resident altercation, a small laceration to the middle of her upper lip, and a small bruise below her lower lip. The assailant was an older resident with severe vascular dementia with agitation, memory deficit after intracranial hemorrhage, and recurrent depressive disorder. Her MDS documented short- and long-term memory problems, fluctuating disorganized thinking, and verbal behaviors directed toward others that could significantly intrude on others’ privacy or disrupt the environment. Her behavior/dementia care plan identified verbal aggression (yelling/screaming), physical aggression (hitting), refusal of care, withdrawal, tearfulness, and negative statements, and noted that she was protective of her room and became upset if others entered or tried to enter. The care plan included use of a velcro stop sign across her doorway or keeping her door closed, but also documented that she often declined having the door closed, requiring staff to redirect other residents away from her room. Staff statements indicated that at the time of the incident there was one CNA and one nurse on the memory care unit, that one CNA had called in and was not replaced, and that it was hard when there were not two CNAs on the unit. The facility’s investigation substantiated the incident as abuse and identified that both residents may have been experiencing increased pain leading up to the altercation, with pain, constipation, and urinary retention noted as contributing factors for the victim and hand contracture pain and refusal of interventions noted for the assailant.
Resident Dragged on Blanket Instead of Honoring Request to Sit on Floor
Penalty
Summary
The deficiency involves a failure to honor a resident’s right to dignity and self-determination when staff did not allow the resident to remain seated on the floor per his wishes and instead dragged him on a blanket between floors. Late at night, the resident, who lived on the second floor, was in his wheelchair on the first floor and intentionally slid out of his wheelchair to sit on the ground according to his own wishes. When staff offered assistance to help him back into his wheelchair, he refused. Despite this refusal, an LPN directed two CNAs to move the resident from the first floor back to the second floor. Following the resident’s refusal to get back into his wheelchair, the LPN instructed the CNAs to place a blanket underneath the resident so he could be dragged while lying on it. The CNAs and the LPN maneuvered the blanket under the resident by moving him from side to side. One CNA positioned herself behind the resident and placed her arms under his armpits, while the other CNA held the resident’s pants at his ankles. The LPN then pulled on the blanket with the resident on it. Together, the three staff members dragged the resident on the blanket across the floor and onto the elevator, transported him to the second floor, and then dragged him off the elevator onto the second floor hallway. Once on the second floor, the resident agreed to have two staff members assist him back into his wheelchair, and a two-person transfer was performed to lift him from the floor into the chair. The resident later reported that he remembered being pulled on the blanket, stated that he "tried to fight them like crazy," and said he did not like what had been done. The nursing progress note written by the LPN the following morning documented that the resident had remained on the first floor until late at night, refused to talk with staff, refused care, and declined snacks, fluids, and redirection, but the note did not document how he was actually relocated to the second floor. The resident’s records showed he had severe cognitive impairment with a BIMS score of 3/15, diagnoses including Parkinson’s disease, depression, unspecified intellectual disabilities, traumatic brain injury, seizures, and chronic kidney disease stage 3, and care plan goals that included being treated with dignity and autonomy. The facility’s dignity policy stated that residents are to be treated with dignity and respect at all times, that their choices and preferences are to be honored, and that demeaning practices are prohibited, which was not followed in this incident.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to hand hygiene and adherence to Enhanced Barrier Precautions (EBP) on all four units. The facility’s own policies require hand hygiene before and after direct patient care and the use of gowns and gloves during high-contact care activities for residents on EBP. CDC guidance cited in the report emphasizes that hand hygiene protects both healthcare personnel and patients, and that EBP requires targeted gown and glove use during high-contact resident care activities, particularly for residents with wounds, indwelling devices, or MDRO colonization or infection. Surveyors observed multiple instances where staff did not follow these requirements. An unidentified CNA exited a room of a resident on EBP without wearing a gown while providing care. On another occasion, a CNA exited a resident’s room carrying a soiled mechanical lift sling without gloves, failed to perform hand hygiene, touched his hair and face, used a touchscreen to document care, and then entered another resident’s room to answer a call light and assist with a request without performing hand hygiene before or after assisting that resident. Another CNA entered the room of a resident on EBP, donned only gloves without a gown, provided incontinence care, then left the room with soiled linens and trash properly disposed of, removed gloves, but did not perform hand hygiene before caring for another resident. Additional observations showed an LPN entering the room of a resident on EBP for gastric tube feeding, setting up and handling the feeding tube without performing hand hygiene beforehand and without wearing a gown. The same LPN later entered another EBP room, provided care, and left without performing hand hygiene. A resident’s representative reported seeing staff work with the resident’s feeding tube without gloves or a gown. In interviews, CNAs and nursing staff described correct hand hygiene and EBP practices, including washing hands for about 20 seconds and using gowns and gloves for residents on EBP, and the DON stated she expected staff to perform hand hygiene when entering and exiting rooms and to follow EBP procedures requiring gown and glove use. These stated practices conflicted with the observed failures in hand hygiene and EBP adherence documented by surveyors.
Failure to Notify Health Care Proxy and Return Calls Regarding Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to inform a resident’s physician-appointed health care proxy of changes in the resident’s condition and new treatments, and to return the proxy’s calls in a timely manner. Facility policy on Notification of Changes required informing the resident, consulting with the physician, and notifying the family member or legal representative when there was a change requiring such notification, and specified that when residents were incapable of making their own decisions, the representative would make necessary decisions. Resident #1 was under 65, admitted with diagnoses including paralysis and weakness following a stroke, respiratory failure, cognitive communication deficit, and encephalopathy, and was documented as severely cognitively impaired with a BIMS score of 0/15, indicating reliance on the health care proxy for decision-making. The health care proxy reported that the facility made it very difficult to contact the resident, stating that staff did not return calls for days and that she was not informed when the resident developed an infection and was started on an antibiotic until after the medication had already been initiated. She stated she had several questions about the medication and was not consulted on the medical decision prior to its start. Another representative reported that calls to the facility went to a general voicemail and that her messages were either not returned or took several days for a response. Grievance records showed repeated concerns from the resident’s representatives about delays in speaking with the resident, delays in return calls, and lack of notification about new medications and changes in condition. Additional interviews with other residents’ representatives supported a broader pattern of delayed or absent communication. One representative of another resident reported that his call to check on a newly admitted resident went to voicemail and was not returned for two days. Another resident’s representative and a secondary witness reported that when they attempted to report suspected verbal abuse, their calls to the facility and to the SSD went to voicemail and were never returned. Staff interviews confirmed that calls first went to the front desk and then to the nurses’ stations, that calls often went to voicemail when nurses were unable to answer, and that voicemail messages were expected to be returned within 24 hours. The NHA acknowledged that several calls from the resident’s representatives went to voicemail and that calls were often made during shift change when it was harder to reach the nurse on duty, but there was no documentation to support the claimed regular communication with the health care proxy.
Failure to Investigate Alleged Verbal Abuse Between Cognitively Impaired Roommates
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of verbal abuse and threats between two cognitively impaired residents after a family member reported overhearing the incident. Facility policy on abuse, neglect, exploitation, and misappropriation requires that all possible incidents of abuse, including verbal and mental abuse by other residents, be identified, investigated, and reported within required timeframes, with residents protected from further harm during investigations. The policy on identifying types of abuse specifies that yelling or hovering over a resident with intent to intimidate is an example of mental and verbal abuse. Despite these policies, the facility did not initiate or document an investigation into a reported verbal altercation that included alleged threats. One resident, under age 65, with dysphagia, left-sided hemiplegia, attention and concentration deficit, delusional disorder, and major depressive disorder, had moderate cognitive impairment and was dependent on staff for most ADLs. He reported that he and his roommate yelled back and forth at each other after the roommate told him to “shut the [expletive],” but he did not recall the specific words used and denied any physical contact. His guardian stated that he later reported being fearful of his roommate after the incident. Another representative, who was on the phone with him during the event, reported hearing the roommate yelling loudly and making threats toward him, then hearing a nurse enter to calm the situation. This representative attempted to call the facility to report the yelling and threatening behavior, was sent to voicemail without a return call, and subsequently contacted emergency services. The roommate, an older resident with dementia, cognitive communication deficit, depression, and insomnia, also had moderate cognitive impairment and required staff assistance for most ADLs. He did not recall the incident, and his representative only learned of it the following day and was told it involved yelling about loud phone use. A review of both residents’ medical records revealed no documentation of the verbal altercation, the alleged threats, or related concerns, and no investigation documents were produced when requested. Staff interviews confirmed there had been loud yelling and arguing, that EMS responded to the facility, and that a room change was initiated due to the incident, but the RN who responded did not report the EMS involvement to the DON. The SSD, who was not present during the incident, characterized it as just an argument and stated there were no threats, and the NHA stated the event was not reported as abuse because they believed no threats were made. No contemporaneous interviews with the residents were documented, and no inquiry was made by facility staff into why EMS had been called in relation to the altercation, resulting in a failure to investigate the allegation of verbal abuse as required by facility policy.
Unsafe Food Handling and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the main kitchen and dining areas. During meal service observations, staff repeatedly handled ready-to-eat foods with bare hands and did not perform hand hygiene when changing tasks, after touching dirty dishes, after using the bathroom, or before serving food. An LPN cut a resident’s patty melt and handed pieces to the resident with her bare hand without sanitizing her hands. A DA passed drinks by touching the rims of cups, and another DA tore a resident’s patty melt into smaller pieces with bare hands and handed food to the resident. During a later observation, kitchen staff continued to work without washing hands between tasks and while handling food, dishes, and meal tickets. A DA entered the kitchen from the dishroom and did not wash his hands before putting away snacks. A cook did not wash her hands after working at the sink, after touching dirty dishes, after exiting the bathroom in the kitchen, or before serving room trays. She was observed touching shrimp, corn bread, rice, squash, cheese, and frozen fries with bare hands while plating and preparing meals, and she also handled fryer baskets and food items without washing her hands. Another cook wiped her hands on her clothing, handled meal tickets, and touched ready-to-eat foods with bare hands while assembling plates and serving meals. The facility also failed to discard expired or spoiled food, maintain equipment in good repair, and prevent staff from wearing prohibited items while preparing or serving food. A plastic bag of croissants in dry storage contained bread-like food covered in dark green and black fuzz and remained on the bread rack on two separate observations. In the kitchen hood system above the grill, a half wooden pencil was being used to hold up the grease drip pan on two observations. In addition, a dietary aide taking meal orders, passing drinks, and serving meals had artificial nails approximately half an inch long and multiple fabric bracelets on her wrists while working with residents.
Failure to Maintain and Document Safe Food Temperatures During Meal Service
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner by not maintaining appropriate food temperatures during meal service and by not consistently documenting food temperatures as required. During a continuous observation of lunch meal service, chicken salad, including soft and bite-sized and pureed versions, was found on the steam table at temperatures of 55°F and 45°F, which were within the documented temperature danger zone and below the required cold-holding standard. Despite these temperatures, plates with wedge chicken salad and a Hawaiian roll were assembled and placed on the meal cart for service. A resident reported that meals delivered to his room were always cold, leading him not to eat them and to attempt to obtain food from outside the facility. Review of the facility’s April 2026 food temperature logs showed multiple instances where temperatures were not documented for breakfast, lunch, and dinner services on numerous dates. Staff interviews revealed inconsistent understanding and application of proper holding temperatures, with the cook and dietary manager providing varying temperature thresholds that did not align with the facility policy or the Colorado Retail Food Establishment Rules and Regulations. The cook acknowledged that the wedge chicken salad should not have been served at 55°F and attributed difficulty maintaining proper temperatures to a hot room with inadequate ventilation, while the dietary manager stated that cooks sometimes forgot to complete the temperature logs.
Failure to Honor Residents’ Choice of Attending Physician
Penalty
Summary
The facility failed to ensure three cognitively intact residents were allowed to choose their own attending physician. Resident #15, Resident #28, and Resident #30 each stated during a group interview that they did not have a choice in who their physician could be while in the facility and that they had to see the facility’s MD. Resident #15 said she had a primary care physician in town that she wanted to continue seeing, but she was told she could not see that physician. Resident #28 and Resident #30 each said they were required to see the facility’s MD instead of choosing their own physician. Record review for each of the three residents, including the admission agreement and EMR, showed no documentation that they were provided a choice of attending physician. Resident #15 had diagnoses including COPD, cirrhosis of the liver, and osteoarthritis, and her MDS showed she was cognitively intact with a BIMS score of 15. Resident #28 had diagnoses including type 2 diabetes mellitus, asthma, osteoarthritis, and TIA/cerebral infarction, and was also cognitively intact with a BIMS score of 15. Resident #30 had diagnoses including type 2 diabetes mellitus, wedge compression fracture of T11-T12 and L3, and hypertension, and his MDS likewise showed a BIMS score of 15. The NHA stated residents were able to choose their attending physician when admitted, but also said the facility had one physician residents could choose from and was not aware that these residents wanted different physicians.
Psychotropic Medication Documentation and PRN Behavior Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure four residents were free from unnecessary psychotropic medication use and chemical restraint concerns. Survey review found that the facility did not document a physician’s rationale for the continued use of psychotropic medications for three residents, did not document resident-specific care approaches with medication-specific target behaviors and person-centered interventions for those residents, and did not ensure one resident’s PRN antipsychotic use had corresponding documentation of identified behaviors and non-pharmacological interventions. For one resident with PTSD, anxiety, and depression, the record showed buspirone, Valium, duloxetine, and Lexapro orders with behavior-monitoring language, but the orders did not identify resident-specific non-pharmacological interventions for specific behaviors. The resident’s PASRR described a history of self-harm, suicidal thoughts, mood swings, loss of interest, and low energy, and recommended therapeutic interventions, coping skills, psychiatric oversight, increased socialization, and activities such as puzzles, games, and painting. The EMR review did not show documented behaviors during the review period, and it did not show a physician rationale to justify continued psychotropic use. For another resident with schizoaffective disorder, dementia, anxiety, and depression, the care plan and orders listed generic interventions and behavior targets such as screaming, hallucinations, kicking, and yelling, but the resident-specific behaviors and interests identified in the PASRR, including hearing the devil inside her head and being soothed by prayer and rosary use, were not incorporated into the behavior-monitoring orders or care plan. The record also lacked documentation of non-pharmacological interventions used for the resident’s behaviors and lacked a physician rationale for continued psychotropic use despite notes stating the resident was stable and not experiencing unwanted behaviors. A third resident with vascular dementia, anxiety, and PTSD had orders for Abilify, mirtazapine, sertraline, clonazepam, and behavior monitoring tied to verbal aggression, exit seeking, tearfulness, and hitting staff, but the orders remained generic and did not reflect the resident’s individualized approaches such as listening to 80’s rock music or watching a favorite program when crying or confused. The EMR again did not show a physician rationale for continued psychotropic use despite notes indicating pleasant mood and no unwanted behaviors. For the resident who died during the stay and had dementia and depression, the record showed Lexapro, Seroquel, and PRN injectable haloperidol ordered for behaviors such as swinging at staff and agitation. The PRN haloperidol order did not list a diagnosed specific condition, only behaviors, and the order for non-pharmacological interventions was not initiated until after the resident had already been receiving psychotropic medications. MAR and order administration notes showed multiple PRN haloperidol administrations, but several entries lacked documentation of attempted non-pharmacological interventions before the medication was given, and one note only documented encouragement to sit down without identifying the other ordered interventions or their effectiveness.
Failure to Address Suicidal Ideation and Individualized Psychosocial Needs
Penalty
Summary
The facility failed to ensure that residents with mental disorders, psychosocial adjustment difficulties, and trauma histories received appropriate treatment and services to support their mental and psychosocial well-being. For one resident with vascular dementia, anxiety, and PTSD, the record showed repeated depression screens indicating little interest, depressed mood, poor appetite, sleep problems, low energy, and feelings of worthlessness, along with notes describing chronic behaviors potentially causing harm, tearfulness, withdrawal, and anxiety. A behavior note documented that the resident stated she was going to kill herself, but the record did not show documented interventions to keep her safe afterward or ongoing monitoring for suicidal ideation. A second resident with PTSD, anxiety, depression, and a documented history of trauma, self-harm, suicidal thoughts, and numerous suicide attempts had a PASRR evaluation identifying the need for therapeutic interventions, psychiatric oversight, coping skills development, and a safety plan. The resident told staff she had previously seen a therapist at the facility, but that therapy had stopped and no new arrangements had been made. She also reported that staff had not asked about her PTSD triggers or what interventions would help her. The record showed depression screens with ongoing depressive symptoms, but no follow-up documentation after those screenings, and the care plan and physician orders did not reflect the resident’s suicidal history or the specialized services identified in the PASRR. The facility also failed to provide individualized care approaches for a resident with autistic disorder, dementia with mood disturbance, anxiety disorder, major depressive disorder, and cognitive communication deficit. The resident had a history of inappropriate sexual behaviors and was documented as having sexually inappropriate contact with the DON when he squeezed her breast during a dining activity. Although the resident was placed on 15-minute behavior monitoring for 24 hours, the care plan was not revised to reflect a person-centered intervention specific to that sexual behavior. Staff interviews showed that interventions were inconsistently understood and that the nursing staff did not know what person-centered interventions were in place for the resident’s behaviors.
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