Oakwood Care And Rehabilitation
Inspection history, citations, penalties and survey trends for this long-term care facility in Lakewood, Colorado.
- Location
- 5301 W 1st Ave, Lakewood, Colorado 80226
- CMS Provider Number
- 065248
- Inspections on file
- 29
- Latest survey
- February 26, 2026
- Citations (last 12 mo.)
- 30
Citation history
Health deficiencies cited at Oakwood Care And Rehabilitation during CMS and state inspections, most recent first.
The facility’s QAPI program did not effectively identify or address significant issues related to abuse, neglect, and dementia care. Despite a policy requiring a data-driven QAPI plan and PIPs, there was no active PIP for the secure memory unit, where residents were able to wander into other rooms and engage in resident-to-resident physical abuse. The NHA and DON reported that staff had not received needed education on abuse and dementia, and although they mentioned working on PIPs such as falls and dementia training, they could not provide specific details, indicating that the QAPI process was not functioning as required to manage these concerns.
The facility failed to protect multiple residents from physical and verbal abuse by other residents, particularly in a secure memory care unit where many had severe dementia, wandering, and known behavioral disturbances. A resident who wandered frequently was physically assaulted on several occasions by different residents after entering their rooms, including being grabbed in bed, pushed, and physically redirected, sometimes resulting in a fall. Other residents with severe cognitive impairment and psychiatric conditions were knocked down, pushed in hallways, grabbed by the face, scratched, and involved in altercations over preferred seating, with at least one resident sustaining a forehead laceration. Two male roommates with cognitive and impulse‑control issues engaged in escalating verbal taunting and pushing over TV noise, leading to a fall and abrasion. Staff reported that residents commonly wandered into others’ rooms, that there were no proactive barriers to prevent unauthorized entry, and that they typically redirected residents only after conflicts began, while some incidents were not substantiated as abuse despite clear aggressive contact.
The facility failed to implement person-centered dementia care and supervision for multiple residents with dementia who frequently wandered and intruded into others’ rooms. Despite care plans and facility policy requiring assessment, monitoring, and redirection of wandering and territorial behaviors, residents were repeatedly observed pacing hallways without purpose, attempting to exit locked doors, and entering both occupied and unoccupied rooms without staff in line of sight or providing timely redirection. Some residents had documented triggers for aggression when others entered their rooms or personal space, yet planned interventions such as door barrier straps and close supervision were not consistently in place. Staff interviews confirmed that many residents wandered into others’ rooms, that staff did not consistently prevent this, and that some CNAs were unaware of where to find or how to follow care plans, resulting in residents not receiving the individualized dementia management needed to maintain their well-being.
The facility did not provide required, facility-specific training on abuse, neglect, exploitation, misappropriation, and reporting procedures to contracted and agency staff, despite a policy stating it applied to all caregivers. A hospice CNA observed a resident left wet for an extended period and believed this was neglect but did not report the concern to the facility for ten days. During the survey, an agency CNA reported receiving no supplemental training on the facility’s abuse and neglect policies, and leadership acknowledged that agency staff had not been trained by the facility and that communication with the hospice agency about concerns was lacking.
The facility failed to conduct a thorough investigation into an abuse allegation when a resident with moderately impaired cognition, depression, anxiety, and mobility limitations reported that a CNA pushed her onto a bath chair, threw a towel or wash cloth at her, and spoke to her in a rough manner during showering and at bedtime on more than one occasion. The investigation included interviews with the resident and the accused CNA, but did not document when the CNA last provided care to the resident, did not include interviews with other CNAs, nursing staff, or other residents about the CNA’s care, and did not assess the shower environment or observe the CNA’s shower and transfer technique. Despite the resident’s emotional distress and existing care plan to monitor behaviors and underlying causes, the facility concluded the allegation was unsubstantiated without completing the investigative steps required by its abuse policy.
A dependent resident with severe cognitive impairment, schizophrenia, mood disorder, and epilepsy, who required staff assistance for toileting hygiene, was not checked or changed for incontinence for over six hours despite the facility’s stated expectation that dependent residents be checked at least every two hours. Continuous observation showed no direct care staff entering the room to offer incontinence care until a CNA eventually found and changed a urine-soaked brief and bed linens. Staff interviews and prior nursing notes confirmed the resident’s ongoing incontinence issues, frequent refusal of care, and history of urinating in bed and on the floor, while multiple staff, including CNAs, an RN, an LPN, the DON, and the NHA, all acknowledged the two-hour incontinence check standard.
Surveyors found that the facility did not maintain a safe, clean, and comfortable environment, with persistent odors of urine and feces, unclean floors, stained linens, and unrepaired damage in resident rooms and common areas. Residents and their representatives reported frequent unpleasant odors and visible cleanliness issues, while staff interviews revealed confusion about cleaning responsibilities and inconsistent maintenance practices.
Two residents with significant cognitive impairment and complex medical needs did not have their representatives consistently involved in care plan development, as required. Representatives reported not being invited to or having difficulty scheduling care conferences, and facility records confirmed a lack of documented conferences and incomplete contact attempts over several months.
A resident's designated representative was not notified of multiple significant changes in the resident's condition, including facial swelling, urgent dental care, leg edema, loose stools, and bruising, despite facility policy requiring such notifications. The resident was cognitively impaired and unable to communicate, and staff interviews confirmed these events should have triggered notification and documentation.
Two residents did not receive their scheduled pain medications, including Oxycontin and oxycodone, within the prescribed time frames as documented in the MARs. In several instances, medications were administered late or missed entirely, despite physician orders and professional standards requiring timely administration. Both residents reported ongoing pain and noted that delays in medication administration affected their comfort.
Multiple residents reported not having access to incontinence briefs for several days, being told by staff to use towels as substitutes, and receiving incorrectly sized briefs. Staff confirmed that the facility ran out of briefs, with limited alternatives available, and described being instructed to use towels due to budget restrictions. Facility leadership denied these claims, but grievances and observations supported the reports of inadequate supply and compromised resident dignity.
A resident was discharged home without proper documentation and communication of essential medical equipment needs, specifically two transfer poles required for safe transfers. The discharge summary and care plan did not include these needs, and only one transfer pole was installed at the time of discharge. Verbal confirmations with referral sources and home health were not documented, and the physician's discharge order was inaccurate and delayed.
A resident with multiple chronic conditions did not receive prescribed doses of Farxiga for three days due to delays in pharmacy delivery and lack of follow-up by staff. Documentation failed to show that the pharmacy or physician was notified about the missed doses, and the medication was not administered even after it became available, with no explanation provided.
A resident with a history of aggressive behavior due to dementia physically assaulted two other residents, causing injuries. The facility's care planning and supervision were inadequate, failing to address the resident's behavior history and implement effective interventions. Additionally, another resident verbally abused others, highlighting the facility's failure to protect residents from abuse.
The facility failed to provide residents with food at palatable temperatures, as evidenced by resident complaints and observations of meal service. Food items were served at inadequate temperatures, and there were issues with food coverage and shortages. Staff interviews revealed that plates were not pre-warmed, contributing to the problem.
The facility failed to maintain sanitary conditions in food storage and preparation areas, with expired and unlabeled food items found in the main kitchen and nourishment rooms. Medications were improperly stored in a refrigerator, and staff interviews revealed lapses in adherence to food safety protocols.
The facility failed to report potential abuse incidents involving two residents to the State Agency. One resident, with a history of aggressive behavior, was involved in multiple unreported incidents of aggression. Another resident was found with injuries after an altercation, but the facility documented it as a fall and did not report it. Documentation errors and reliance on agency staff contributed to the reporting failures.
A facility failed to implement a timely and person-centered care plan for a resident with dementia and a history of aggression. Despite the resident's known history of physical and verbal aggression, the care plan lacked specific interventions upon admission, leading to delayed management of aggressive behaviors. Staff interviews indicated difficulties in predicting the resident's sporadic behaviors, contributing to the deficiency.
A facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a suprapubic catheter and stage 4 pressure wounds. Staff, including therapists and CNAs, did not use required PPE during high-contact activities, and there was no EBP signage or PPE bin outside the resident's room. Interviews revealed staff were unaware of EBP requirements, and the ADON mistakenly removed precautionary signs and bins, leading to a deficiency in infection control.
The facility failed to protect four residents from mental and verbal abuse, leading to significant emotional distress. One resident was belittled by the activities director, another was neglected by a CNA, and two residents were repeatedly verbally abused by another resident. Despite staff reporting these incidents, the facility did not take timely or effective corrective actions.
The facility failed to ensure timely access to vision services for three residents, leading to deficiencies in their care. One resident with quadriplegia and astigmatism was not seen by the eye doctor despite multiple requests. Another resident with moderate cognitive impairment had not been offered an eye doctor appointment after losing her glasses. A third resident with worsening vision had not received his prescribed glasses months after his eye exam.
The facility failed to maintain a safe and sanitary laundry room, with issues including a wet and slippery floor, an uncovered drain, water leaks, and non-functional washing machines and dryers. The maintenance director acknowledged these problems but had not yet resolved them.
The facility failed to provide a consistent and engaging activity program for residents in the secured dementia care unit, leading to a lack of meaningful activities and inadequate supervision. Residents were often left idle, and staff did not engage them in activities or conversation. Additionally, the facility did not monitor residents effectively, resulting in resident-to-resident altercations and inappropriate interactions between staff and residents.
The facility failed to assist residents in obtaining routine or emergency dental services. One resident waited five months for extractions and dentures, another had no follow-up for dentures, a third had not seen a dentist since admission despite requests, and a fourth was not referred to a specialist as recommended.
The facility failed to maintain an effective infection control program, with housekeeping staff not consistently changing gloves or performing hand hygiene, improper use of disinfectant chemicals, and lapses in COVID-19 vaccination tracking. Additionally, infection control practices were not followed during wound care and medication administration.
The facility failed to implement policies and procedures related to pneumococcal immunizations for five residents, resulting in incomplete and outdated vaccination records and a lack of determination regarding additional doses needed.
The facility failed to manage pain according to professional standards and resident preferences for two residents, leading to unmanaged pain and inappropriate administration of pain medications outside the specified parameters in physician orders.
The facility failed to ensure that a resident received treatment and care in accordance with professional standards by not consistently assessing and documenting the resident's blood pressure prior to administering blood pressure medications. Staff interviews confirmed that the medication administration record did not prompt nurses to document the blood pressure, and the resident's blood pressure had not been documented since 3/11/24.
The facility failed to provide proper catheter care and maintenance for two residents, leading to deficiencies in minimizing the risk of urinary tract infections. Both residents had no orders for routine catheter care, maintenance, or monitoring, despite having comprehensive care plans that included such interventions. Interviews with staff revealed a lack of awareness and adherence to proper catheter care protocols.
The facility failed to ensure a resident was free of unnecessary psychotropic medications by not attempting a gradual dose reduction (GDR) or providing substantial documentation on why a GDR was contraindicated. Despite quarterly reviews, no GDR attempts were documented for the resident, who was prescribed multiple psychotropic medications.
The facility failed to ensure controlled medications were securely stored and that medication carts were locked when not in use. Controlled medications were found in an unsecured refrigerator, and medication carts were left unattended and unlocked by LPNs, posing a risk to residents.
The facility failed to ensure that two residents received showers according to their preferences and that these preferences were included in their care plans. One resident preferred showers at a specific time and with female caregivers due to a history of sexual abuse, while another resident required increased oxygen during showers but was given bed baths instead. Staff cited reasons such as being busy and unaware of specific needs for not accommodating these preferences.
A resident with quadriplegia reported feeling very hot and sweaty in his room, which lacked a window and had locked double doors leading to an atrium. The maintenance director confirmed the atrium was not in use and suggested a fan as a solution, but acknowledged safety concerns. The facility failed to assess the resident's preference for fresh air and did not provide an alternative solution, leading to the deficiency.
The facility failed to promptly investigate an alleged verbal abuse incident involving a resident and the Activities Director (AD). Despite the incident being reported by three staff members, the AD continued to work with unrestricted access to residents for over five hours. The investigation lacked specific details and did not document the emotional impact on the resident.
The facility failed to provide necessary hygiene services for a resident fully dependent on staff for ADLs, resulting in long, discolored, and soiled fingernails, greasy hair, and only two showers in the past 30 days. The resident expressed frustration and distress over the lack of proper care, while staff cited time constraints and the need for additional assistance as reasons for not providing showers.
Ineffective QAPI Program Fails to Address Abuse and Dementia Care Concerns
Penalty
Summary
The facility failed to maintain an effective Quality Assurance and Performance Improvement (QAPI) program capable of identifying and addressing compliance concerns related to abuse, neglect, and dementia care. The facility’s written QAPI policy required establishment and implementation of a Quality Assessment and Assurance Committee, development of a written QAPI plan reviewed and updated annually, and implementation of data-driven Performance Improvement Projects (PIPs). However, surveyors found that the QAPI committee did not identify or address issues associated with abuse, neglect, and dementia care, despite existing concerns in these areas. Cross-referenced deficiencies included failures to ensure residents were free from abuse and failures to provide appropriate dementia care to help residents attain or maintain their highest level of functioning. Record review and staff interviews further showed that the facility did not have a QAPI PIP plan in place for the secure memory care unit, even though residents in that unit were able to wander from room to room, resulting in resident-to-resident physical abuse. The NHA and DON acknowledged that, at the time of the survey, there was no active PIP specific to the secure memory unit and that staff had not received needed education related to abuse and dementia. Although the DON stated the facility was working on several PIPs, including falls and dementia training, they were unable to provide specific details about these projects, demonstrating that the QAPI process was not effectively organized or implemented to address the identified concerns.
Failure to Prevent Resident-to-Resident Abuse in Dementia and Behavioral Care Units
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from physical and verbal abuse by other residents, despite known behavioral risks and repeated resident‑to‑resident altercations. The facility’s abuse policy states that residents have the right to be free from abuse, neglect, and exploitation, including freedom from verbal, mental, sexual, or physical abuse. Surveyors found that six residents experienced abusive interactions that met the regulatory definition of abuse, even when the facility sometimes concluded that incidents were not intentional or did not substantiate them. Many of the involved residents had severe dementia, behavioral disturbances, wandering, and histories of aggression, yet the facility did not consistently implement preventive measures to keep them and others safe. One resident with severe dementia and wandering and aggressive behaviors was physically abused on three separate occasions by three different residents. In one incident, a roommate with Alzheimer’s disease and a history of several resident‑to‑resident altercations grabbed at this resident’s feet and tried to pull him out of bed while yelling that it was his room. In another incident, a resident with severe dementia and aggressive behaviors physically redirected the same wandering resident out of her room, causing him to lose balance and fall. In a third incident, a resident with severe cognitive impairment and a history of physical behaviors pushed this same wandering resident and yelled at him to get out of his room after the resident entered without invitation. Staff interviews confirmed that residents frequently wandered into others’ rooms and that staff generally redirected them only after they had already entered, with no proactive measures in place to prevent unauthorized room entry. Other residents were also subjected to physical abuse. One resident with severe dementia and delusional beliefs was knocked to the floor and struck with a wheelchair by a resident with Alzheimer’s disease who became highly agitated; in a separate event, the same victim was pushed in the hallway by another resident with severe dementia and a known potential for physical aggression, who told her to walk faster. Another severely cognitively impaired resident was physically abused twice: once when her roommate, who had severe dementia and a known tendency to become aggressive when her personal space was invaded, took her face in her hands and pushed it away, and again when a different resident, with impaired coping skills and poor impulse control, became verbally distressed over a preferred chair in the common area, reached toward her, and during the altercation she fell and sustained a forehead laceration requiring first aid. In another incident, a resident with dementia wandered into the room of a resident with severe dementia and behavioral problems and grabbed and scratched her hand. The facility also failed to protect two cognitively impaired or partially impaired male roommates from escalating verbal and physical abuse toward each other. One resident with memory deficits, poor impulse control, and a behavior care plan noting potential for physical aggression reported that tension over television noise had been building between him and his cognitively intact roommate. On the day of the incident, he described flipping off his roommate, exchanging verbally hostile remarks, asking if the roommate wanted to fight, and then engaging in a shoving match after the roommate hit his leg, which resulted in him falling and sustaining a small abrasion to his knee. Staff interviews indicated that abuse was understood to include bullying and hitting, and that the altercation was preceded by days of increasing tension between the two residents. Overall, staff acknowledged frequent wandering, frequent entry into others’ rooms, and reliance on redirection after the fact, rather than preventive strategies, in a unit where many residents had dementia, mental health issues, and known behavioral risks. In several investigations, the facility did not substantiate abuse despite clear physical contact and aggression, citing lack of malicious intent or dementia‑related agitation, and sometimes made no changes to care plans or room assignments. For example, the facility concluded that a wheelchair collision and repeated contact with a resident on the floor was due to impulsive propulsion rather than an attempt to harm, and it unsubstantiated incidents where one resident pushed another in the hall and where a roommate pushed another resident’s face away. In another case, the facility’s investigation of a fall with injury following a confrontation over a preferred chair did not clearly describe the sequence of events and focused on the absence of intentional harm rather than the regulatory definition of abuse. Staff interviews further revealed that many resident‑to‑resident altercations occurred at night or on weekends when agency staff were present, and that there were no measures in place to prevent residents from entering others’ rooms, despite widespread wandering and known behavioral triggers.
Failure to Implement Person-Centered Dementia Care and Supervision for Wandering Residents
Penalty
Summary
The deficiency involves the facility’s failure to provide appropriate, person-centered dementia care and supervision for multiple residents with dementia who exhibited wandering and territorial behaviors. Facility policy required individualized care plans, least restrictive approaches, thorough clinical assessment, monitoring of mood and behavior, and staff training in dementia care and behavior management. Despite this, surveyors observed residents with known dementia and wandering tendencies roaming hallways without purpose, entering other residents’ rooms, and intruding into others’ personal space and rooms without consistent staff monitoring or redirection. During group activities, several residents wandered the halls unobserved, and one resident repeatedly attempted to exit locked doors and became frustrated without timely staff intervention. Specific residents with documented dementia, severe cognitive impairment, and care plans addressing wandering and behavioral risks were not managed according to their care plan interventions. One resident with severe cognitive impairment and documented wandering and aggressive behaviors was observed going into other residents’ rooms without staff supervision or redirection, despite care plan directives for early staff-led redirection and immediate intervention when entering others’ rooms. Another resident with dementia and daily documented wandering was seen attempting to exit locked doors and then wandering the unit and trying to exit the front door without staff maintaining line-of-sight supervision, even though the resident had an elopement/wandering care plan. Additional residents with severe cognitive impairment and documented frequent wandering were observed pacing hallways, standing idly, and entering other residents’ rooms without staff monitoring or redirection, contrary to care plan interventions that called for structured activities, reorientation strategies, and redirection. Residents identified as territorial or prone to aggression when others entered their rooms or personal space were also not consistently protected through care-planned interventions. One resident with dementia and a care plan noting potential physical aggression and territoriality, including triggers such as others entering his room or personal space, was not supervised or protected when another resident rested her head on him and touched his head and hand, and when other residents were in close proximity, without staff monitoring or redirection. Another resident with a history of becoming physically aggressive when others wandered into his room had a care-planned intervention for retractable barrier straps across his doorway, but surveyors observed that these straps were not consistently in place, allowing wandering residents to enter his room unimpeded. Staff interviews confirmed that many or all residents on the secure memory unit wandered and entered other residents’ rooms, that staff relied on red barrier straps to deter entry, and that staff did not consistently prevent residents from going into others’ rooms, with some CNAs unaware of where to find care plans or unable to clearly describe non-restrictive behavior management approaches. The record reviews further showed a pattern of frequent wandering documented in daily activity tracking for many of these residents, including those whose MDS assessments did not always reflect wandering behaviors, while care plans for elopement and wandering called for identifying patterns, determining purpose of wandering, and providing structured activities and redirection. Despite these documented needs and interventions, surveyor observations over multiple days showed residents repeatedly wandering aimlessly, entering occupied and unoccupied rooms, and intruding on others’ privacy without consistent staff intervention. This mismatch between assessed needs, written care plans, and actual staff practices led to residents with dementia not receiving the individualized, person-centered dementia management and supervision necessary to maintain their highest practicable physical, mental, and psychosocial well-being, particularly in relation to wandering, room entry, and resident-to-resident interactions. Staff interviews corroborated that wandering and room entry by residents were common and difficult to manage, and that staff did not always know or follow care-planned interventions. One CNA acknowledged that residents frequently wandered into others’ rooms and that barrier straps were used only after complaints, while another CNA admitted not knowing where care plans were located. An LPN stated that all residents wandered, especially one younger resident, and that staff only redirected residents when they saw them enter rooms that were not theirs, which conflicted with observations showing a lack of consistent redirection. Another LPN stated that residents could not be stopped from going into other residents’ rooms and that redirection was difficult, underscoring the facility’s failure to implement effective, person-centered dementia management strategies as outlined in its own policy and residents’ care plans.
Failure to Train Contracted and Agency Staff on Abuse, Neglect, and Reporting Requirements
Penalty
Summary
The facility failed to provide required training to all staff, including contracted and agency personnel, on dementia care and on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property, as well as procedures for reporting such incidents and resident abuse prevention. The facility’s Abuse policy, revised April 2025, states that it applies to all staff, including employees, consultants, contractors, volunteers, students, and other caregivers, and requires that care and services be delivered in a way that promotes residents’ rights to be free from abuse, neglect, misappropriation, exploitation, or privacy violations. Despite this policy, the regional nurse consultant was unable to produce documentation of facility-specific abuse training for contracted or agency staff and stated that these staff were educated on abuse only by their agencies prior to working at the facility. Record review showed an allegation of neglect initiated by a hospice CNA, who believed a resident receiving care from him and his contracted hospice provider was being neglected by the facility when the resident was left wet for an extended period. The incident report documented that the hospice CNA observed suspected neglect on 11/9/25 but did not report it to the facility until 11/19/25, a delay of ten days. The facility’s investigation concluded that the contracted hospice CNA failed to report suspected neglect in a timely manner. In interviews, an agency CNA confirmed she had not received any supplementary training from the facility on facility policies or expectations related to abuse and neglect, and the regional nurse consultant and DON acknowledged that the facility had not provided abuse-reporting training to agency staff and needed better coordination with the hospice agency regarding communication of concerns.
Failure to Thoroughly Investigate Resident’s Abuse Allegation Against CNA
Penalty
Summary
The deficiency involves the facility’s failure to conduct a thorough investigation into an allegation of physical abuse by a CNA toward a resident. Facility policy on abuse prevention and prohibition required that investigations include interviews with staff on all shifts who might have information about the alleged incident, interviews with staff on all shifts who had contact with the accused employee, and actions based on the information gathered. In this case, the facility’s investigation documented that the resident reported being pushed onto a bath chair, having a towel thrown at her, and being told to wash herself during shower assistance, and that she felt she had been physically abused. The social services director interviewed the resident and noted she initially appeared emotionally distressed and tearful, with a flat affect and guarded posture, and later concluded the resident was a poor historian with difficulty recalling long-term details. The investigation included an interview with the accused CNA, who denied the allegation and stated she had not provided care to the resident in a long time, but the report did not document the last date the CNA had been assigned to or assisted with the resident’s care. The facility concluded the allegation was unsubstantiated due to lack of corroborating evidence, inability to identify a specific timeframe, and findings they considered consistent with routine care. However, the investigation lacked documentation of interviews with other CNAs or nursing staff who worked with the resident to determine whether she had reported rough care or problems with showering assistance to others during the relevant period. It also lacked documentation of interviews with other residents to determine whether they had concerns about the CNA’s care. The investigation further failed to document any assessment of the shower area to identify environmental factors that might have contributed to the resident feeling abused, and did not include any attempts to observe or assess the CNA’s performance while assisting residents with showering and transfers. The resident, who had moderately impaired cognition, a history of knee injury, generalized weakness, falls, depression, anxiety, and insomnia, required assistance from one to two staff for transfers and bathing and had a behavior care plan that included monitoring behavior episodes and attempting to determine underlying causes. During a later interview, the resident reiterated that the CNA had been rough with her on more than one occasion, including pushing her onto the bath chair, throwing a wash cloth at her, telling her to wash herself, and telling her to put herself to bed, and she became visibly upset when recalling these events. The DON acknowledged that no additional investigation was done beyond what was documented in the facility’s investigation report.
Failure to Provide Timely Incontinence Care for Dependent Resident
Penalty
Summary
The facility failed to provide timely incontinence care and assistance with activities of daily living for a resident who was dependent on staff for toileting hygiene. The resident, an older adult with schizophrenia, an unspecified mood and behavior disorder, epilepsy, and severe cognitive impairment (BIMS score 0/15), was care planned for ADL self-care deficits requiring substantial supervision and encouragement due to frequent refusal of care. During continuous observation on 2/24/26 from 9:20 a.m. to 11:45 a.m. and again from 11:46 a.m. to 12:18 p.m., the resident remained in bed and no direct care staff were observed entering the room to offer incontinence care. An activities staff member briefly checked the room at 9:50 a.m. but left when the resident was sleeping, and a hospice social worker entered at 10:49 a.m. only to talk with the resident. At 12:07 p.m., a CNA entered the room and provided incontinence care, changing a urine-soaked brief and soiled bed linens. The CNA reported she believed the resident was last changed before her shift began at about 6:00 a.m., when hospice staff would have showered him, and acknowledged she had not checked him for incontinence since her shift started. This meant the resident had not received incontinence care for over six hours. The CNA further stated the resident often refused care, removed his own briefs, urinated in bed and on the floor, and lay in urine-soaked sheets, which she was responsible for changing. Nursing progress notes from prior dates documented episodes of the resident urinating on the floor and being found in bed with stool on the floor and urine-soaked linens and clothing. Multiple CNAs, an RN, the LPN, the DON, and the NHA all stated that dependent residents, including this resident, were expected to be checked and changed for incontinence at least every two hours, which did not occur during the observed period.
Failure to Maintain a Safe, Clean, and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in three of five units. Multiple observations and interviews revealed persistent odors of urine and feces in common hallways, resident rooms, and dining areas. Residents and their representatives reported frequent and strong smells of urine and feces, with some stating that the odors were so strong they had to cover their mouths and noses. Additionally, representatives noted issues such as broken blinds, missing lights, and sticky or stained floors in resident rooms and common areas. Direct observations by surveyors documented stained footprints, sticky and stained floors, dried feces in resident rooms, spills left uncleaned for hours, and cracks in floors and walls. Used linens and water pitchers were left in common areas for extended periods, and cleaning was observed to be incomplete, with crumbs and stains remaining under tables and on surfaces. Handrails and baseboards throughout the facility were scratched, chipped, and marked, and some repairs appeared to be temporary or incomplete. The facility's cleaning and maintenance practices were inconsistent, with unclear responsibilities between housekeeping and nursing staff regarding the cleaning of bodily fluids and spills. Staff interviews confirmed confusion about cleaning responsibilities and the frequency of deep cleaning. Housekeeping staff did not always clean under tables or mop common areas, and nursing staff were sometimes responsible for cleaning spills, but there was uncertainty about the cleaning solutions used and the condition of cleaning equipment. Maintenance issues, such as cracked floors and missing lights, were sometimes delayed due to communication problems and staff turnover. The facility's own policy required a sanitary, orderly, and comfortable environment, but observations and interviews indicated that these standards were not consistently met.
Failure to Involve Representatives in Care Plan Development
Penalty
Summary
The facility failed to ensure that residents and their representatives were given the opportunity to participate in the development and implementation of person-centered care plans for two residents out of a sample of twelve. Both residents were cognitively impaired, with BIMS scores of zero, and required significant assistance with daily activities. For one resident, the representative reported only being invited to the initial care conference upon admission and had not been invited to any subsequent conferences for several months, despite attempts to contact social services. Documentation confirmed that no care conferences had occurred for this resident between July and December, except for a voicemail left during the survey period. For the second resident, the representative stated difficulty in scheduling care conferences and could not recall the last time one was held. The facility's records indicated that the representative did not attend the last documented care conference due to unsuccessful contact attempts, and there was no evidence of any further care conferences in the following months. Staff interviews confirmed that the facility was behind in scheduling both initial and quarterly care conferences for all residents, including the two in question, and that documentation of contact attempts was expected but not consistently completed.
Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
The facility failed to notify a resident's designated representative of significant changes in the resident's condition, as required by facility policy. The policy states that the responsible party must be informed of any change in the resident's condition and the steps being taken, with all attempts at notification documented in the nursing progress notes. However, record review and interviews revealed that the representative was not notified of several notable changes, including facial swelling, an urgent dental visit, leg edema, loose stools, and bruising on the knee and face. The resident involved was cognitively impaired, with a BIMS score of zero, and required maximal assistance with daily activities. The medical record showed multiple incidents: a limp and mild bruising on the left knee, facial swelling and dental issues requiring urgent referral, right periorbital ecchymosis, and episodes of loose stools and leg edema. In each case, there was no documentation that the resident's representative was informed of these changes or the interventions ordered by physicians, despite the facility's policy and the resident's inability to communicate his needs. Interviews with staff, including RNs and regional clinical resources, confirmed that bruising, black eye, edema, and loose stools are considered changes of condition that require notification of the physician, DON, and the resident's representative. Staff acknowledged a gap in documentation regarding who was notified when a change of condition occurred. The resident's representative also reported not being informed about these significant health events, emphasizing the importance of communication due to the resident's inability to advocate for himself.
Failure to Administer Pain Medications Timely per Physician Orders
Penalty
Summary
The facility failed to ensure that two of five sampled residents received medication administration in accordance with professional standards and physician orders. Specifically, the facility did not administer scheduled pain medications, including Oxycontin and oxycodone, within the prescribed time frames for both residents. The medication administration records (MARs) showed multiple instances where medications were given outside the allowed one-hour window before or after the scheduled time, and in one case, a dose was missed entirely. One resident, who had diagnoses including fibromyalgia, neuropathy, and chronic pain, was cognitively intact and relied on scheduled opioid medications to manage severe pain. The MARs indicated that her Oxycontin doses were administered late on several occasions, sometimes by more than an hour past the scheduled time. The resident reported experiencing high levels of pain and noted that her pain medications were not always given on time, although she could not recall specific dates. Another resident, with diagnoses including dementia, chronic kidney disease, and chronic pain, also received scheduled pain medications. The MARs for this resident documented several late administrations of oxycodone, with one dose not administered at all. This resident expressed a desire not to experience any pain and stated that delayed administration of her pain medication resulted in increased discomfort. Staff interviews confirmed that the medications were not administered within the required time frames and acknowledged the importance of timely medication administration as per physician orders.
Failure to Provide Adequate Incontinence Supplies and Maintain Resident Dignity
Penalty
Summary
The facility failed to maintain residents' dignity and provide equal access to incontinence care supplies, as evidenced by multiple resident and staff interviews, observations, and grievance documentation. Several residents reported that they did not have access to incontinence briefs for several days due to the facility running out of supplies. Residents described being told by staff to use towels as a substitute for briefs, and some residents delayed having their briefs changed or were given incorrectly sized briefs. One resident reported that a pull-up garment provided as an alternative leaked, resulting in wet bedding that required changing by staff. Staff interviews corroborated the residents' accounts, with several staff members stating that the facility ran out of briefs at the end of May and beginning of June. Staff described limited availability of pull-up garments, which were not suitable for all residents, and reported taking briefs from some residents' rooms to use for others. Staff also stated that they were instructed by management to use towels as a substitute for briefs and that supply orders were restricted due to budget concerns. Grievance forms further documented resident concerns about running out of supplies and being told by staff that briefs were unavailable. Facility leadership, including the DON and NHA, denied instructing staff to use towels or restricting supply orders, and stated that the facility did not run out of briefs. However, the consistent reports from residents and staff, as well as direct observations of supply shortages and the use of incorrect brief sizes, indicate that the facility did not ensure adequate and appropriate incontinence care supplies were available to all residents, compromising their dignity and individualized care.
Failure to Document and Communicate Resident Discharge Needs and Equipment
Penalty
Summary
The facility failed to accurately document and communicate essential information regarding a resident's transfer and discharge. Specifically, the discharge summary did not include the resident's need for two transfer poles, and the discharge care plan lacked documentation of the resident's specific durable medical equipment requirements for a safe transition home. Additionally, there was no record of communication or confirmation from referral sources to ensure the resident's discharge needs were met, and the discharge date in the physician's orders was incorrect and not obtained in a timely manner. The resident, who was cognitively intact and required partial assistance with mobility and transfers, was discharged to his home with ongoing needs for specialized equipment, including two transfer poles for safe transfers. Despite therapy notes indicating the necessity of these poles and a purchase order being placed, only one transfer pole was installed at the time of discharge, and the second was not set up until later. The discharge documentation failed to reflect these needs, and the care plan did not address the equipment required for the resident's safety at home. Interviews with staff revealed that verbal confirmations regarding the resident's equipment and services were made with the home health agency and transition services team, but these communications were not documented in the resident's record. The transition services agent and supervisor confirmed that only one transfer pole was initially installed, and the second was found and installed after the resident had already been discharged. The social services director also acknowledged that the discharge date was communicated verbally but not documented.
Failure to Administer Prescribed Medication and Notify Physician
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering Farxiga as ordered by the physician for three consecutive days. The resident, who had diagnoses including type 2 diabetes mellitus, congestive heart failure, ischemic cardiomyopathy, and chronic kidney disease, did not receive the prescribed medication on three occasions. Documentation in the medication administration record indicated that the facility was awaiting delivery of the medication from the pharmacy, but there was no evidence that the pharmacy or the physician was notified about the missed doses. Additionally, on one of the days, the medication was available but still not administered, and no explanation was documented for this omission. Interviews with staff revealed that the process for ordering and following up on medications was inconsistent. Nursing staff reported that they would typically contact the pharmacy and notify the physician if a medication was unavailable, but there was no documentation to support that these actions were taken in this case. The clinical nurse consultant confirmed that the medication order was present in the resident's profile but was not filled by the pharmacy initially, and the medication was reordered and delivered, yet still not administered as required. The lack of timely communication and documentation contributed to the resident missing multiple doses of a critical medication.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect several residents from abuse, resulting in multiple incidents of physical and verbal abuse. Resident #2, who had a history of aggressive behavior due to dementia, was involved in two separate incidents of physical abuse. On one occasion, Resident #2 hit his roommate, Resident #8, causing a bruise under the eye. Despite being placed on one-on-one supervision initially, this was later reduced to 15-minute checks, which proved insufficient as Resident #2 later assaulted Resident #1, causing significant injuries that required hospitalization. The facility's care planning for Resident #2 was inadequate, as it did not address his history of aggressive behavior upon admission. Despite multiple documented incidents of verbal and physical aggression, the facility failed to implement effective interventions or consistently notify the physician of these behaviors. The care plan lacked specificity in documenting triggers and de-escalation strategies, and there was a failure to report certain incidents to the nursing home administrator, who was the designated abuse coordinator. Additionally, the facility failed to protect Residents #7 and #27 from verbal abuse by Resident #4. Resident #4, who had a history of verbal aggression and personality disorder, was involved in an incident where he verbally abused Resident #27. The facility's response to Resident #4's behavior was insufficient, as the interventions in place did not prevent the verbal abuse from occurring. The facility's documentation and reporting of these incidents were also found to be lacking, contributing to the overall deficiency in protecting residents from abuse.
Deficiency in Food Temperature and Palatability
Penalty
Summary
The facility failed to ensure that residents consistently received food that was palatable in taste and temperature. Interviews with residents revealed dissatisfaction with the food, noting that it was often served cold and that the facility sometimes ran out of common food items. Observations during meal preparation and service showed that food was not maintained at appropriate temperatures, with test tray items such as broccoli and penne pasta being served at 102 degrees Fahrenheit and chicken breast at 120 degrees Fahrenheit. Additionally, the facility ran out of zucchini and broccoli during meal service, and the test tray was not properly covered, leaving food exposed. Staff interviews indicated that the plates used for room trays were not pre-warmed, contributing to the issue of cold food. The dietitian resource acknowledged that plates were not placed in the plate warmer prior to meal assembly and that there was a shortage of plate covers and lids, which may have contributed to the problem. The facility's dietary improvement plan, initiated in October 2024, was updated to address food temperature issues, but additional plates were not purchased until the survey was conducted.
Food Storage and Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen and three of five nourishment rooms. Observations revealed several issues with food storage, including expired and unlabeled food items. In the main kitchen refrigerator, there were sealed containers of potato salad past their use-by dates, unsealed hot dogs, and unlabeled sauces. Additionally, thawed pork roasts and orange liquid packages lacked pull or expiration dates. An open bottle of expired cooking wine was also found. In the drink station refrigerator, expired and bloated apple slices, unwrapped cake, and expired yogurt and cottage cheese were observed. Multiple spills and crumbs were noted in the refrigerator and freezer. The 400 hall nourishment refrigerator contained a frozen pasta dish without a resident name or date, corn tortillas, grapes, and green chile sauce without proper labeling. Despite a sign indicating food should be discarded after 72 hours if not labeled, these items remained the following day. Medications were improperly stored in the 500 hall nourishment refrigerator, with vaccines placed in a butter conditioner that did not seal completely. Interviews with staff revealed a lack of adherence to labeling and dating protocols, with dietary staff responsible for managing nourishment refrigerators and ensuring food safety. The director of nursing confirmed that medications were not typically stored in nourishment refrigerators and were subsequently removed.
Failure to Report Alleged Abuse and Document Incidents
Penalty
Summary
The facility failed to report alleged violations of potential abuse to the State Survey and Certification agency for two residents. Resident #2, who had a history of cerebral palsy, dementia with behavioral disturbance, and violent behavior, was involved in multiple incidents of aggressive behavior towards other residents. These incidents, which included verbal and physical aggression, were not reported to the State Agency as required. The facility's documentation was inadequate, and the incidents were not properly investigated for potential abuse. Resident #24, who was cognitively impaired and resided in a secure unit due to wandering behavior, was involved in an incident with Resident #2. During this incident, Resident #24 was found with injuries, including a laceration over the left eyebrow and a skin tear on the left hand. Despite the visible injuries and Resident #24's statement that he was hurt by someone, the facility documented the incident as a fall and did not report it to the State Agency. The facility's investigation was based on interviews with both residents, who denied physical contact, leading to the conclusion that no abuse occurred. Interviews with the Director of Nursing (DON) and the Nursing Home Administrator (NHA) revealed that the facility's reporting process was flawed. Some incidents were not visible in the 24-hour report due to documentation errors, and agency staff were identified as contributing to these errors. The facility acknowledged that certain incidents should have been reported to the abuse coordinator and the State Agency but were not. The DON and NHA admitted to not seeing some of the documented notes, which contributed to the failure to report potential abuse.
Failure to Implement Timely Care Plan for Aggressive Resident
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident diagnosed with dementia, who had a history of physical aggression. Upon admission, the resident's care plan did not include person-centered interventions to address his history of physical and verbal aggression, which was necessary to prevent altercations with other residents. The resident, who was over 65 years old, had multiple diagnoses including cerebral palsy, acute respiratory failure, dementia with behavioral disturbance, and violent behavior. Despite these conditions, the facility did not implement a care plan addressing his aggressive behaviors until two months after his admission. The resident's comprehensive care plan, initiated shortly after admission, focused on monitoring cognitive function but lacked specific interventions for managing his aggressive behaviors. It was not until several months later that a focused care plan for verbally aggressive behaviors was initiated, and even then, it did not specify the playful behaviors that could be misconstrued. The care plan for physical behaviors was only initiated after further incidents, indicating a delay in addressing the resident's known history of aggression. Interviews with facility staff revealed that the resident's behaviors were sporadic and difficult to predict, which contributed to the delay in implementing a comprehensive care plan. The Director of Nursing stated that the facility initially aimed to establish a baseline for the resident's behavior before adding specific interventions to the care plan. However, this approach resulted in a lack of timely and effective interventions to prevent resident-to-resident abuse, as the facility did not update the care plan with necessary measures based on the resident's documented history of aggression.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection control program on one of its units, specifically in the care of a resident with a suprapubic catheter and stage 4 pressure wounds. The deficiency was observed when staff did not follow Enhanced Barrier Precautions (EBP) during high-contact activities with the resident. The Centers for Disease Control and Prevention (CDC) guidelines require the use of gowns and gloves during such activities to prevent the transmission of multidrug-resistant organisms (MDROs). However, staff members, including a physical therapist, a speech language pathologist, and certified nurse aides, were observed entering the resident's room and providing care without donning the necessary personal protective equipment (PPE). The facility's policy required the use of EBP for residents with wounds and indwelling medical devices, such as the resident in question. Despite this, there was no EBP sign or PPE bin outside the resident's room to alert staff of the need for enhanced precautions. Observations revealed that staff members, including CNAs, failed to wear gowns while providing care, such as repositioning and toileting the resident, who had visible serosanguineous drainage from a wound dressing. Interviews with staff indicated a lack of awareness and understanding of the EBP requirements for the resident. The director of nursing (DON) and assistant director of nursing (ADON) acknowledged the absence of appropriate signage and PPE bins, which were supposed to alert staff to the resident's high infection risk status. The ADON admitted to removing the droplet precautions sign and PPE bin due to a misunderstanding of the resident's infection status and EBP requirements. This lack of adherence to infection control protocols and inadequate staff training contributed to the deficiency in maintaining a safe and sanitary environment for the resident.
Failure to Protect Residents from Mental and Verbal Abuse
Penalty
Summary
The facility failed to protect four residents from mental and verbal abuse, leading to significant emotional distress. Resident #79 reported that the activities director (AD) spoke to her rudely, raised her voice, and belittled her, making her feel like a scolded child. Despite three staff members promptly reporting the incident to the nursing home administrator (NHA), the facility did not initiate an investigation or take corrective actions for several hours, allowing the AD to continue working and interacting with residents, including Resident #79, for five hours after the incident. Resident #60 experienced severe pain from being reclined in his wheelchair for an extended period. When he asked a certified nurse aide (CNA) to help him into bed, the CNA raised his voice and told him that other residents had more important needs, making Resident #60 feel unimportant and neglected. The facility's response was inadequate, as the NHA acknowledged that the CNA should have sought assistance but did not ensure timely care for Resident #60. Residents #13 and #60 were subjected to repeated verbal abuse by Resident #31, who used racial slurs and offensive language. Despite staff witnessing these incidents and the facility conducting investigations, no effective corrective actions were taken to prevent further abuse. The facility failed to update care plans for the affected residents or adequately address the emotional impact of the abuse, leaving Residents #13 and #60 feeling fearful and distressed.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to ensure timely access to vision services for three residents, leading to deficiencies in their care. Resident #93, who has quadriplegia and is cognitively intact, reported needing glasses due to astigmatism and had requested to see an eye doctor multiple times since admission. Despite the eye doctor visiting the facility in March 2024, Resident #93 was not seen because he was not on the list, and his vision needs were not addressed in his care plan. Resident #40, who has moderate cognitive impairment and requires supervision for eating and oral hygiene, reported needing to see an eye doctor because she had lost her glasses and had not been offered an appointment by the facility. Her vision needs were also not addressed in her care plan, and she had not seen an eye doctor in the past year. Resident #57, who has moderate cognitive impairment and multiple chronic conditions, saw an eye doctor in February 2024 and was found to need corrective lenses due to worsening vision. However, he had not received his glasses, and the facility was unaware of the status of his new glasses. The social services director acknowledged the inconsistency in ancillary services and the delay in providing necessary vision care to these residents.
Unsafe and Unsanitary Conditions in Laundry Room
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment in the laundry room. Observations revealed multiple environmental concerns, including a wet and slippery floor, a large uncovered drain, water leaking from the ceiling onto the floor and washing machines, and a container of sharps placed next to a washing machine. Additionally, there was water build-up on top of the washing machines, pieces of equipment, and a glove sticking out of one of the machines. Only two out of three washing machines and one out of three dryers were operational. The housekeeping supervisor was unsure about the items on top of the machines and the cause of the leak, while the maintenance director acknowledged the issues but had not yet resolved them. The maintenance director, who started working at the facility in February 2024, admitted that the laundry room needed attention and had not been cleaned. He pointed out the uncovered drain as a significant hazard and mentioned an ongoing investigation into the source of the leak. The maintenance director also noted that the container of sharps should not be in the laundry room and that the broken washing machine had been out of order for several years. He was in the process of obtaining quotes to repair or replace the non-functional machines. The overall condition of the laundry room was unsafe and unsanitary, posing risks to residents, staff, and the public.
Failure to Provide Engaging Activities and Adequate Supervision in Dementia Care Unit
Penalty
Summary
The facility failed to provide a consistent and engaging activity program for residents in the secured dementia care unit, leading to a lack of meaningful activities for residents. Observations revealed that residents were often left idle, dozing, or wandering the halls without access to independent activity supplies such as books, puzzles, or coloring pages. Staff did not engage residents in conversation or activities, and there was no structured activity schedule consistently followed. For example, Resident #97 repeatedly asked about exercise class but received no acknowledgment from staff, and Resident #84 expressed boredom and anxiety without staff intervention. Additionally, the facility did not provide adequate supervision to prevent resident-to-resident altercations. Resident #78, who had a history of wandering into other residents' rooms, was not monitored effectively, leading to an incident where Resident #78 entered Resident #41's room, resulting in a physical altercation. Staff were unaware of Resident #78's location during these incidents, and there was no documentation of increased monitoring for Resident #78 following the altercation. The facility also failed to interact with residents in a safe and appropriate manner. For instance, Resident #71 was involved in two separate incidents where staff engaged in a tug-of-war over nonessential objects, such as a towel and a chair, instead of offering a diversion or a more appropriate object. These interactions were not only confrontational but also left the resident unsupported and at risk of falling. The facility's lack of person-centered care and failure to address the residents' needs contributed to the residents' inability to attain or maintain their highest practicable physical, mental, and psychosocial well-being.
Failure to Provide Dental Services
Penalty
Summary
The facility failed to assist residents in obtaining routine or emergency dental services as needed. Resident #57, who had broken teeth and was in pain, had been waiting for five months for follow-up dental services to have his teeth extracted and dentures made. Despite multiple dental consultations and recommendations for extractions, the resident's dental issues were not addressed in his care plan, and he did not receive prescribed pain relief medication from 4/1/24 through 4/8/24. Resident #40, who was edentulous, had been waiting several months for dentures to be made. The resident had no follow-up dental visits after 1/3/24, and her dental issues were not included in her care plan. The resident expressed difficulty eating without teeth and had not received any updates on the progress of her dentures. Resident #93, who had quadriplegia and a broken tooth causing pain, had not seen a dentist since being admitted to the facility despite multiple requests. The resident's dental needs were not addressed in his care plan, and he did not receive prescribed pain relief medication from 4/1/24 through 4/8/24. Additionally, Resident #84, who had dementia and required dental services, had not been referred to a dental specialist as recommended. The resident's representative had been calling the facility for months without receiving a response, and the resident's dental issues were not documented in her medical record or progress notes.
Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain an effective infection control program, leading to multiple deficiencies. Housekeeping staff did not consistently change gloves or perform hand hygiene when appropriate. Observations revealed that housekeepers used disinfectant chemicals improperly, failing to allow the necessary contact time for effective disinfection. Additionally, housekeeping staff did not follow proper hand hygiene protocols, such as washing hands for the required duration or using hand sanitizer correctly. These lapses were observed during routine cleaning of resident rooms and bathrooms, where surfaces were not visibly wet after being wiped down, indicating insufficient disinfection. Interviews with housekeeping staff and supervisors confirmed these practices, highlighting a lack of adherence to the facility's infection control policies and procedures. The facility also failed to track, offer, and administer the COVID-19 vaccination to residents. Record reviews showed that several residents had not been offered or received the 2023/2024 COVID-19 booster. The Infection Preventionist (IP) admitted that no COVID-19 vaccination clinics had been held since she started working at the facility, and the previous pharmacy used by the facility did not have access to the COVID-19 booster. This lack of vaccination tracking and administration is a significant lapse in infection control, especially given the ongoing pandemic. Infection control practices were also not followed during wound care and medication administration. An RN was observed performing wound care without sanitizing the bedside table or laying down a barrier for supplies. The RN did not perform hand hygiene after touching dirty items and before providing wound care. Similarly, an LPN did not wash or sanitize her hands between residents during medication administration, and when she did wash her hands, it was only for six seconds, far short of the recommended 20 seconds. These observations indicate a broader issue with adherence to infection control protocols among clinical staff, further compromising the safety and well-being of residents.
Failure to Implement Pneumococcal Immunization Policies
Penalty
Summary
The facility failed to implement policies and procedures related to pneumococcal immunizations for five residents. Specifically, the facility did not ensure that the electronic medical records (EMR) of these residents were up to date with their vaccination history. Additionally, the facility did not determine which pneumococcal vaccine was given to these residents and whether additional doses were needed. This deficiency was identified through record reviews and interviews with staff and residents' representatives. Resident #63, aged 70, was admitted with diagnoses including dementia and abnormal weight loss. The resident's minimum data set (MDS) assessment revealed that she was not up to date on her pneumococcal vaccination and had not been offered the vaccination. A review of her EMR confirmed the absence of documentation indicating that she had received or been offered the pneumococcal vaccination. Similar issues were found with Resident #68, who had diagnoses including hypertension, Alzheimer's disease, and depression. The MDS assessment for Resident #68 did not indicate if the resident was up to date on his pneumococcal vaccination, and the EMR review revealed that the resident had not received the vaccination despite consent being provided. Resident #84, aged 78, with diagnoses including heart disease, COPD, and dementia, was also found to be not up to date on the pneumococcal vaccination and had not been offered the vaccination. The EMR review confirmed this. Resident #3, aged 72, with diagnoses including dementia and multiple sclerosis, had an MDS assessment indicating that he was not up to date on the pneumococcal vaccination, and his power of attorney confirmed that the facility had not contacted her recently to obtain consent. Resident #31, aged 65, with multiple sclerosis, had an MDS assessment that did not indicate if he was up to date on the pneumococcal vaccination, and the EMR review revealed that he had not received the vaccination despite consent being provided.
Failure to Manage Pain Consistently with Professional Standards
Penalty
Summary
The facility failed to manage pain in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for two residents. Specifically, the facility did not offer person-centered non-pharmacological pain interventions for one resident and did not follow physician orders for pain parameters when administering as-needed pain medications for both residents. This resulted in the residents experiencing unmanaged pain and receiving inappropriate pain medications outside the specified parameters in their physician orders. Resident #57, a 66-year-old with multiple diagnoses including chronic pain, reported frequent pain that interfered with his sleep and daily activities. Despite his preference for non-pharmacological interventions like heat packs, the facility did not offer these options. Additionally, the resident was administered Hydrocodone-Acetaminophen for pain levels that did not align with the physician's specified parameters, leading to inappropriate pain management. Resident #87, under the age of 65 with diagnoses including morbid obesity and chronic pain, also experienced frequent pain that affected her daily activities. The facility administered Oxycodone at incorrect dosages based on her reported pain levels, which did not match the physician's orders. This included instances where the resident received higher doses of Oxycodone for lower pain levels and vice versa, indicating a failure to adhere to the prescribed pain management plan.
Failure to Document Blood Pressure Before Administering Medication
Penalty
Summary
The facility failed to ensure that Resident #87 received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan. Specifically, the facility did not consistently assess and document the resident's blood pressure prior to administering blood pressure medications. According to the April 2024 computerized physician orders, Resident #87 was prescribed Prazosin HCI Oral Capsule for hypertension, with instructions to hold the medication if the systolic blood pressure (SBP) was less than 110 mmHg. However, the April 2024 vital signs summary and medication administration record (MAR) revealed that the resident's blood pressure was not assessed from 4/1/24 to 4/8/24 when the medication was administered. Interviews with staff confirmed the deficiency. Registered Nurse (RN) #3 stated that the medication administration record typically required the blood pressure to be taken prior to administering the medication, but the physician order for Prazosin was not prompting the nurses to document the blood pressure. The Assistant Director of Nursing (ADON) also confirmed that the physician orders instructed the licensed nurses to take the resident's blood pressure and hold the medication if the blood pressure was less than 110. However, the ADON acknowledged that Resident #87's blood pressure had not been documented since 3/11/24, although he trusted the nurses to take the blood pressure prior to administering the medication.
Failure to Provide Proper Catheter Care and Maintenance
Penalty
Summary
The facility failed to consistently provide catheter care, treatment, and services to minimize the risk of urinary tract infections for two residents. Resident #13, who had a suprapubic catheter, reported experiencing pain from his catheter and stated that he had been asking nursing staff for over a week to replace it, but it had not been done. A review of Resident #13's medical records revealed no orders for routine catheter care, maintenance, or monitoring, despite a history of recurrent catheter-associated urinary tract infections (CAUTI). The comprehensive care plan for Resident #13 included interventions for catheter care, but there was no documentation of catheter care or replacement being performed since his readmission. Resident #83, who had an indwelling catheter, also had no orders for routine catheter care, maintenance, or monitoring in her medical records. The resident could not remember the last time her catheter was changed. The comprehensive care plan for Resident #83 included interventions for catheter care, but there was no documentation of a void trial after the physician's note. Both residents had intact cognition and did not reject care or assistance. Interviews with the assistant director of nursing (ADON) and a licensed practical nurse (LPN) revealed that residents with catheters should have orders for care and monitoring to prevent infection. The ADON was not aware of Resident #13's complaints of pain or requests to have his catheter changed. The LPN stated that routine orders for changing a catheter were usually every three months and that all residents with catheters should have physician orders for care. The facility's failure to ensure proper catheter care and maintenance for these residents led to the identified deficiencies.
Failure to Attempt Gradual Dose Reduction for Psychotropic Medications
Penalty
Summary
The facility failed to ensure that residents were free of unnecessary psychotropic medications, specifically for one resident who did not receive a gradual dose reduction (GDR) for her antidepressant, sedative, and antipsychotic medications. The facility's policy required that residents on psychotropic drugs receive GDRs and behavioral interventions unless clinically contraindicated. However, the facility did not attempt a GDR for the resident's medications or provide substantial documentation from the prescribing physician on why a GDR was contraindicated. Resident #87, under the age of 65, had multiple diagnoses including morbid obesity, bipolar disorder, PTSD, mood disorder, and cognitive communication deficit. Despite being cognitively intact and having minimal signs of depression, the resident was prescribed several psychotropic medications, including Citalopram, Latuda, Zolpidem Tartrate, and Valproic Acid. The interdisciplinary team (IDT) psychotropic reviews conducted on multiple occasions did not indicate any attempts for a GDR, and the medical record lacked a risk versus benefit statement requested by the facility. Interviews with the Social Services Director (SSD) confirmed that the resident's psychotropic medications were reviewed quarterly, but no GDR attempts were documented. The SSD was unsure when the last dose reduction was attempted for the resident. The facility's failure to follow its own policy and procedure for GDRs and to document the clinical justification for not attempting a GDR led to the deficiency identified in the report.
Failure to Properly Store and Secure Medications
Penalty
Summary
The facility failed to ensure medications and biologicals were stored in accordance with accepted professional standards. Specifically, controlled medications were not stored in a locked storage container that was permanently affixed to the refrigerator. Six vials of liquid Ativan and one bottle of oral Ativan were found in a ziploc bag on the bottom shelf of the medication refrigerator, which was not securely affixed. The nursing home administrator in training acknowledged the issue and mentioned a temporary solution using zip ties until a permanent fix could be implemented. Additionally, the facility failed to ensure that medications were not left unattended. An LPN left a medication cup containing cardiac medications on top of the medication cart while stepping away to administer medications to a resident, leaving the cart out of direct line of sight. Another instance involved an LPN leaving the medication cart unlocked while not in sight, with other facility staff passing meal trays to residents. Both incidents were immediately reported to the assistant director of nursing, who confirmed that medications should not be left unattended and that medication carts should always be locked when not in use.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to ensure that two residents received showers according to their preferences and that these preferences were included in their care plans. Resident #87, who has diagnoses including morbid obesity, bipolar disorder, and PTSD, preferred to shower at 7:00 p.m. on Thursdays but did not receive showers on her preferred days on multiple occasions. Additionally, her care plan did not include her preference for female caregivers due to her history of sexual abuse. The staff acknowledged the resident's preferences but cited staff availability as a reason for not accommodating her requests consistently. Resident #57, with diagnoses including COPD and chronic respiratory failure, preferred to shower on Sunday and Wednesday nights but was given bed baths instead due to his increased oxygen needs during showers. The resident expressed dissatisfaction with bed baths, stating they did not make him feel clean. The facility staff were unaware of his increased oxygen needs and did not include his shower preferences in his care plan. The resident's previous facility had been able to accommodate his oxygen needs during showers, but this facility failed to do so. Interviews with staff, including CNAs and the ADON, revealed that while the residents' preferences were documented, they were not consistently followed due to various reasons such as staff being busy or unaware of specific needs. The facility's policies on bathing and ADLs were not effectively implemented, leading to the residents' preferences being overlooked and not included in their comprehensive care plans.
Failure to Provide a Comfortable and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for Resident #93, who was under the age of 65 and diagnosed with quadriplegia, among other conditions. The resident's room did not have a window, and the only access to fresh air was through double doors leading to an atrium, which were locked and inaccessible. The resident reported feeling very hot and sweaty, which made him feel unclean. He had a fan in the room, but it was loud and not sufficient to cool the room. The maintenance director confirmed that the atrium was not in use and that he did not have a key to open the doors. He also mentioned that installing a window was impossible due to the building's original structure. The maintenance director suggested providing a fan as a solution but acknowledged that it would be a safety hazard to allow access to the atrium. The facility's policy on maintaining a safe, homelike environment emphasizes the importance of comfortable temperature levels and the resident's opinion of their living environment. Despite this, the facility did not assess the safety of the resident's preference for fresh air and did not provide an alternative solution to ensure the resident's comfort. The resident expressed a desire to open the double doors to the atrium for fresh air and sunlight, but this request was not accommodated, leading to the deficiency noted in the report.
Failure to Investigate Alleged Verbal Abuse
Penalty
Summary
The facility failed to initiate and complete a thorough investigation of an alleged violation of mental and verbal abuse involving a resident. The incident occurred when the Activities Director (AD) spoke to a resident in a mean and belittling manner, causing the resident emotional distress. Despite the incident being reported by three staff members, the facility did not start an investigation or take immediate corrective actions to protect the resident from further abuse. The AD continued to work in the facility with unrestricted access to the resident and other residents for over five hours after the incident. The investigation documentation and interviews revealed several deficiencies. The witness statements lacked specific details such as the location and time of the incident, the proximity of the staff assailant to the resident, the exact words used, and the demeanor, gestures, tone, and volume of the AD's voice. Additionally, the investigation report did not document the findings, conclusions, or recommendations to prevent further abuse. The facility also failed to document the emotional impact of the incident on the resident and did not explore potential biases between the alleged abuser and witnesses. Interviews with staff members indicated that the incident was reported to the Nursing Home Administrator (NHA) around 12:30 p.m., but the NHA did not start an investigation or suspend the AD until over five hours later. The NHA stated that the staff did not explicitly mention that the incident was verbal abuse, which led to the delay in taking action. The AD admitted to raising her voice and not handling the situation well, acknowledging the need for more training in de-escalation techniques.
Failure to Provide Necessary Hygiene Services
Penalty
Summary
The facility failed to provide necessary services to maintain personal hygiene for Resident #60, who was fully dependent on staff for all activities of daily living (ADLs) due to functional limitations in both lower extremities and cognitive communication deficits. Despite being cognitively intact, the resident's care plan indicated a need for assistance with bathing and grooming, including two staff members for bathing and transfers. However, observations revealed that the resident's fingernails were long, discolored, and visibly soiled on multiple occasions, and his hair was greasy. The resident reported receiving only two showers and one bed bath in the past 30 days, contrary to the care plan that scheduled showers twice a week. The resident expressed frustration and distress over the lack of proper hygiene care, stating that staff refused to provide showers, citing time constraints and the need for additional assistance with the hoyer lift. The facility's documentation did not indicate any refusals of showers by the resident, and the care plan did not document any refusals either. Interviews with staff revealed inconsistencies in the provision of care, with one CNA stating that the resident sometimes refused care but was unsure whose responsibility it was to trim the resident's nails. The assistant director of nursing (ADON) acknowledged the resident's history of refusals but noted that the resident was compliant when approached correctly. The ADON also stated that the resident should not have had visibly dirty and ungroomed nails, especially if the resident wanted assistance. The nursing home administrator (NHA) emphasized that residents requiring assistance should have been cared for, particularly those in visible discomfort and distress. The NHA stated that staff members unable to assist residents in a timely manner should notify the charge nurse and seek help from other staff. Despite these policies, the facility failed to provide adequate hygiene care for Resident #60, leading to the resident's frustration and distress over his unclean condition.
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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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