Park Forest Care Center Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Westminster, Colorado.
- Location
- 7045 Stuart St, Westminster, Colorado 80030
- CMS Provider Number
- 06A172
- Inspections on file
- 23
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Park Forest Care Center Llc during CMS and state inspections, most recent first.
A nonverbal, fully dependent resident who received all nutrition and hydration via G-tube did not receive ordered continuous enteral feeding from late afternoon through the night. One RN reported that no tube feeding formula was available and placed the feeding on hold, despite other staff confirming formula was present in the building. The RN then gave inaccurate handoff information that the feeding was on hold, and the oncoming RN did not verify the physician’s orders or check supply availability, resulting in no enteral nutrition being administered during that period. Progress notes documented the feeding as on hold without a stated reason or physician order, and the resident’s representative later reported significant stress and anxiety after being told the feeding had not been provided as ordered.
Two residents with dementia, severe cognitive impairment, and documented fall histories did not consistently receive their care-planned, person-centered fall-prevention interventions. One resident with hemiplegia and wandering behavior, identified as high fall risk, experienced multiple unwitnessed falls, including a head laceration requiring stitches, while staff left the resident alone in the bathroom, did not use the ordered communication board, and did not maintain the bed in a low position. Another resident with prior pelvic fractures and head injury was observed in bed without a fall mat in place, with the bed not in the lowest or locked position, and later in a wheelchair wearing regular socks instead of proper footwear, despite care-plan directives for a fall mat, low locked bed, and appropriate footwear.
Surveyors found that the facility failed to prevent significant medication errors for two residents. One resident with complex medical and SUD history had an external addiction provider order increasing Methadone from 40 mg to 50 mg for relapse prevention, but facility orders and MARs were not updated for over a month, doses were documented and administered as 40 mg against the external order, narcotic count sheets lacked required strength documentation, and care plans did not address Methadone use or SUD triggers. The same resident became unresponsive and was given Narcan without a prior standing order or documented physician order, and the Narcan administration was not recorded on the MAR. Another resident ordered Doxycycline 100 mg BID for infection missed multiple doses, with blank MAR entries and no corresponding explanatory progress note, and documentation inconsistencies showed the antibiotic recorded as given before it had arrived from the pharmacy.
A resident with multiple complex conditions, including functional quadriplegia, PTSD, schizophrenia, and chronic pain, was receiving methadone management from an external addiction provider, but the provider’s visit notes and methadone dose changes were not obtained and uploaded into the EMR. Facility policy required complete and timely documentation, and the process described by the DON and ADON indicated that nursing staff were responsible for reviewing external orders and updating the EMR using physician communication forms. However, the addiction provider notes documenting methadone dose increases and a later decrease due to sedation were missing from the EMR, and the DON reported uncertainty about the full process for handling external provider documentation and whether a backlog of records existed.
The facility did not consistently follow up on or resolve group grievances raised during resident council meetings, despite having a policy requiring prompt investigation and written resolution. While individual concerns were sometimes addressed, group issues such as building temperature, call light response times, and meal options were not documented as resolved, and staff confirmed there was no process for following up on these group grievances.
Surveyors identified multiple failures in infection prevention and control, including improper cleaning techniques by housekeeping staff and failure of direct care staff to use required PPE during high-contact care activities for residents on Enhanced Barrier Precautions. Residents with wounds, indwelling devices, and complex medical needs were not consistently protected due to lapses in hand hygiene, environmental cleaning, and PPE use, as confirmed by direct observation and staff interviews.
A deficiency was identified when exhaust fans in one shower room and nine resident bathrooms were found to be nonfunctional, missing, or improperly installed, resulting in inadequate ventilation. Observations showed that some vents were dirty, some had exposed wiring, and the facility's maintenance monitoring did not detect all issues.
A resident with a history of dementia and behavioral disturbances was diagnosed with bipolar disorder, but the facility did not notify the State Mental Health Agency or complete a required PASRR Level II evaluation. The new diagnosis was not identified during multiple care plan reviews, and there was no supporting documentation in the medical record. The deficiency was discovered during a survey.
The facility did not consistently implement or update safety interventions for three residents at risk for accidents, including a resident with severe cognitive impairment who eloped and removed his wander alert device, a resident with a seizure disorder who was repeatedly left in bed without a fall mat, and a resident with a history of multiple falls whose care plan was not updated after each incident. Staff failed to reassess risks or ensure care-planned interventions were in place, and documentation of reviews and interventions was incomplete.
A resident with a tracheostomy and complex medical history was observed receiving 4.8 LPM of oxygen instead of the physician-ordered 4 LPM. Nursing staff did not verify or adjust the oxygen flow rate as required, and the care plan lacked specific details about the ordered flow rate. Interviews confirmed that staff were unaware of the discrepancy and did not consistently follow facility policy for verifying and administering oxygen therapy.
A resident with multiple chronic conditions did not receive scheduled Percocet for pain management on two occasions, as documented in the MAR. Despite experiencing severe pain and expressing that the medication regimen was ineffective, the prescribed medication was not available and not administered, and there was no documentation that the physician was notified. The DON confirmed that required protocols, such as notifying the physician or using the emergency kit, were not followed, resulting in a significant medication error.
A facility failed to protect residents from abuse, resulting in repeated incidents of harm. A resident, who was blind and nonverbal, was sexually abused by another resident with a history of inappropriate behavior. Despite previous incidents, the facility did not implement effective interventions, allowing the abusive behavior to continue. The facility's inadequate response to reports of inappropriate behavior left residents vulnerable, creating a situation of immediate jeopardy.
The facility failed to designate a full-time Director of Nursing (DON), as the DON was frequently utilized as a floor nurse despite the facility's policy and the presence of 80 residents. This led to the DON falling behind on administrative duties, including investigating and logging falls, due to time spent on the floor.
The facility's QAPI program failed to identify and address concerns related to resident-to-resident abuse, leading to immediate jeopardy and harm. Despite previous citations for abuse, the QAPI committee did not recognize abuse as a concern, indicating a significant gap in their quality assurance processes.
Failure to Provide Ordered Continuous Tube Feeding to Dependent G-Tube Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a nonverbal, fully dependent resident receiving nutrition and hydration solely via a G-tube received ordered continuous enteral feeding and water flushes. The resident had severe cognitive impairment, was dependent for all ADLs, and had diagnoses including crushing head injury and dysphagia. Physician orders required continuous Isosource 1.5 (or equivalent) via G-tube at a specified rate and duration to meet nutritional and hydration needs. On one evening, beginning at 4:00 p.m., the ordered tube feeding was not initiated and was not provided through the night until 6:00 a.m. the following morning, and there was no documentation that the ordered tube feeding was administered during this entire period. Nursing documentation and progress notes showed that the enteral feed order was placed on hold, with entries on consecutive days indicating the tube feeding remained on hold, but without any documented clinical reason or physician order explaining why it was held. The facility’s investigation identified two RNs as responsible for not administering the tube feeding as ordered. One RN reported that there was no tube feeding formula available in the building and placed the tube feeding on hold, while the ADON and central supply staff reported visually confirming that tube feeding formula was in fact available in the facility that day. The same RN also provided inaccurate information to the oncoming shift that the tube feeding order was on hold. The oncoming RN accepted the report that the tube feeding was on hold and did not verify the physician’s orders or follow up on the actual availability of formula, resulting in the resident receiving no enteral nutrition from late afternoon through the night. Interviews documented that other nursing staff were aware of established processes to obtain formula from central supply, pharmacy, or sister facilities and that tube feedings could only be held with a physician’s order or for specific clinical reasons. The resident’s representative reported being informed that the tube feeding was not administered because the facility ran out of the specific formula and that a similar formula was later initiated, and she described experiencing significant stress, fear, and anxiety upon learning that the resident’s tube feeding had not been provided as ordered.
Failure to Consistently Implement Person-Centered Fall-Prevention Interventions
Penalty
Summary
The deficiency involves the facility’s failure to ensure person-centered fall interventions were consistently implemented for two residents identified as being at risk for falls, resulting in multiple unwitnessed falls and injuries. One resident with hemiplegia, vascular dementia, severe cognitive impairment, wandering behavior, and a history of frequent falls was care planned as high risk for falls with multiple individualized interventions, including use of a communication board, low bed, anti-rollbacks and anti-tippers on the wheelchair, grip tape on the floor, scheduled toileting assistance, a soft-touch call light, and relocation of the room closer to the nurses’ station. Despite these identified needs and interventions, the resident experienced several unwitnessed falls in her room and bathroom, including one fall where she hit the back of her head and required five stitches. Progress notes documented that many of her falls occurred when she attempted to use the bathroom independently. During surveyor observations, staff actions and inactions showed that these person-centered interventions were not consistently implemented. The resident was observed sitting on the edge of her bed, unstable on her feet, attempting to manipulate her wheelchair and reach for items out of her reach without staff assistance. She was assisted to the bathroom by an LPN, who then left her alone and did not return, despite the resident’s known high fall risk and history of attempting to toilet independently. The resident did not use her call light and repeatedly self-transferred between the toilet and wheelchair and self-propelled in and out of her room and into the hallway without staff assistance or supervision. Although the interdisciplinary team had previously added a communication board to help the resident express her needs and reduce frustration that led to unsafe ambulation, staff were not observed using a communication board with her. Additionally, after the physician documented that a low bed was being ordered to help prevent further falls, observations showed the resident’s bed was not in a low position. The second resident had dementia, severe cognitive impairment, a history of falls, and documented pelvic fractures, and was care planned as being at moderate risk for falls with specific interventions. These interventions included ensuring the call light was within reach, providing proper footwear such as tennis shoes or non-skid socks, educating the resident to lock wheelchair brakes prior to self-transfer, providing contact guard assist for transfers, placing a fall mat at bedside when the resident was in bed, and keeping the bed in the lowest position. The resident had multiple documented falls, including falls resulting in pelvic fractures and a fall from bed with head involvement and a hematoma. Despite these identified risks and interventions, surveyor observations found the resident in bed without a fall mat in place, with the fall mat folded against the wall, and the bed not in the lowest position or locked. The resident was also observed self-transferring from wheelchair to bed and sitting in her wheelchair wearing regular socks without appropriate footwear, while the bed remained unlocked. Staff entering the room did not correct the absence of the fall mat or the unlocked bed, and the care plan did not document that the resident refused these fall-prevention interventions.
Significant Medication Errors in Methadone, Narcan, and Antibiotic Management
Penalty
Summary
The deficiency involves the facility’s failure to ensure residents remained free from significant medication errors, particularly in the management of Methadone and Narcan for one resident and antibiotic therapy for another. For the first resident, who had diagnoses including cervical vertebral fracture, functional quadriplegia, PTSD, schizophrenia, chronic pain due to trauma, and neuromuscular bladder dysfunction, an addiction provider visit on 12/18/25 documented that the resident continued to experience cravings while on Methadone 40 mg daily and ordered an increase to 50 mg daily for relapse prevention. Despite this, the facility’s computerized physician orders (CPO) for December 2025, January 2026, and February 2026 continued to list Methadone 40 mg daily until 1/20/26, and documented the indication as pain rather than relapse prevention. There were no CPOs addressing the resident’s history of substance use disorder (SUD) or orders to identify, monitor, assess, or document triggers and cravings related to SUD. Review of narcotic count sheets and medication administration records (MARs) showed that from 12/27/25 through 1/9/26, staff administered and documented Methadone 40 mg daily, contrary to the addiction provider’s order for 50 mg daily. Narcotic count sheets dated 12/26/25–1/2/26 and 1/2/26–1/9/26 did not include the strength of Methadone received from the pharmacy, as required by the form. Later count sheets dated 1/10/26–1/16/26 and 1/16/26–1/23/26 documented Methadone 50 mg being administered, but the January MAR still showed 40 mg given through 1/20/26. The CPOs showed the order to discontinue 40 mg and start 50 mg was not entered until 1/20/26, more than a month after the external provider increased the dose. The resident’s substance abuse and psychosocial care plans contained general psychosocial and substance abuse interventions but did not include specific interventions to identify, address, monitor, or document Methadone use, SUD triggers, or cravings. The same resident experienced an unresponsive episode on 1/26/26. A nurse note documented that at approximately 5:00 p.m. the resident was found unresponsive with a respiratory rate of 11 breaths per minute, and Narcan nasal spray was administered (one spray in each nostril) with immediate effect, followed by EMS activation and hospital transfer. Another nurse note later that evening referenced increased lethargy, disorientation, and sedation after the Methadone dose increase and a request to discuss lowering the dose, but there were no prior progress notes documenting these symptoms or provider notification before the Narcan event. The January CPOs showed a Narcan order starting 1/30/26, and there was no documented order to administer Narcan on 1/26/26 or any standing Narcan order prior to that date, despite the resident’s history of SUD and orders for Methadone and Oxycodone. The January MAR contained no documentation of Narcan administration on 1/26/26. Interviews with the LPN, DON, ADON, and PCP confirmed that Narcan was given before an order was obtained, that it was not documented on the MAR, that there was no standing Narcan order in place at the time, and that the process for updating EMR orders from external providers and maintaining complete records was inconsistent. For the second resident, who had diagnoses including neuronal ceroid lipofuscinosis, pervasive developmental disorder, acute respiratory failure with hypoxia, and a history of recurrent pneumonia, the December 2025 MAR showed an order for Doxycycline Hyclate 100 mg by mouth twice daily for an infection from 12/24/25 through 12/31/25. The MAR contained blank administration boxes for the evening dose on 12/24/25 and the morning dose on 12/25/25, indicating the medication was not administered. The evening shift on 12/25/25 documented a “9” on the MAR, which should correspond to a progress note explaining the omission, but no such progress note was found in the EMR. A nursing progress note on 12/26/25 at 1:12 a.m. documented that the antibiotic had not arrived from the pharmacy, yet the MAR indicated the medication was administered despite its non-arrival. Another progress note on 12/26/25 at 4:48 p.m. documented that the resident was under continued monitoring for the start of doxycycline. The DON confirmed that blank MAR spaces meant the medication was not given, that there was no explanatory progress note for the missed dose on the evening of 12/25/25, and that the resident missed three doses of doxycycline.
Failure to Maintain Complete EMR Documentation for Addiction Treatment
Penalty
Summary
The deficiency involves the facility’s failure to maintain accurate and complete medical records for one resident by not obtaining and uploading addiction provider visit notes into the resident’s EMR. Facility policy required each resident’s medical record to contain an accurate representation of the resident’s experiences with complete, accurate, and timely documentation. Resident #1, under age 65, was admitted with multiple diagnoses including a displaced C5 vertebral fracture, functional quadriplegia, PTSD, schizophrenia, chronic pain due to trauma, and neuromuscular bladder dysfunction. The resident was cognitively intact per an MDS assessment and required varying levels of assistance with mobility and toileting. A review of the resident’s EMR for February 2026 showed no documentation of addiction provider visit notes since admission. Upon request during the survey, the NHA obtained external addiction provider notes dated 9/18/25, 12/18/25, and 1/27/26, which showed multiple methadone dose adjustments based on the resident’s reported cravings and sedation. These notes and associated treatment plans had not been incorporated into the EMR. Interviews with the DON and ADON revealed that when residents returned from external provider visits, transportation staff were to give a physician communication form to nursing staff, who were responsible for reviewing orders and updating the EMR, then placing the forms in a medical records box for upload. The DON reported uncertainty about the complete process for reviewing external provider notes and updating the EMR, noted that the health information manager had left the facility, and was unsure whether there was a backlog of records needing upload. The DON acknowledged the importance of maintaining an accurate medical record and stated that not doing so could result in untimely updates to care orders and adverse resident outcomes.
Failure to Address and Resolve Group Grievances Raised by Resident Council
Penalty
Summary
The facility failed to ensure prompt action was taken upon the filing of group grievances brought up by the resident council, as required by its own grievance policy. The policy states that all grievances must be forwarded to the grievance official, with written acknowledgment provided within three calendar days, and a written resolution within 14 days, or interim updates if more time is needed. However, interviews with alert and oriented residents who regularly attended resident council meetings revealed that group grievances raised during these meetings were not consistently followed up on or resolved by the facility. While individual grievances were addressed, group concerns were not documented as resolved or brought back to the council for follow-up. Review of resident council meeting minutes from three consecutive months showed multiple group concerns, such as issues with building temperature, call light response times, staffing, meal options, and maintenance needs. There was no documentation in the minutes indicating that these group grievances were addressed or resolved. Staff interviews confirmed that while there was a process for individual grievances, there was no established process for following up on group grievances from resident council meetings. Only a few individual concerns resulted in work orders, with no evidence of resolution for the broader group grievances.
Infection Control and Enhanced Barrier Precautions Lapses
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by multiple observed lapses in housekeeping and direct care practices. Housekeeping staff did not follow proper infection control guidelines when cleaning resident bathrooms, including not cleaning from cleaner to dirtier areas and using the same rag for both the toilet and grab bars. Additionally, a housekeeper was observed applying alcohol-based hand sanitizer and immediately donning gloves without allowing the sanitizer to dry, which is contrary to CDC guidelines and reduces the effectiveness of hand hygiene. The housekeeper also placed a dirty toilet brush container on a cleaned sink surface, further contributing to cross-contamination risks. Staff failed to adhere to Enhanced Barrier Precautions (EBP) protocols for residents with wounds and indwelling devices. Multiple instances were observed where staff, including CNAs and a restorative nurse aide, provided high-contact care activities such as repositioning, range of motion exercises, and changing linens for residents on EBP without donning the required gowns and, in some cases, gloves. One LPN performed wound care for a resident on EBP wearing only gloves and not a gown, despite clear signage and facility policy requiring both gown and gloves for such activities. Interviews with staff revealed gaps in knowledge and understanding of EBP requirements, with some staff unaware that gowns were necessary for certain care activities. The residents involved had significant medical needs, including wounds, diabetic ulcers, pressure injuries, indwelling catheters, and colostomies, placing them at high risk for infection. Despite facility policies and posted signage outlining the need for PPE and proper cleaning procedures, staff did not consistently follow these protocols during the provision of care and environmental cleaning. These failures were corroborated by staff interviews, which confirmed lapses in both knowledge and practice regarding infection control and EBP implementation.
Failure to Maintain Adequate Ventilation in Resident Bathrooms and Shower Room
Penalty
Summary
The facility failed to provide adequate outside ventilation in one of two shower rooms and in nine of sixteen resident bathrooms. Observations revealed that the exhaust fan in the north shower room was not functioning and was covered in lint, while exhaust fans in several resident bathrooms did not generate air movement when tested. In some bathrooms, large holes around the vents exposed electrical wires, and in two bathrooms, the exhaust fans were missing entirely. These deficiencies were identified during an environmental observation conducted with the maintenance director, who confirmed the issues with the exhaust fans and noted that some were old and in need of replacement. The facility's policy required maintaining safe, functional, and comfortable indoor environmental conditions, including proper ventilation in all resident-use areas. However, the maintenance director stated that monthly monitoring was performed but had not identified the missing fans in two bathrooms. The nursing home administrator acknowledged the importance of functioning exhaust fans for air quality and indicated that the maintenance monitoring form did not include specific checks for the ventilation system at the time of the deficiency.
Failure to Coordinate PASRR Level II Evaluation After New Mental Health Diagnosis
Penalty
Summary
The facility failed to coordinate changes to the Pre-Admission Screening and Resident Review (PASRR) Level II determination and evaluation report with the State Mental Health Agency when a resident received a new diagnosis of a serious mental disorder. Specifically, a resident was diagnosed with bipolar disorder by a nurse practitioner, but this new diagnosis was not promptly communicated to the State Mental Health Agency for a PASRR Level II evaluation as required by facility policy. The policy mandates re-screening for new or changed psychiatric diagnoses, but the diagnosis was not identified or acted upon during multiple quarterly care plan reviews by the social services director. The resident in question had a history of dementia with behavioral disturbances and was receiving psychotropic medication. Despite the addition of bipolar disorder to the resident's electronic medical record, there was no documentation supporting the basis for this diagnosis, and the resident was unaware of the diagnosis. The oversight was only identified during the survey, and prior to that, no updated PASRR screening had been completed in response to the new diagnosis.
Failure to Implement and Update Safety Interventions for Accident Prevention
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of safety interventions for multiple residents, resulting in deficiencies related to accident hazards and prevention. One resident with severe cognitive impairment and a history of wandering and exit-seeking behaviors eloped from the facility. Despite this event and subsequent removal of his wander alert device on two occasions, the facility did not reassess his elopement risk or update interventions accordingly. Staff interviews revealed uncertainty about the effectiveness of 15-minute checks, and there was no documentation of additional exit-seeking assessments after the resident refused to wear the wander alert device. Another resident, who was dependent on staff for all activities of daily living and had a history of falls and seizures, was observed multiple times in bed without the required fall mat in place, despite this being a care-planned intervention. Several staff members entered or passed by the resident's room without ensuring the fall mat was present. Staff interviews indicated confusion about whether the fall mat was still an active intervention, and the intervention was not consistently documented or implemented as required by the care plan. A third resident with a history of falls and mild cognitive impairment experienced 14 falls in less than six months. The care plan was not consistently updated after each fall to reflect a review of the effectiveness of interventions or the addition of new interventions. Documentation of interdisciplinary team (IDT) reviews was often delayed or missing, and new interventions, such as staff education or equipment changes, were not always added to the care plan. There was also a lack of documentation to show that staff were following scheduled interventions, such as toileting programs, and that care plans were revised in response to changes in the resident's condition or fall risk.
Failure to Administer Oxygen Therapy as Ordered for Resident with Tracheostomy
Penalty
Summary
A deficiency occurred when a resident who required respiratory care did not receive oxygen therapy as ordered by the physician. The resident, who had a history of cardiac arrest, acute respiratory failure with hypoxia, anoxic brain damage, cerebrovascular disease, and dependence on supplementary oxygen, was observed with a tracheostomy and was completely dependent on staff for all activities of daily living. The physician's order specified that the resident should receive 4 liters per minute (LPM) of oxygen via tracheostomy, with no titration order in place. During multiple observations, the resident was found to be receiving 4.8 LPM of oxygen instead of the ordered 4 LPM. Nursing staff, including an RN, failed to check or adjust the oxygen flow rate at the start of their shift and were unaware that the resident was receiving more oxygen than prescribed. The RN confirmed that only nurses were permitted to adjust the oxygen settings, and the resident was not physically able to change the settings independently. The care plan also did not specify the required oxygen flow rate as per the physician's order. Interviews with nursing staff and facility leadership confirmed that the physician's order for oxygen was not being followed, and that nurses were responsible for ensuring oxygen was administered according to orders. The facility's policy required verification of physician orders and regular assessment of respiratory status, but these procedures were not consistently followed, resulting in the resident receiving a higher oxygen flow rate than ordered.
Failure to Administer Prescribed Pain Medication as Ordered
Penalty
Summary
A deficiency occurred when a resident with multiple complex medical conditions, including heart failure, chronic obstructive pulmonary disease, a history of myocardial infarction, and a fractured thoracic vertebra, did not receive prescribed pain medication as ordered by the physician. The resident was on a scheduled pain medication regimen, including Percocet three times daily for chronic pain and as-needed oxycodone. On two separate occasions, the resident did not receive the scheduled Percocet, as documented in the medication administration record. Progress notes and administration records indicated that the Percocet was not available and was not administered, despite the resident experiencing significant pain, with pain scores reported as high as 8 out of 10. The resident expressed dissatisfaction with pain management and reported that the medication changes were not effective. There was no documentation that the physician was notified about the unavailability of the prescribed medication or the ineffectiveness of the alternative pain management provided. Interviews with the DON confirmed that the nurse should have notified the physician when the medication was not available and that alternative sources, such as the emergency kit, could have been used. However, these actions were not taken, and the resident's pain was not effectively managed according to the physician's orders, resulting in a significant medication error.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect eight residents from abuse, resulting in repeated incidents of abuse and actual harm. Resident #1, who was blind, nonverbal, and severely cognitively impaired, was sexually abused by Resident #2, who had a history of inappropriate sexual behavior towards other residents. Despite previous incidents involving Resident #2, the facility did not implement effective interventions to prevent further abuse. Resident #2 had previously engaged in unwanted sexual contact with other residents, including grabbing male residents and entering a female resident's room at night, causing discomfort and fear. The facility's investigation revealed that Resident #2 had been exhibiting an increase in inappropriate behaviors, which coincided with a gradual dose reduction of his psychotropic medications. Despite these warning signs, the facility did not update Resident #2's behavior care plan to address his escalating behaviors or implement additional interventions. The facility's failure to act on these indicators allowed Resident #2 to continue his abusive behavior, culminating in the sexual assault of Resident #1. Additionally, the facility's response to previous reports of Resident #2's inappropriate behavior was inadequate. Staff failed to investigate or address these allegations, leaving other residents vulnerable to abuse. The facility's lack of effective interventions and failure to protect residents from abuse created a situation of immediate jeopardy, resulting in actual harm to Resident #1 and the likelihood of serious harm to other residents.
Removal Plan
- All facility employees were re-educated on abuse training. Any facility staff unable to complete the training due to pre-approved leave would complete training prior to their next scheduled shift.
- Abuse training with all residents and their responsible parties would be completed with residents currently in the facility. Any resident not at the facility would receive abuse training on the same day of their return.
- The facility temporarily increased resident monitoring.
- Increased signage instructing staff how to identify abuse and who/how to report potential signs of abuse were hung throughout the facility.
- The facility's abuse coordinators would complete additional training on occurrence reporting guidelines and investigations.
- The facility created and distributed personalized reminder cards to staff that contained the definitions of abuse, when to report abuse, who a mandated reporter is, resident rights, and abuse coordinators.
Failure to Designate Full-Time Director of Nursing
Penalty
Summary
The facility failed to designate a registered nurse (RN) to serve as the director of nursing (DON) on a full-time basis. Despite the facility's policy requiring sufficient nursing staff to meet resident care needs, the DON was utilized as a floor nurse several times a week. This occurred even though the facility's average daily census was over 60 residents, and there were 80 residents residing in the facility at the time of the report. The facility's assessment and the DON's position description both indicated that the DON was intended to work full-time in her administrative role, overseeing nursing care and ensuring compliance with regulations. However, the time sheets for December revealed that the DON spent a significant portion of her working hours on the floor, specifically 35.91 hours and 47.23 hours during two separate pay periods, which impacted her ability to fulfill her administrative duties. During an interview, the DON confirmed that her responsibilities as a floor nurse caused her to fall behind on her daily duties, including investigating and logging falls. This deficiency highlights the facility's failure to adhere to its staffing policy and ensure that the DON could focus on her primary responsibilities, which are critical for maintaining high-quality resident care and compliance with regulations.
Failure in QAPI Program Leads to Immediate Jeopardy
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program to identify and address compliance concerns, specifically related to freedom from abuse, reporting, and investigating incidents. The QAPI committee did not identify or address concerns related to resident-to-resident sexual and physical abuse, which led to a situation of immediate jeopardy and caused harm. The facility's policy outlined a comprehensive QAPI program involving all staff and stakeholders, focusing on resident safety and quality of care. However, the program did not effectively monitor or address deviations from standards, particularly in preventing abuse. The facility had previously been cited for failing to protect residents from abuse during recertification surveys, with citations indicating a potential for more than minimal harm. Despite these citations, the QAPI committee did not identify abuse as a concern in their meetings, and the topic of abuse was only recently added to their agenda. The facility's failure to operate a QA program that prevented repeat deficiencies and initiated corrective plans resulted in a serious adverse outcome, highlighting a significant gap in their quality assurance processes.
Latest citations in Colorado
A resident with severe dementia, hallucinations, delusions, and chronic pain, who was independent with mobility and at risk for wandering, was struck in the face by another cognitively impaired resident known to exhibit verbal and physical aggression and to be highly protective of her room. An RN heard a commotion, saw the victim outside the aggressor’s room, and attempted to intervene but witnessed the aggressor hit the victim before reaching them, resulting in a lip laceration and bruise. The aggressor’s care plan noted use of a doorway stop sign or closed door and the need to redirect others away from her room, but she often refused these measures. At the time of the incident, only one CNA and one nurse were on the memory care unit due to an unfilled CNA call-in, and staff reported it was difficult to manage when two CNAs were not present. The facility investigation substantiated the event as abuse and identified that both residents may have had increased pain contributing to agitation before the altercation.
A resident with severe cognitive impairment and multiple chronic conditions intentionally slid from a wheelchair to sit on the floor and refused assistance to return to the chair. An LPN directed two CNAs to place a blanket under the resident and drag the resident across the floor, onto an elevator, and to another floor, rather than allowing the resident to remain seated on the floor as requested. The resident later reported trying to resist and stated dislike of the experience. Documentation by the LPN omitted how the resident was actually moved between floors, despite care plan goals for dignity and autonomy and a facility policy requiring residents be treated with dignity and respect and that their choices and preferences be honored.
Surveyors found that staff repeatedly failed to follow hand hygiene and Enhanced Barrier Precautions (EBP) requirements. CNAs and an LPN provided direct care, including incontinence care, use of a mechanical lift sling, and gastric tube feeding, without performing hand hygiene before or after care and without using required gowns for residents on EBP. One CNA handled a soiled lift sling, touched his hair and face, used a touchscreen to document care, and then assisted another resident without cleaning his hands. Another CNA entered an EBP room wearing only gloves, not a gown, and did not perform hand hygiene after removing gloves. An LPN handled a feeding tube and provided care to residents on EBP without hand hygiene or gown use. A resident’s representative reported seeing staff work with a feeding tube without gloves or a gown, while staff interviews and facility policy described correct practices that were not followed in practice.
A resident with severe cognitive impairment and multiple serious diagnoses had a physician-appointed health care proxy who reported that the facility did not inform her when the resident’s condition changed or when an antibiotic was started, and that her calls were not returned for days. Another representative for the same resident stated that calls went to a general voicemail and were rarely or very slowly returned. Grievance records documented repeated concerns about delayed communication, lack of notification about new medications, and difficulty reaching staff. Other residents’ representatives similarly reported that calls to check on residents or report suspected verbal abuse went to voicemail and were returned late or not at all, while staff acknowledged that calls often went to voicemail and that several calls from representatives were missed or delayed.
The facility failed to investigate an allegation of verbal abuse and threats between two cognitively impaired roommates after a family member, who was on the phone with one resident, reported hearing the other resident yelling loudly and making threats. The resident’s representative could not reach staff by phone and contacted EMS, which responded to the facility, yet no investigation or documentation of the altercation, alleged threats, or EMS involvement was found in either resident’s record. Staff acknowledged loud yelling and arguing and initiated a room change, but the RN did not fully inform the DON, the SSD—who was not present—dismissed the event as a simple argument, and the NHA did not treat or report it as abuse, contrary to facility policies requiring identification, investigation, and reporting of possible verbal or mental abuse by other residents.
Unsafe food handling and kitchen sanitation practices were observed in the dining room and main kitchen. Staff handled ready-to-eat foods with bare hands, failed to wash hands between tasks and after bathroom use, and touched food, dishes, and meal tickets while plating and serving meals. The facility also kept moldy croissants in dry storage, used a pencil to prop up a hood drip pan, and allowed a dietary aide with artificial nails and multiple bracelets to serve residents.
The facility failed to maintain and document safe food temperatures during meal service, resulting in cold foods being held and served within the temperature danger zone and incomplete temperature logs on multiple days. During a lunch service observation, various forms of chicken salad were held at 45–55°F, yet plates were assembled and sent out, and a resident reported that meals delivered to the room were always cold and often not eaten. Staff interviews showed inconsistent understanding of required hot and cold holding temperatures and confirmed that temperature logs were sometimes not completed as required.
Failure to Honor Residents’ Choice of Attending Physician: Three cognitively intact residents said they were not allowed to choose their own attending physician and were required to see the facility MD instead. EMR and admission agreement review showed no documentation that they were offered a choice of physician, despite one resident wanting to continue with a community PCP. The NHA stated residents could choose their attending physician, but also said the facility had only one physician available for residents to choose from.
Psychotropic Medication Documentation and PRN Behavior Monitoring Deficiencies Survey review found that several residents had psychotropic medications ordered without documented physician rationale, resident-specific target behaviors, or individualized non-pharmacological interventions. Generic behavior-monitoring orders were used instead of approaches tied to each resident’s history, interests, and identified behaviors, and one resident’s PRN antipsychotic was administered multiple times without documentation of attempted non-pharmacological interventions before use. The EMR also showed notes of stability or no unwanted behaviors for some residents, yet the records still lacked rationale supporting continued psychotropic treatment.
Failure to Address Suicidal Ideation and Individualized Psychosocial Needs: The facility did not adequately address suicidal statements, trauma-related needs, or individualized behavioral interventions for multiple residents. One resident with dementia, anxiety, and PTSD made a suicidal threat, but the record did not show ongoing safety monitoring or documented follow-up. Another resident with PTSD, depression, and a history of trauma and suicide attempts had ongoing depressive symptoms, but the care plan and orders did not reflect the PASRR-identified need for therapeutic support, psychiatric oversight, coping skills, or a safety plan. A third resident with autism and mood disturbance had inappropriate sexual behavior toward the DON, but the care plan was not updated with person-centered interventions specific to that behavior.
Failure to Prevent Resident-to-Resident Physical Abuse on Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. On the date of the incident, an RN heard a commotion in the hallway outside the alleged assailant’s room and observed that resident strike another resident, causing the victim’s lip to bleed. The RN had seen both residents near the medication cart a few minutes earlier without concern and attempted to intervene when she saw the victim standing outside the assailant’s room, but was unable to reach them before the strike occurred. The two residents were then separated, and frequent checks were initiated. The victim was a younger-than-65 resident with vascular dementia (severe, with agitation), Alzheimer’s disease, Lewy body disease, bipolar disorder, and chronic pain. Her MDS showed short- and long-term memory problems, hallucinations, delusions, and physical and verbal behaviors toward others, with moderately impaired cognition and impaired decision-making. She was independent with mobility and had a care plan for wandering and dementia that identified her as pleasantly confused and easily redirected, with interventions to identify wandering patterns, offer diversions, and assess for pain or toileting needs when agitated. Documentation on the day of the incident noted her involvement in a resident-to-resident altercation, a small laceration to the middle of her upper lip, and a small bruise below her lower lip. The assailant was an older resident with severe vascular dementia with agitation, memory deficit after intracranial hemorrhage, and recurrent depressive disorder. Her MDS documented short- and long-term memory problems, fluctuating disorganized thinking, and verbal behaviors directed toward others that could significantly intrude on others’ privacy or disrupt the environment. Her behavior/dementia care plan identified verbal aggression (yelling/screaming), physical aggression (hitting), refusal of care, withdrawal, tearfulness, and negative statements, and noted that she was protective of her room and became upset if others entered or tried to enter. The care plan included use of a velcro stop sign across her doorway or keeping her door closed, but also documented that she often declined having the door closed, requiring staff to redirect other residents away from her room. Staff statements indicated that at the time of the incident there was one CNA and one nurse on the memory care unit, that one CNA had called in and was not replaced, and that it was hard when there were not two CNAs on the unit. The facility’s investigation substantiated the incident as abuse and identified that both residents may have been experiencing increased pain leading up to the altercation, with pain, constipation, and urinary retention noted as contributing factors for the victim and hand contracture pain and refusal of interventions noted for the assailant.
Resident Dragged on Blanket Instead of Honoring Request to Sit on Floor
Penalty
Summary
The deficiency involves a failure to honor a resident’s right to dignity and self-determination when staff did not allow the resident to remain seated on the floor per his wishes and instead dragged him on a blanket between floors. Late at night, the resident, who lived on the second floor, was in his wheelchair on the first floor and intentionally slid out of his wheelchair to sit on the ground according to his own wishes. When staff offered assistance to help him back into his wheelchair, he refused. Despite this refusal, an LPN directed two CNAs to move the resident from the first floor back to the second floor. Following the resident’s refusal to get back into his wheelchair, the LPN instructed the CNAs to place a blanket underneath the resident so he could be dragged while lying on it. The CNAs and the LPN maneuvered the blanket under the resident by moving him from side to side. One CNA positioned herself behind the resident and placed her arms under his armpits, while the other CNA held the resident’s pants at his ankles. The LPN then pulled on the blanket with the resident on it. Together, the three staff members dragged the resident on the blanket across the floor and onto the elevator, transported him to the second floor, and then dragged him off the elevator onto the second floor hallway. Once on the second floor, the resident agreed to have two staff members assist him back into his wheelchair, and a two-person transfer was performed to lift him from the floor into the chair. The resident later reported that he remembered being pulled on the blanket, stated that he "tried to fight them like crazy," and said he did not like what had been done. The nursing progress note written by the LPN the following morning documented that the resident had remained on the first floor until late at night, refused to talk with staff, refused care, and declined snacks, fluids, and redirection, but the note did not document how he was actually relocated to the second floor. The resident’s records showed he had severe cognitive impairment with a BIMS score of 3/15, diagnoses including Parkinson’s disease, depression, unspecified intellectual disabilities, traumatic brain injury, seizures, and chronic kidney disease stage 3, and care plan goals that included being treated with dignity and autonomy. The facility’s dignity policy stated that residents are to be treated with dignity and respect at all times, that their choices and preferences are to be honored, and that demeaning practices are prohibited, which was not followed in this incident.
Failure to Follow Hand Hygiene and Enhanced Barrier Precautions
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program, specifically related to hand hygiene and adherence to Enhanced Barrier Precautions (EBP) on all four units. The facility’s own policies require hand hygiene before and after direct patient care and the use of gowns and gloves during high-contact care activities for residents on EBP. CDC guidance cited in the report emphasizes that hand hygiene protects both healthcare personnel and patients, and that EBP requires targeted gown and glove use during high-contact resident care activities, particularly for residents with wounds, indwelling devices, or MDRO colonization or infection. Surveyors observed multiple instances where staff did not follow these requirements. An unidentified CNA exited a room of a resident on EBP without wearing a gown while providing care. On another occasion, a CNA exited a resident’s room carrying a soiled mechanical lift sling without gloves, failed to perform hand hygiene, touched his hair and face, used a touchscreen to document care, and then entered another resident’s room to answer a call light and assist with a request without performing hand hygiene before or after assisting that resident. Another CNA entered the room of a resident on EBP, donned only gloves without a gown, provided incontinence care, then left the room with soiled linens and trash properly disposed of, removed gloves, but did not perform hand hygiene before caring for another resident. Additional observations showed an LPN entering the room of a resident on EBP for gastric tube feeding, setting up and handling the feeding tube without performing hand hygiene beforehand and without wearing a gown. The same LPN later entered another EBP room, provided care, and left without performing hand hygiene. A resident’s representative reported seeing staff work with the resident’s feeding tube without gloves or a gown. In interviews, CNAs and nursing staff described correct hand hygiene and EBP practices, including washing hands for about 20 seconds and using gowns and gloves for residents on EBP, and the DON stated she expected staff to perform hand hygiene when entering and exiting rooms and to follow EBP procedures requiring gown and glove use. These stated practices conflicted with the observed failures in hand hygiene and EBP adherence documented by surveyors.
Failure to Notify Health Care Proxy and Return Calls Regarding Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to inform a resident’s physician-appointed health care proxy of changes in the resident’s condition and new treatments, and to return the proxy’s calls in a timely manner. Facility policy on Notification of Changes required informing the resident, consulting with the physician, and notifying the family member or legal representative when there was a change requiring such notification, and specified that when residents were incapable of making their own decisions, the representative would make necessary decisions. Resident #1 was under 65, admitted with diagnoses including paralysis and weakness following a stroke, respiratory failure, cognitive communication deficit, and encephalopathy, and was documented as severely cognitively impaired with a BIMS score of 0/15, indicating reliance on the health care proxy for decision-making. The health care proxy reported that the facility made it very difficult to contact the resident, stating that staff did not return calls for days and that she was not informed when the resident developed an infection and was started on an antibiotic until after the medication had already been initiated. She stated she had several questions about the medication and was not consulted on the medical decision prior to its start. Another representative reported that calls to the facility went to a general voicemail and that her messages were either not returned or took several days for a response. Grievance records showed repeated concerns from the resident’s representatives about delays in speaking with the resident, delays in return calls, and lack of notification about new medications and changes in condition. Additional interviews with other residents’ representatives supported a broader pattern of delayed or absent communication. One representative of another resident reported that his call to check on a newly admitted resident went to voicemail and was not returned for two days. Another resident’s representative and a secondary witness reported that when they attempted to report suspected verbal abuse, their calls to the facility and to the SSD went to voicemail and were never returned. Staff interviews confirmed that calls first went to the front desk and then to the nurses’ stations, that calls often went to voicemail when nurses were unable to answer, and that voicemail messages were expected to be returned within 24 hours. The NHA acknowledged that several calls from the resident’s representatives went to voicemail and that calls were often made during shift change when it was harder to reach the nurse on duty, but there was no documentation to support the claimed regular communication with the health care proxy.
Failure to Investigate Alleged Verbal Abuse Between Cognitively Impaired Roommates
Penalty
Summary
The deficiency involves the facility’s failure to investigate an allegation of verbal abuse and threats between two cognitively impaired residents after a family member reported overhearing the incident. Facility policy on abuse, neglect, exploitation, and misappropriation requires that all possible incidents of abuse, including verbal and mental abuse by other residents, be identified, investigated, and reported within required timeframes, with residents protected from further harm during investigations. The policy on identifying types of abuse specifies that yelling or hovering over a resident with intent to intimidate is an example of mental and verbal abuse. Despite these policies, the facility did not initiate or document an investigation into a reported verbal altercation that included alleged threats. One resident, under age 65, with dysphagia, left-sided hemiplegia, attention and concentration deficit, delusional disorder, and major depressive disorder, had moderate cognitive impairment and was dependent on staff for most ADLs. He reported that he and his roommate yelled back and forth at each other after the roommate told him to “shut the [expletive],” but he did not recall the specific words used and denied any physical contact. His guardian stated that he later reported being fearful of his roommate after the incident. Another representative, who was on the phone with him during the event, reported hearing the roommate yelling loudly and making threats toward him, then hearing a nurse enter to calm the situation. This representative attempted to call the facility to report the yelling and threatening behavior, was sent to voicemail without a return call, and subsequently contacted emergency services. The roommate, an older resident with dementia, cognitive communication deficit, depression, and insomnia, also had moderate cognitive impairment and required staff assistance for most ADLs. He did not recall the incident, and his representative only learned of it the following day and was told it involved yelling about loud phone use. A review of both residents’ medical records revealed no documentation of the verbal altercation, the alleged threats, or related concerns, and no investigation documents were produced when requested. Staff interviews confirmed there had been loud yelling and arguing, that EMS responded to the facility, and that a room change was initiated due to the incident, but the RN who responded did not report the EMS involvement to the DON. The SSD, who was not present during the incident, characterized it as just an argument and stated there were no threats, and the NHA stated the event was not reported as abuse because they believed no threats were made. No contemporaneous interviews with the residents were documented, and no inquiry was made by facility staff into why EMS had been called in relation to the altercation, resulting in a failure to investigate the allegation of verbal abuse as required by facility policy.
Unsafe Food Handling and Kitchen Sanitation Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the main kitchen and dining areas. During meal service observations, staff repeatedly handled ready-to-eat foods with bare hands and did not perform hand hygiene when changing tasks, after touching dirty dishes, after using the bathroom, or before serving food. An LPN cut a resident’s patty melt and handed pieces to the resident with her bare hand without sanitizing her hands. A DA passed drinks by touching the rims of cups, and another DA tore a resident’s patty melt into smaller pieces with bare hands and handed food to the resident. During a later observation, kitchen staff continued to work without washing hands between tasks and while handling food, dishes, and meal tickets. A DA entered the kitchen from the dishroom and did not wash his hands before putting away snacks. A cook did not wash her hands after working at the sink, after touching dirty dishes, after exiting the bathroom in the kitchen, or before serving room trays. She was observed touching shrimp, corn bread, rice, squash, cheese, and frozen fries with bare hands while plating and preparing meals, and she also handled fryer baskets and food items without washing her hands. Another cook wiped her hands on her clothing, handled meal tickets, and touched ready-to-eat foods with bare hands while assembling plates and serving meals. The facility also failed to discard expired or spoiled food, maintain equipment in good repair, and prevent staff from wearing prohibited items while preparing or serving food. A plastic bag of croissants in dry storage contained bread-like food covered in dark green and black fuzz and remained on the bread rack on two separate observations. In the kitchen hood system above the grill, a half wooden pencil was being used to hold up the grease drip pan on two observations. In addition, a dietary aide taking meal orders, passing drinks, and serving meals had artificial nails approximately half an inch long and multiple fabric bracelets on her wrists while working with residents.
Failure to Maintain and Document Safe Food Temperatures During Meal Service
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner by not maintaining appropriate food temperatures during meal service and by not consistently documenting food temperatures as required. During a continuous observation of lunch meal service, chicken salad, including soft and bite-sized and pureed versions, was found on the steam table at temperatures of 55°F and 45°F, which were within the documented temperature danger zone and below the required cold-holding standard. Despite these temperatures, plates with wedge chicken salad and a Hawaiian roll were assembled and placed on the meal cart for service. A resident reported that meals delivered to his room were always cold, leading him not to eat them and to attempt to obtain food from outside the facility. Review of the facility’s April 2026 food temperature logs showed multiple instances where temperatures were not documented for breakfast, lunch, and dinner services on numerous dates. Staff interviews revealed inconsistent understanding and application of proper holding temperatures, with the cook and dietary manager providing varying temperature thresholds that did not align with the facility policy or the Colorado Retail Food Establishment Rules and Regulations. The cook acknowledged that the wedge chicken salad should not have been served at 55°F and attributed difficulty maintaining proper temperatures to a hot room with inadequate ventilation, while the dietary manager stated that cooks sometimes forgot to complete the temperature logs.
Failure to Honor Residents’ Choice of Attending Physician
Penalty
Summary
The facility failed to ensure three cognitively intact residents were allowed to choose their own attending physician. Resident #15, Resident #28, and Resident #30 each stated during a group interview that they did not have a choice in who their physician could be while in the facility and that they had to see the facility’s MD. Resident #15 said she had a primary care physician in town that she wanted to continue seeing, but she was told she could not see that physician. Resident #28 and Resident #30 each said they were required to see the facility’s MD instead of choosing their own physician. Record review for each of the three residents, including the admission agreement and EMR, showed no documentation that they were provided a choice of attending physician. Resident #15 had diagnoses including COPD, cirrhosis of the liver, and osteoarthritis, and her MDS showed she was cognitively intact with a BIMS score of 15. Resident #28 had diagnoses including type 2 diabetes mellitus, asthma, osteoarthritis, and TIA/cerebral infarction, and was also cognitively intact with a BIMS score of 15. Resident #30 had diagnoses including type 2 diabetes mellitus, wedge compression fracture of T11-T12 and L3, and hypertension, and his MDS likewise showed a BIMS score of 15. The NHA stated residents were able to choose their attending physician when admitted, but also said the facility had one physician residents could choose from and was not aware that these residents wanted different physicians.
Psychotropic Medication Documentation and PRN Behavior Monitoring Deficiencies
Penalty
Summary
The facility failed to ensure four residents were free from unnecessary psychotropic medication use and chemical restraint concerns. Survey review found that the facility did not document a physician’s rationale for the continued use of psychotropic medications for three residents, did not document resident-specific care approaches with medication-specific target behaviors and person-centered interventions for those residents, and did not ensure one resident’s PRN antipsychotic use had corresponding documentation of identified behaviors and non-pharmacological interventions. For one resident with PTSD, anxiety, and depression, the record showed buspirone, Valium, duloxetine, and Lexapro orders with behavior-monitoring language, but the orders did not identify resident-specific non-pharmacological interventions for specific behaviors. The resident’s PASRR described a history of self-harm, suicidal thoughts, mood swings, loss of interest, and low energy, and recommended therapeutic interventions, coping skills, psychiatric oversight, increased socialization, and activities such as puzzles, games, and painting. The EMR review did not show documented behaviors during the review period, and it did not show a physician rationale to justify continued psychotropic use. For another resident with schizoaffective disorder, dementia, anxiety, and depression, the care plan and orders listed generic interventions and behavior targets such as screaming, hallucinations, kicking, and yelling, but the resident-specific behaviors and interests identified in the PASRR, including hearing the devil inside her head and being soothed by prayer and rosary use, were not incorporated into the behavior-monitoring orders or care plan. The record also lacked documentation of non-pharmacological interventions used for the resident’s behaviors and lacked a physician rationale for continued psychotropic use despite notes stating the resident was stable and not experiencing unwanted behaviors. A third resident with vascular dementia, anxiety, and PTSD had orders for Abilify, mirtazapine, sertraline, clonazepam, and behavior monitoring tied to verbal aggression, exit seeking, tearfulness, and hitting staff, but the orders remained generic and did not reflect the resident’s individualized approaches such as listening to 80’s rock music or watching a favorite program when crying or confused. The EMR again did not show a physician rationale for continued psychotropic use despite notes indicating pleasant mood and no unwanted behaviors. For the resident who died during the stay and had dementia and depression, the record showed Lexapro, Seroquel, and PRN injectable haloperidol ordered for behaviors such as swinging at staff and agitation. The PRN haloperidol order did not list a diagnosed specific condition, only behaviors, and the order for non-pharmacological interventions was not initiated until after the resident had already been receiving psychotropic medications. MAR and order administration notes showed multiple PRN haloperidol administrations, but several entries lacked documentation of attempted non-pharmacological interventions before the medication was given, and one note only documented encouragement to sit down without identifying the other ordered interventions or their effectiveness.
Failure to Address Suicidal Ideation and Individualized Psychosocial Needs
Penalty
Summary
The facility failed to ensure that residents with mental disorders, psychosocial adjustment difficulties, and trauma histories received appropriate treatment and services to support their mental and psychosocial well-being. For one resident with vascular dementia, anxiety, and PTSD, the record showed repeated depression screens indicating little interest, depressed mood, poor appetite, sleep problems, low energy, and feelings of worthlessness, along with notes describing chronic behaviors potentially causing harm, tearfulness, withdrawal, and anxiety. A behavior note documented that the resident stated she was going to kill herself, but the record did not show documented interventions to keep her safe afterward or ongoing monitoring for suicidal ideation. A second resident with PTSD, anxiety, depression, and a documented history of trauma, self-harm, suicidal thoughts, and numerous suicide attempts had a PASRR evaluation identifying the need for therapeutic interventions, psychiatric oversight, coping skills development, and a safety plan. The resident told staff she had previously seen a therapist at the facility, but that therapy had stopped and no new arrangements had been made. She also reported that staff had not asked about her PTSD triggers or what interventions would help her. The record showed depression screens with ongoing depressive symptoms, but no follow-up documentation after those screenings, and the care plan and physician orders did not reflect the resident’s suicidal history or the specialized services identified in the PASRR. The facility also failed to provide individualized care approaches for a resident with autistic disorder, dementia with mood disturbance, anxiety disorder, major depressive disorder, and cognitive communication deficit. The resident had a history of inappropriate sexual behaviors and was documented as having sexually inappropriate contact with the DON when he squeezed her breast during a dining activity. Although the resident was placed on 15-minute behavior monitoring for 24 hours, the care plan was not revised to reflect a person-centered intervention specific to that sexual behavior. Staff interviews showed that interventions were inconsistently understood and that the nursing staff did not know what person-centered interventions were in place for the resident’s behaviors.
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