Rehabilitation And Nursing Center Of The Rockies
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Collins, Colorado.
- Location
- 1020 Patton St, Fort Collins, Colorado 80524
- CMS Provider Number
- 065192
- Inspections on file
- 20
- Latest survey
- September 23, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Rehabilitation And Nursing Center Of The Rockies during CMS and state inspections, most recent first.
A resident with cognitive impairment and neurological conditions was found with a medication cup containing prescribed tablets and a capsule left on their bedside table. An LPN had documented the medications as administered in the MAR without observing the resident swallow them, after unsuccessfully attempting to wake the resident and leaving the medications at the bedside. Facility policy required staff to stay with residents until medications were swallowed and to document only after administration, but these procedures were not followed.
A resident with hypertension did not receive any doses of Cardura as ordered, yet the MAR inaccurately reflected that the medication was administered on several occasions. Nursing staff failed to document the withholding of the medication or the reasons for it in the EMR, and there was no official physician hold order. This resulted in inaccurate medical records and a lack of clarity regarding the resident's medication status.
Two residents experienced deficiencies when the facility failed to thoroughly investigate an injury of unknown origin and allegations of staff-to-resident verbal and mental abuse. One resident, who was fully dependent for transfers, sustained a leg fracture after being transferred without a mechanical lift, but staff did not document or assess the injury in a timely manner. Another resident reported feeling abused by staff, but the facility did not conduct a comprehensive investigation or follow-up, and the staff involved continued to provide care to the resident.
Two residents did not receive adequate supervision or person-centered interventions to prevent accidents and falls. One resident, requiring a mechanical lift for transfers, was manually transferred by a CNA, resulting in undiagnosed leg fractures and delayed treatment. Another resident with severe cognitive impairment and repeated falls was not provided with individualized fall interventions, and staff failed to update care plans or systematically review the effectiveness of interventions after each fall.
The facility did not provide follow-up or communicate outcomes to residents regarding grievances raised in resident council meetings or through individual complaints. Although some actions were taken, such as staff education and cleaning, residents were not informed of these resolutions and were unclear about the grievance process. Staff interviews confirmed that documentation and communication of grievance outcomes to residents were lacking.
A resident with multiple complex medical conditions was not given the opportunity to choose her attending physician after her previous PCP stopped providing services. The facility assigned the resident to its contracted physician without documented consent or providing alternative options, and staff interviews confirmed that the process for selecting a new physician was not clearly communicated.
Two residents were administered psychotropic medications without individualized care plans or documentation of specific behaviors to justify their use. The facility used generic templates for behavior monitoring and non-pharmacological interventions, failing to address each resident's unique triggers, preferences, and symptoms as identified in assessments and staff interviews.
A resident with multiple medical conditions left the facility against medical advice due to dissatisfaction with care and environment. The facility did not document physician notification regarding the discharge request or the actual AMA discharge, nor did staff document attempts to address the resident's concerns or discuss alternative discharge plans. Required AMA discharge procedures and documentation were not followed.
A resident with major depressive disorder and cognitive impairment did not receive a neurocognitive evaluation as recommended by the PASRR Level II determination. The care plan and physician orders lacked documentation of the required assessment, and staff interviews confirmed that the evaluation was neither scheduled nor completed.
A resident with moderate cognitive impairment and a history of depression did not receive a personalized activity program as outlined in their care plan. Despite documented interests in reading, animal therapy, religious services, and outdoor activities, the resident was observed spending extended periods alone without engagement, and there was no evidence of participation in scheduled activities. Staff interviews and record reviews confirmed that the resident's preferences and needs were not consistently addressed.
A resident with a history of bipolar disorder, depression, and alcohol dependence exhibited fluctuating symptoms of depression and suicidal ideation, as documented in multiple MDS assessments. Despite these symptoms and physician orders for counseling, the facility did not consistently assess, monitor, or provide timely behavioral health services, and staff failed to document or act upon high PHQ-9 scores or expressions of suicidal ideation.
Facility leadership failed to provide sufficient oversight, resulting in delayed investigation and reporting of abuse allegations, untimely response to an injury of unknown origin, and inadequate monitoring of a resident with worsening depression and suicidal ideations. Staff were aware of these issues, but appropriate actions were not taken, and protocols were not followed.
Surveyors identified multiple infection control failures, including housekeeping staff not performing hand hygiene between rooms, improper separation of clean and soiled laundry, staff handling plastic drinking cups in a way that risked contamination, unsanitary tracheostomy care, and a urinary catheter drainage bag being stored in a resident's bathtub with urine still inside and tubing in a soap dish.
The facility failed to provide timely and person-centered assistance with meals for three residents. One resident, who required maximum assistance, was left without help for extended periods, leading to distress. Another resident, needing meal setup due to cognitive deficits, waited 43 minutes for assistance. A third resident, requiring encouragement and setup, was not adequately supported, resulting in poor food intake.
The facility failed to ensure the safety of two residents by not attaching foot pedals to their wheelchairs during transportation, posing a fall risk. Despite being identified as high fall risks, the residents were observed being pushed without foot pedals, requiring them to hold their feet up. Interviews revealed a lack of a system to ensure foot pedal availability and use, contributing to the deficiency.
The facility failed to ensure adequate supervision and implementation of fall interventions for a resident, resulting in a fall and wrist fracture. Despite care-planned measures like bolsters and a fall mat, these were not consistently in place. Staff interviews revealed a lack of awareness and understanding of the interventions, contributing to the deficiency.
The facility failed to manage the pain of two residents according to professional standards, as physician's orders for pain medications lacked documented parameters for administration. This led to inconsistent and potentially inadequate pain management, as confirmed by staff interviews and record reviews.
Failure to Ensure Proper Medication Administration and Documentation
Penalty
Summary
A deficiency occurred when nursing staff failed to follow professional standards of medication administration for a resident with multiple neurological and cognitive diagnoses, including encephalopathy, vascular dementia, and spastic hemiplegia. The resident required staff supervision and cueing due to moderate cognitive impairment. During an observation, a medication cup containing three white tablets and one brownish capsule was found on the resident's bedside table, which was later identified as Baclofen and Valerian root. The medications had been documented as administered in the resident's medication administration record (MAR), despite the fact that the resident had not taken them. Record review showed that the resident did not have an assessment for self-administration of medications, and care plans required staff to administer medications as ordered and provide necessary cues due to cognitive impairment. Interviews with the DON and nursing staff confirmed that the nurse responsible had left the medications at the bedside after unsuccessfully attempting to wake the resident, intending to return but failing to do so. The nurse had documented the medications as given in the MAR without observing the resident swallow them, contrary to facility policy and professional standards. Further interviews revealed that staff were aware of the correct procedures, which included staying with the resident until medications were swallowed and documenting only after administration. The DON confirmed that the nurse did not follow these procedures and that there was no documentation of medication refusal or self-administration capability for the resident. The incident was identified during a survey, and the facility's policy was clear that medications should not be left at the bedside and must be administered and documented accurately.
Failure to Accurately Document Medication Administration and Withholding
Penalty
Summary
The facility failed to maintain accurate medical records and documentation for one resident regarding the administration of Cardura, a medication prescribed for hypertension. The resident, who was cognitively intact and required assistance with most activities of daily living, was discharged from the hospital with an order for Cardura. The physician's order for Cardura remained active for over two months, but the medication was not administered during this period. Despite this, the medication administration records (MARs) inaccurately documented that the resident received several doses of Cardura, while other opportunities were marked as 'other/see nurse's notes.' Nursing staff interviews revealed that the medication was not actually administered, and the documentation of administration was done in error. Staff also failed to document the reason for withholding the medication in the electronic medical record (EMR), and there was no official physician hold order for Cardura. Progress notes indicated that the medication was unavailable and that the physician was aware, but this was not consistently or accurately reflected in the MAR or EMR. The DON confirmed that the resident did not receive any doses of Cardura and that the medication had never been delivered to the facility. The facility's policy required that medication administration be documented as per physician order and that any withheld drugs be appropriately documented on the MAR. In this case, the staff did not follow these procedures, resulting in inaccurate records and a lack of clear documentation regarding the resident's medication status. The breakdown in process led to discrepancies between what was recorded and what actually occurred regarding medication administration.
Failure to Investigate Injury of Unknown Origin and Allegations of Staff Abuse
Penalty
Summary
The facility failed to initiate a thorough investigation of an injury of unknown origin involving a resident who was cognitively intact and required total assistance for transfers and mobility due to multiple medical conditions, including autoimmune disease, arthritis, edema, and a history of stroke. The resident reported sustaining an injury when a male CNA transferred her without a mechanical lift, resulting in pain, swelling, and ultimately a diagnosis of right distal tibia and fibula fractures. Despite the resident's ongoing complaints of pain and visible swelling, documentation in skin assessments and progress notes did not reflect these observations, and staff failed to conduct or document a timely and thorough assessment of the injury. Staff interviews revealed that CNAs noticed the resident's complaints of pain and visible bruising but did not consistently report these findings to nursing staff, and there was no designated place in CNA charting to document new injuries. When a nurse was informed of the injury, he observed swelling and bruising but did not perform a full assessment, notify the physician or family, or document the findings, assuming that all parties were already aware due to pending Xrays. Other nursing staff stated that any change in a resident's condition, such as a swollen ankle, should prompt a full assessment, documentation, and notification of the physician and family, as well as reporting to facility leadership to rule out potential abuse, but these steps were not followed in this case. Additionally, the facility failed to recognize, address, and thoroughly investigate allegations of staff-to-resident verbal and mental abuse reported by another resident. The resident reported feeling mentally and verbally abused by nursing staff, including being accused of medication-seeking behavior and being yelled at by a CNA. Despite reporting these concerns to the social services director and other leadership, there was no formal follow-up, and the staff members involved continued to work with the resident. The facility's investigation did not include interviews with other residents or staff, observations of interactions, or documentation of unofficial investigations, resulting in an incomplete response to the allegations.
Removal Plan
- Interview the resident by a clinical resource and the corporate licensed clinical social worker; provide psychosocial support and offer additional mental health support.
- Suspend the NHA and RN; suspend the CNA.
- Conduct education with the NHA, the SSD, and the DON on how to identify instances and allegations of abuse and the difference between a concern and forms of abuse; complete competencies.
- Provide education to the RN and CNA regarding the differences between concerns and forms of abuse and how to report appropriately; ensure the CNA does not return to work until education and return demonstration is provided in person.
- Initiate interviews with all residents who can participate to ensure all allegations of abuse are identified and thoroughly investigated; for residents who cannot be interviewed, reach out to the emergency contact/resident representative to discuss concerns; if an interview cannot be completed, have social services complete an observation to identify signs of psychosocial distress or change in mood; complete all interviews/observations.
- Educate all staff on identification of allegations of abuse versus customer service and abuse reporting, including differentiating potential abuse allegations from concerns/customer service issues; ensure any employee unable to complete education in person is educated prior to their next scheduled shift.
- Have social services or designee complete weekly audits on random residents, including resident interviews about abuse/observations of abuse and record review; if allegations are identified, notify the abuse coordinator per regulations, complete a thorough investigation with interventions to prevent recurrence, complete state occurrence reporting and police reporting; for concerns, complete corrective action; record audits on an audit form; promptly report discrepancies to the administrator; report results to the quality assurance committee.
- Have the director of nursing services or designee interview employees weekly for comprehension about types of abuse and signs of mental abuse, the difference between customer service concerns and allegations, and immediate reporting.
- Provide weekly oversight to review investigations and audit whether managers understand the difference between customer service concerns and allegations.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, who was cognitively intact and required a sit-to-stand mechanical lift for transfers due to musculoskeletal impairments and a history of stroke, was manually transferred by a CNA without the required lift device. During this transfer, the resident experienced a popping sound in her leg, followed by pain, swelling, bruising, and redness. Despite these symptoms, the facility did not assess her pain or change in condition, nor did they provide timely treatment or X-rays. The injury was only properly addressed after the resident reported increased pain to her community physician, who then ordered X-rays and facilitated a hospital transfer, where fractures of the right distal tibia and fibula were diagnosed. The facility also failed to update the resident's care plan to reflect the new fracture as a risk factor and did not investigate the injury when it was first reported by the resident and observed by staff. Another resident with severe cognitive impairment, a history of repeated falls, and an above-the-knee amputation was not provided with person-centered fall interventions tailored to her cognitive deficits. Despite multiple unwitnessed falls, the interventions implemented primarily focused on visual cues such as signs and colored tape to prompt the resident to use her call light and lock her wheelchair brakes. Therapy and nursing documentation indicated that the resident had significant deficits in memory, executive functioning, and safety awareness, which limited her ability to benefit from interventions requiring memory recall and judgment. Staff interviews revealed that additional interventions, such as frequent checks and toileting, were verbally communicated but not documented in the care plan, and there was no evidence of a systematic review of why previous interventions failed after each fall. The facility's interdisciplinary team did not consistently review or update care plans to include effective, individualized interventions based on the residents' needs and cognitive abilities. There was a lack of documentation and follow-up regarding staff observations of injuries and pain, and the process for implementing and communicating fall interventions was not clearly defined or consistently followed. These failures resulted in preventable injuries and inadequate supervision for residents at risk for accidents and falls.
Failure to Communicate Grievance Resolutions to Residents
Penalty
Summary
The facility failed to provide appropriate follow-up, response, and rationale to residents regarding grievances raised during resident council meetings and through individual complaints. According to the facility's grievance policy, the grievance official or designee is required to respond to concerns within three working days, acknowledging receipt and describing steps taken toward resolution. However, record reviews and interviews revealed that while grievances were documented and some actions were taken (such as staff education or cleaning the patio), there was no evidence that the facility communicated the outcomes or resolutions back to the residents or the resident council. Interviews with residents who regularly attended resident council meetings indicated that they were unaware of how grievances were handled after being raised. Residents reported that while department heads sometimes addressed issues during meetings, there was no follow-up or feedback provided regarding the resolution of their concerns. Specific issues brought up by residents included call light response times, unchanged linens, cigarette butts in the smoking area, cold food, delayed room trays, poor communication from therapy, and cleanliness of rooms and bathrooms. Despite these concerns being documented in meeting minutes and grievance forms, residents stated they did not know the outcomes or how to file grievances properly. Staff interviews confirmed the lack of follow-up. The activities director stated that department managers were supposed to bring back resolutions to the next resident council meeting, but this did not consistently occur. The social services director, who served as the grievance official, acknowledged that documentation of follow-up with residents or families was missing from grievance forms for several months. This failure to communicate resolutions left residents uninformed about the actions taken in response to their concerns.
Failure to Honor Resident's Right to Choose Attending Physician
Penalty
Summary
The facility failed to honor a resident's right to choose her own attending physician when her previous primary care provider (PCP) stopped seeing residents at the facility. According to the facility's Resident Rights policy, residents have the right to select their personal attending physician and be informed about how to contact them. However, when the resident's PCP's clinic closed, the facility did not provide the resident with options or documentation to select a new physician, instead assigning her to the facility's contracted physician without her documented consent. The resident involved was cognitively intact, as evidenced by a perfect BIMS score, and had multiple complex medical conditions, including chronic kidney disease, a history of cervical cancer, short bowel syndrome, severe sepsis, and several mental health diagnoses. The resident expressed that she valued making personal choices and reported that she was not given the opportunity to choose her new physician after her previous provider left. Facility records indicated that the resident was notified of her physician's departure and that she wished to transfer to the facility's provider, but there was no documentation showing she was informed of her right to choose or that her permission was obtained for the assignment. Interviews with facility staff revealed that the process for selecting a new physician was not clearly communicated to the resident, and the facility did not provide alternative options due to the abrupt departure of the previous medical group. Staff acknowledged that the resident should have been informed about the process for choosing a different physician and that the facility only had one contracted physician available at the time. The lack of documentation and communication regarding the resident's right to choose her attending physician led to the deficiency.
Failure to Individualize Psychotropic Medication Use and Behavior Monitoring
Penalty
Summary
The facility failed to ensure that two residents were free from chemical restraints and that psychotropic medications were used only with appropriate, individualized, and least restrictive approaches. For both residents, the care plans and documentation did not include resident-specific behaviors, triggers, or person-centered interventions related to the use of psychotropic medications. Instead, the facility relied on generic templates for behavior monitoring and non-pharmacological interventions, which were not tailored to the individual needs or documented behaviors of the residents. For one resident with severe cognitive impairment, anxiety, and depression, the care plan interventions and medication orders referenced monitoring for generic symptoms such as tearfulness and nervousness, but there was no documentation in the medical record, medication administration records, or progress notes to indicate that the resident exhibited any behaviors justifying the continued use of psychotropic medications. The resident expressed feelings of loneliness and anxiety related to her husband’s absence, and staff reported that reassurance and facilitating communication with her husband were effective interventions. However, these specific expressions and interventions were not reflected in the care plan or behavior monitoring documentation. For another resident with moderate cognitive impairment and major depressive disorder, the care plan and physician orders also used generic behavior monitoring and interventions, failing to address resident-specific behaviors such as isolation, obsessions, need for routine, and hoarding tendencies identified in the PASRR evaluation. The documentation did not indicate any behaviors that would justify the use of psychotropic medications, nor did it reflect the resident’s preference for solitude or the triggers identified by family and staff. Staff interviews confirmed that behavior monitoring and interventions were not individualized, and that staff primarily used generic templates rather than customizing care to the residents’ needs.
Failure to Document and Notify Physician During AMA Discharge
Penalty
Summary
The facility failed to provide and document adequate discharge preparation and notification for a resident who left the facility against medical advice (AMA). The resident, who had diagnoses including anxiety, a patella fracture, and hypertension, was admitted following a fall and subsequently left the facility with her representative due to dissatisfaction with facility conditions. The discharge care plan indicated a desire to return home or transfer to another facility, but there was no evidence in the electronic medical record (EMR) that the physician was notified of the resident's or representative's request to discharge, nor was there documentation explaining why the physician could not be reached until the following day. Additionally, there was no documentation that the physician was notified after the resident left AMA. The EMR also lacked evidence that staff attempted to discuss the resident's concerns or reasons for leaving, or that alternative discharge plans were explored. An AMA discharge form was present but was not signed by the representative. Staff interviews confirmed the absence of required documentation and indicated that the expected process for AMA discharges, including physician notification and progress notes, was not followed in this case.
Failure to Implement PASRR Level II Neurocognitive Evaluation Recommendation
Penalty
Summary
The facility failed to incorporate and arrange for the recommendations outlined in the Pre-Admission Screening and Resident Review (PASRR) Level II determination for a resident with a diagnosis of major depressive disorder. Specifically, the PASRR Level II evaluation recommended that the resident receive a neurocognitive evaluation to assess cognitive functions and the impact of neurological conditions. However, the resident's care plan did not include this recommendation, and there was no physician order or documentation indicating that a neurocognitive evaluation had been scheduled or completed since the resident's admission. Record review showed that the resident was cognitively impaired and had a history of dementia and major depressive disorder, with ongoing use of antidepressant medications. Despite the PASRR Level II recommendation, progress notes and computerized physician orders lacked any reference to a neurocognitive evaluation. Staff interviews confirmed that the social services director was responsible for implementing PASRR recommendations but was unable to find evidence that the evaluation had been arranged or performed. The only related documentation was a behavioral health progress note by a licensed clinical social worker, which did not meet the requirements for a neurocognitive evaluation as defined by professional standards.
Failure to Provide Individualized Activity Program for Resident
Penalty
Summary
The facility failed to provide an ongoing, individualized activity program for one resident, resulting in unmet needs and interests as identified in the resident's care plan and assessments. The resident, who was moderately cognitively impaired with diagnoses including dementia with agitation, anxiety disorder, and insomnia, expressed that it was important to have access to reading materials, music, animal visits, religious services, and opportunities to go outside. Despite these preferences being documented, there was no evidence that the resident was consistently offered or able to participate in these activities. Observations revealed that the resident spent significant time alone in his room without engagement in activities, even when group activities such as animal therapy were occurring nearby. On one occasion, a therapy dog visited other rooms on the unit but did not visit the resident's room, despite his documented interest in animal therapy. Staff interviews confirmed that the resident had become more withdrawn following the death of his spouse and that he required reminders and encouragement to participate in activities, but there was no documentation or observation of such efforts being made during the review period. Record review further indicated that, although the resident's care plan included interventions such as inviting him to religious activities, offering animal therapy, and encouraging outdoor time, there was no documentation in the electronic medical record that these interventions were implemented. Staff acknowledged the importance of activities for residents' well-being but did not provide evidence that the resident's individualized needs and preferences were being met as required by facility policy.
Failure to Assess and Monitor Resident with Suicidal Ideation and Depression
Penalty
Summary
The facility failed to ensure that a resident with a history of mental disorder and psychosocial adjustment difficulties received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. The resident, who had diagnoses including bipolar 2 disorder, depression, and alcohol dependence, exhibited fluctuating symptoms of depression and suicidal ideation as documented in multiple MDS assessments. Despite these documented symptoms, the facility did not consistently assess or monitor the resident for worsening signs of depression or suicidal ideation, nor did they provide timely behavioral health services as ordered by the physician. The resident expressed feelings of frustration, lack of autonomy, and dissatisfaction with his living situation and care, including issues with daily routines and access to preferred food and services. He reported feeling bad about himself, being a failure, and having thoughts of being better off dead or hurting himself during several assessment periods. However, there was no evidence that the facility followed up on these expressions with appropriate assessments, documentation, or interventions. The last documented psychotherapy visit was over a year prior, and although counseling was ordered, the resident was not seen by counseling services as required. Interviews with facility staff revealed a lack of awareness and follow-through regarding the resident's mental health needs. Staff members, including the social services director and MDS coordinator, acknowledged that they did not document or act upon high PHQ-9 scores or expressions of suicidal ideation. There was also a significant gap in behavioral health services due to provider absence, and no alternative arrangements were made for the resident to receive necessary mental health care. The facility's failure to identify, monitor, and address the resident's mental health symptoms and suicidal ideation constituted a deficiency in providing appropriate treatment and services.
Failure to Provide Effective Leadership, Timely Abuse Investigation, and Adequate Resident Monitoring
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in multiple deficiencies related to leadership, abuse prevention, injury investigation, and mental health monitoring. Specifically, management did not provide sufficient leadership to address or avoid concerns, including the failure to promptly investigate and report allegations of abuse. Staff were aware of a potential verbal abuse incident and reported it to the DON and SSD, but facility leadership did not immediately investigate or implement interventions to prevent further abuse, despite the issue being discussed in morning meetings. Additionally, an injury of unknown origin was not reported or investigated in a timely manner. A CNA reported a resident's swollen ankle to a nurse, who failed to follow protocol by not completing a full assessment, not inquiring about the cause, and not notifying management, the physician, or the family. The injury, later found to be a fracture, was not reported to leadership until days later, and hospital records indicated the fracture was several weeks old. Furthermore, the facility did not adequately monitor a resident with worsening depression and suicidal ideations. The resident's MDS assessments showed increasing depression scores over several months, but no actions were taken by the SSD, and there was no evidence of psychotherapy since June 2022. Interviews with staff and management revealed that while some were aware of these issues, including the abuse allegation and the resident's mental health decline, appropriate actions were not taken. The interim NHA acknowledged that some concerns had gone unaddressed and unnoticed prior to his arrival.
Multiple Infection Control Failures Identified
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in multiple deficiencies across several units. Housekeeping staff were observed not performing appropriate hand hygiene between cleaning resident rooms, specifically failing to change gloves and sanitize hands after cleaning one room and before entering another. This was in direct violation of both CDC guidelines and the facility's own policies, which require hand hygiene before donning gloves and after removal, as well as between clean and dirty tasks. In the laundry room, staff did not keep clean and soiled laundry separate as required. Soiled laundry was observed crossing designated boundaries marked by black tape, with soiled items encroaching into areas meant for clean laundry. Additionally, soiled rags were stored in a cart located in the clean area, contrary to the intended separation of clean and dirty zones. The maintenance director acknowledged the improper placement and the need for a different location for soiled rags. Further deficiencies included improper handling of plastic drinking cups by staff, who were seen placing fingers inside cups while filling them with ice and placing cups face down on an unsanitized cart. Tracheostomy care for a resident was not performed in a sanitary manner, as the nurse failed to sanitize the table surface before placing clean supplies, did not change gloves or perform hand hygiene between dirty and clean tasks, and used a dressing that had fallen on an unsanitized surface. Additionally, a urinary catheter drainage bag for another resident was found stored in a bathtub with urine still inside, and the tubing was resting in a soap dish, which staff confirmed was not a sanitary practice.
Failure to Provide Timely Assistance with Meals
Penalty
Summary
The facility failed to provide timely and person-centered assistance with activities of daily living, specifically meal setup and eating, for three residents. Resident #3, who was severely cognitively impaired and required maximum assistance with eating, was observed on multiple occasions not receiving timely assistance. On one occasion, her meal was placed out of reach, and she was left without assistance for 24 minutes, during which she repeatedly hit the table in frustration. On another occasion, she was not assisted until almost ten minutes after her meal was served, despite her visible distress and attempts to reach for her food. Resident #12, who required supervision and assistance with meal setup due to a cognitive communication deficit, was also neglected. Her meal was served without the necessary setup, and she did not begin eating until 43 minutes later when a CNA finally noticed and cut up her food. This delay in assistance was contrary to her care plan, which specified the need for setup assistance due to her weak left arm and aversion to getting her hands dirty. Resident #9, who had moderate cognitive impairments and required meal setup and encouragement, was observed not receiving the necessary assistance during multiple meals. Her breakfast and lunch were served without any staff checking on her or encouraging her to eat, resulting in her consuming only a small portion of her meals. Despite her preference for finger foods and eating in her room, staff failed to provide the necessary setup and encouragement, leading to inadequate food intake.
Inadequate Supervision and Safety Measures for Wheelchair Use
Penalty
Summary
The facility failed to provide adequate supervision and ensure the safety of residents using wheelchairs, specifically by not attaching foot pedals to the wheelchairs of two residents. This deficiency was observed during a survey where Resident #10 and Resident #11 were pushed in their wheelchairs without foot pedals, causing them to hold their feet up off the floor. This lack of proper equipment use posed a safety hazard, as it could lead to falls or injuries. Resident #10, who has a history of cognitive communication deficit, generalized muscle weakness, repeated falls, and dementia, was observed being pushed into and out of the dining room without foot pedals on his wheelchair. The resident's care plan identified him as a high fall risk due to his weakness and impaired mobility, but it did not include specific interventions to ensure the use of foot pedals during transportation. This oversight in the care plan contributed to the deficiency. Similarly, Resident #11, diagnosed with spastic hemiplegia, abnormal involuntary movements, and other conditions, was also observed being transported without foot pedals on his wheelchair. The resident's care plan indicated a high fall risk and required frequent rounding and supervision, yet the absence of foot pedals during transportation was not addressed. Interviews with the DON and DOR revealed that while staff education on the importance of foot pedals was provided, there was no system in place to ensure their availability and use, leading to the observed deficiency.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of person-centered fall interventions for Resident #2, who had a fall resulting in a left wrist fracture. Despite being identified as a medium fall risk and having specific interventions care planned, such as providing bolsters on the air mattress and a fall mat beside the bed, these measures were not consistently implemented. Observations revealed that the fall mat was often placed across the room and not beside the bed, and bolsters were missing from the mattress. Additionally, the resident's reacher was not within reach, contributing to the fall incident when the resident attempted to reach for bed controls without assistance. Interviews with staff, including a CNA and an RN, indicated a lack of awareness and understanding of the fall risk interventions for Resident #2. The CNA was unaware of the significance of the falling star sticker and the required placement of the fall mat and bolsters. The RN acknowledged the importance of these interventions but admitted they were not consistently in place. The DON and ADON confirmed that the interventions were discussed and documented during IDT meetings but were not verified to ensure they were implemented. The facility's failure to follow through on the documented fall interventions for Resident #2 led to the resident's fall and subsequent injury. The lack of consistent implementation of care-planned interventions and inadequate staff awareness and training contributed to the deficiency in providing a safe environment for the resident, as required by the facility's fall management policy.
Inadequate Pain Management Documentation
Penalty
Summary
The facility failed to manage the pain of two residents in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, the facility did not ensure that pain medications had documented parameters for administration. Resident #7, who had diagnoses including left-sided paralysis and arthritis, reported frequent pain that interfered with daily activities. Despite being on a scheduled pain regimen, the resident indicated that the PRN Tylenol was ineffective, leading to loss of sleep. The physician's orders for both Tylenol and Norco did not specify the pain level parameters for administration, nor did they indicate the maximum allowable dosage of acetaminophen from all sources. This was confirmed by RN #1 during an interview, who acknowledged the lack of documented parameters for the pain medications. Resident #8, who had diagnoses including hemiplegia and chronic post-traumatic headache, also experienced frequent pain that interfered with daily activities. The physician's orders for Norco and Tylenol did not specify the pain level parameters for administration. The medication administration record (MAR) listed a numerical pain scale but did not specify the pain levels at which the medications should be administered. According to the MAR, Norco was administered for pain levels ranging from 2 to 7, without clear guidelines. This was confirmed by both CN #1 and RN #1, who acknowledged the absence of pain parameters in the physician's orders. The facility's failure to provide adequately detailed guidance for administering PRN pain medications led to inconsistent and potentially inadequate pain management for both residents. The lack of documented parameters for pain levels and maximum allowable dosages of acetaminophen contributed to the residents' ongoing pain and discomfort, as confirmed by staff interviews and record reviews.
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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