Ridgeview Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Commerce City, Colorado.
- Location
- 5230 E 66th Way, Commerce City, Colorado 80022
- CMS Provider Number
- 065283
- Inspections on file
- 19
- Latest survey
- April 8, 2026
- Citations (last 12 mo.)
- 5 (1 serious)
Citation history
Health deficiencies cited at Ridgeview Post Acute during CMS and state inspections, most recent first.
The facility failed to report four separate allegations of physical abuse between residents to the State Survey and Certification Agency within the required two-hour timeframe. The written abuse reporting policy directed the NHA or designee to submit initial reports within 24 hours, which did not match state requirements. Record review showed that each of the four incidents of alleged physical abuse between pairs of residents was reported between 13 and 26 hours after occurrence. In interviews, the NHA stated he believed the two-hour rule applied only when serious bodily harm occurred, and the clinical resource nurse acknowledged that the facility missed the required two-hour reporting window for these allegations.
A resident with dementia and a documented history of verbal and physical aggression, including throwing objects and hitting others with pillows, shared a room with another cognitively impaired resident who had no history of aggression. In the early morning, a CNA heard arguing, found the aggressive resident attempting to remove a pillow from under the roommate’s head, and separated them. About 20 minutes later, the aggressive resident took a pillow from her own bed and struck the roommate three times, causing the roommate to become upset and yell for staff to remove the aggressor. Documentation and interviews confirmed the incident began with a verbal exchange and that the victim reported being hit several times without retaliating.
The facility failed to maintain a safe and sanitary environment, with issues such as sheetrock damage, chipped paint, debris, and nonfunctional exhaust fans in resident rooms. Work orders for these concerns were not found in the facility's system, despite monthly inspections. Additionally, improper storage of urine collection devices posed infection control risks.
The facility failed to document and monitor wandering behaviors for two residents in a secured unit, leading to deficiencies in care. Despite being at risk for elopement and wandering, the facility did not maintain records of interventions or their effectiveness. Staff interviews revealed a lack of awareness and documentation regarding these issues.
The facility failed to document narcotic medication removal from locked drawers on two medication carts. Discrepancies were found between narcotic logs and actual counts, with nurses admitting to not documenting removals immediately after administering medications to residents. The DON acknowledged the issue, despite recent staff education on controlled substance documentation.
The facility failed to properly store and label medications, as observed in two medication carts and a storage room. An Albuterol inhaler and a tuberculin vial were not labeled with opening dates, and Haloperidol was found for a discharged resident. Medications were found on the floor, indicating improper disposal and supervision. A resident had artificial tears without a physician's order. Staff interviews confirmed these deficiencies, showing non-compliance with storage and administration protocols.
A facility failed to ensure proper communication and documentation of hospice services for a resident with severe cognitive impairments. The care plan did not define hospice services, and staff could not locate the hospice binder or access electronic records. The DON admitted to a lack of a designated hospice coordinator and inadequate communication processes.
A facility failed to prevent a physical altercation between two residents, both with histories of aggression. Despite previous incidents involving one resident, the care plan lacked updated interventions. The altercation involved hair-pulling and was deemed substantiated physical abuse. The facility's response of separating and redirecting the residents was ineffective.
Failure to Timely Report Resident-to-Resident Abuse Allegations
Penalty
Summary
The facility failed to timely report four separate allegations of physical abuse between residents to the State Survey and Certification Agency as required by state law. The facility’s Abuse Prevention and Reporting policy, revised in June 2025, directed the administrator or designee to complete the initial report to the state agency within 24 hours via the occurrence reporting portal and complete the report within five days, which did not align with the state requirement to report any abuse allegations within two hours of the incident. Record review showed that an allegation of physical abuse between Resident #1 and Resident #2 occurred on 11/18/25 at 8:20 a.m., but was reported on 11/19/25 at 10:22 a.m., 26 hours after the incident. An allegation of physical abuse between Resident #3 and Resident #4 occurred on 1/19/26 at 5:00 a.m., but was reported at 7:07 p.m. the same day, 14 hours after the incident. Further record review showed that an allegation of physical abuse between Resident #5 and Resident #6 occurred on 2/8/26 at 8:30 a.m., but was reported on 2/8/26 at 9:40 p.m., 13 hours after the incident. Another allegation of physical abuse between Resident #4 and Resident #11 occurred on 3/22/26 at 11:59 a.m., but was reported on 3/23/26 at 11:56 a.m., 24 hours after the incident. During interviews, the nursing home administrator, DON, and clinical resource nurse stated that the administrator believed the two-hour reporting requirement applied only to allegations resulting in serious bodily harm. The clinical resource nurse stated she showed the administrator the occurrence reporting manual and acknowledged that the facility missed the two-hour reporting guidelines for the four physical abuse allegations.
Failure to Prevent Resident-to-Resident Physical Abuse Involving a Known Aggressive Resident
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from resident-to-resident physical abuse. In the early morning, a certified nurse aide (CNA) heard arguing and activity in a room shared by two residents. When the CNA entered, one resident was standing near the roommate’s bed and attempting to remove a pillow from beneath the roommate’s head while the roommate was lying supine in bed. The CNA separated the residents and assisted the aggressive resident back to her side of the room. Approximately 20 minutes later, the same resident took a pillow from her own bed, went back to the roommate, and struck the roommate three times with the pillow before staff intervened again. The resident who initiated the physical contact had dementia with moderate cognitive impairment, insomnia, COPD, depression, and a documented history of physical and verbal aggression toward others. Her care plan, revised shortly after the survey, reflected a history of being physically aggressive, making threats to kill staff, making repetitive hostile statements, throwing food, drinks, and markers at other residents, pulling another resident’s hair bow, and throwing and hitting others with pillows. Identified triggers included touching her belongings, crowds, strangers, or actions taken from behind her. Interventions listed in the care plan included locating her room near the nurses’ station, decreasing interactions with other residents when possible, keeping her at arm’s length from others, providing distraction and redirection, and providing one-to-one observation during waking hours. The roommate who was the victim of the physical aggression had dementia, COPD, stroke, and kidney disease, required substantial assistance with ADLs, and had no documented behavior symptoms directed toward others. Her behavioral care plan noted paranoia and accusatory behavior related to dementia and stroke, including yelling about people on the television watching her and calling out that she was naked when she was not. After the incident, nursing documentation recorded that she was the recipient of physically aggressive behavior, that the aggressor made physical contact three times before separation by staff, and that the incident began with a verbal exchange between the roommates. The victim stated she was hit several times for no reason, did not hit back, denied pain or discomfort, and expressed that she did not want to remain in the same room with the aggressor. Staff interviews confirmed that the victim was upset and screamed for staff to get the other resident away from her during the incident.
Environmental and Infection Control Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in one of its units. Observations revealed multiple deficiencies in several resident rooms, including sheetrock damage, chipped paint, debris accumulation, and nonfunctional bathroom exhaust fans. Additionally, there were issues with the flooring, such as torn linoleum and separated tiles, as well as missing or damaged heater covers and ceiling tiles. These environmental concerns were not addressed despite the facility's policy to maintain a homelike environment and provide necessary housekeeping and maintenance services. During an environmental tour with the nursing home administrator (NHA) and the maintenance supervisor (MS), it was noted that the facility's computerized system for submitting work orders did not contain any requests for the observed issues. The MS stated that resident rooms were inspected monthly and routinely audited for environmental issues, yet the deficiencies persisted. The NHA confirmed that staff had been trained to use the computerized system for work orders, but no records of the reported concerns were found. Interviews with the NHA and the director of nursing (DON) revealed further issues with infection control practices. Urine collection hats and a male urinal were improperly stored in resident rooms, posing potential infection control risks. The DON acknowledged that these items should not be stored in resident rooms and should be disposed of or stored in plastic bags. The presence of plungers and toilet brushes in resident bathrooms was also noted, which were later removed during the survey.
Failure to Document and Monitor Wandering Behaviors
Penalty
Summary
The facility failed to ensure that two residents, who resided in a secured unit, were free from involuntary seclusion. The facility did not maintain the required ongoing documentation of the review and revision of care plans to meet the criteria and assess if the interventions met the needs of the residents. Specifically, the facility did not document wandering behavior, attempted diversional interventions, or the effectiveness of these interventions for the residents. Resident #19, an 82-year-old with Alzheimer's disease and dementia, was identified as being at high risk for elopement and wandering. Despite this, the facility's records did not show any documentation of wandering behavior or interventions from December 2023 to July 2024. The resident's care plan indicated a risk for elopement, but there was no evidence of monitoring or documentation of wandering behaviors or the effectiveness of interventions after an incident in December 2023. Resident #100, an 81-year-old with dementia and other health issues, was also at risk for wandering. The facility's records showed episodes of aimless walking and wandering, but there was no documentation of interventions used or their effectiveness. The care plan for this resident was only initiated during the survey, and it lacked documentation of wandering behavior and interventions. Interviews with staff revealed a lack of awareness and documentation regarding the effectiveness of interventions for both residents.
Failure to Document Narcotic Medication Removal
Penalty
Summary
The facility failed to ensure that narcotic medications were documented on the narcotic log at the time of removal from the locked narcotic drawer on two of four medication carts. During observations, discrepancies were noted in the narcotic logs compared to the actual counts of medications. Specifically, on the [NAME] unit, a registered nurse (RN) administered a hydrocodone/acetaminophen pill to a resident but forgot to document the removal of the medication from the locked controlled substance drawer. Similarly, on the Golden unit, another RN failed to document the removal of several medications, including lorazepam, pregabalin, oxycodone, and tramadol, from the locked controlled substance drawer after administering them to residents. Interviews with the nursing staff revealed that the nurses were aware of the requirement to document narcotic removals immediately but had not done so. The Director of Nursing (DON) acknowledged the issue and indicated that staff had been provided with recent education regarding the documentation of controlled substances. However, the failure to document the removal of narcotics at the time of administration was still observed, indicating a lapse in adherence to the facility's Controlled Medications Storage and Reconciliation policy.
Medication Storage and Administration Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and labeling of medications and biologicals, as observed in two medication carts and one medication storage room. Specifically, an Albuterol inhaler was found without a date label on the Golden unit medication cart, and two boxes of Haloperidol were found labeled for a resident who had been discharged a week earlier. Additionally, an open vial of tuberculin was found in the Montrose medication storage room without a date label, indicating a failure to adhere to the facility's policy of dating medications upon opening. Further observations revealed medication tablets on the floor near the Sterling unit medication room and the nurses' station, which were identified as Apixiban, Aspirin, and Acetaminophen. This indicates a failure to ensure medications were properly disposed of and that staff did not adequately supervise residents to ensure medications were swallowed. The presence of these medications on the floor suggests lapses in medication administration and disposal procedures. Additionally, a resident was found with artificial tears in their room without a physician's order for self-administration, which was not in compliance with the facility's policy. Interviews with the DON and other staff confirmed these deficiencies, highlighting a lack of adherence to medication storage and administration protocols. The facility's policy requires medications to be stored properly and dated upon opening, and discontinued medications to be promptly removed and disposed of, which was not consistently followed in these instances.
Deficiency in Hospice Service Communication and Documentation
Penalty
Summary
The facility failed to ensure that hospice services provided to a resident met professional standards and principles. Specifically, the facility did not establish a communication process between the facility and the hospice provider for a resident receiving hospice care. The facility's policy required collaboration with hospice, including documentation and record-keeping requirements, but this was not effectively implemented. The resident, who had severe cognitive impairments and was receiving hospice services, did not have a clearly defined care plan outlining the services to be provided by the hospice provider or the facility. Additionally, there was a lack of accessible documentation of hospice care visits in the resident's records. The facility's staff, including an LPN, were unable to locate the hospice binder that should have contained documentation of visits from the hospice provider. The DON acknowledged that the facility did not have a designated hospice coordinator at the time and that the communication process was not documented. The DON also admitted that the unit nursing staff did not have access to the hospice's electronic medical records, which contributed to the deficiency in communication and documentation.
Failure to Prevent Resident Altercation
Penalty
Summary
The facility failed to protect residents from physical abuse, specifically failing to prevent an altercation between two residents. Resident #256, who had a history of verbal and physical aggression related to dementia, engaged in a physical altercation with Resident #19. The incident occurred in the dining room where both residents were seated and began arguing, which escalated to Resident #256 pulling Resident #19's hair. Despite previous incidents involving Resident #256, the facility did not implement new person-centered interventions to prevent further altercations. Resident #256 had a documented history of aggressive behavior, with multiple incidents involving other residents prior to the altercation with Resident #19. The care plan for Resident #256 identified verbal and physical aggression but lacked updated interventions following previous incidents. The facility's investigation revealed that Resident #256 had been involved in four prior incidents with other residents, yet the care plan did not reflect new strategies to address these behaviors. Resident #19, who also had a history of verbal and physical aggression, was involved in the altercation with Resident #256. The facility's response to the incident was to separate and redirect the residents, but this intervention was deemed ineffective. The nursing home administrator acknowledged the altercation as substantiated physical abuse, highlighting the facility's failure to implement effective measures to prevent such incidents.
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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