Skylake Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Thornton, Colorado.
- Location
- 12080 Bellaire Wy, Thornton, Colorado 80241
- CMS Provider Number
- 065238
- Inspections on file
- 26
- Latest survey
- March 4, 2026
- Citations (last 12 mo.)
- 13
Citation history
Health deficiencies cited at Skylake Post Acute during CMS and state inspections, most recent first.
A cognitively intact resident with multiple medical conditions required assistance with bathing but did not have bathing preferences or specific shower days incorporated into the ADL care plan, and no shower preference assessment was completed on admission. The resident’s representative reported that staff were not providing requested showers, observed the resident in the same clothing with a personal odor, and the facility could not produce documentation of completed showers. CNA and LPN interviews described a routine shower schedule, processes for offering and documenting showers and refusals, and communication between shifts, while the DON stated that preference evaluations and post-admission showers were expected but acknowledged staff reported forgetting to document offers or refusals. Record review showed no documented showers during the resident’s stay, demonstrating a failure to provide and document showers consistent with the resident’s preferences.
A resident with sepsis, pneumonia, weakness, and high fall risk required substantial assistance with ADLs and had a care plan that included two-person assistance for incontinence care. During incontinence care, a CNA assisted the resident alone, during which the resident rolled out of bed and sustained right shoulder pain, multiple toe skin tears, and a knee abrasion. The resident later reported that the CNA repeatedly pushed her to roll and that she was pulled up from the floor by her painful arm. The ADL care plan did not clearly specify bed mobility assistance needs, staff understanding of required assistance was inconsistent with the care plan, and there were no nursing progress notes documenting the fall in the EMR on the day of the incident.
A resident with multiple medical conditions and a documented pineapple allergy was served a dinner tray containing pineapple, which the resident ate before the error was recognized, despite the allergy being clearly listed and highlighted on the meal ticket and in the care plan. Facility policy required identification of food allergies at admission, documentation in the care plan, and provision of appropriate substitutions, with meal tickets used by dietary and nursing staff to verify diets and allergies. In this case, a dietary aide did not properly review the meal ticket and placed pineapple on the tray, and a CNA noticed the error only after the resident had already consumed some of it. Resident council feedback later described broader concerns that CNAs were not consistently following meal tickets or correcting meal errors, indicating ongoing issues with adherence to established meal verification processes.
Staff failed to follow infection control protocols by not wearing required gowns during high-contact care for a resident on enhanced barrier precautions and by not sanitizing wound care equipment or maintaining a clean work surface during wound care. These actions were inconsistent with facility policy and were confirmed through staff interviews.
The facility failed to protect residents from abuse in the memory care-secured unit, where a resident with a known history of aggression was admitted without a comprehensive assessment or behavioral management plan. This led to an incident where the resident physically assaulted another resident, causing severe injuries. The facility's inadequate screening and admission process, along with the lack of communication about the resident's history, contributed to the incident.
The facility did not have a written transfer agreement with a local hospital certified by Medicare or Medicaid. During a review, the DON and corporate nurse consultants could not provide the agreement. The INHA stated that hospitals accepted residents based on availability, making a formal agreement unnecessary.
A facility failed to inform a resident's legal representative about care plan meetings, medical appointments, and changes in the resident's condition. The resident, with severe cognitive impairment, had a representative to make decisions on their behalf. Despite daily visits, the representative was not notified of care conferences or medical appointments, learning about them only through a voicemail. Staff interviews revealed inconsistencies in the notification process, impacting the representative's ability to participate in care planning.
A resident in a long-term care facility was found with a bite wound of unknown origin, which was not reported to the State oversight agency within the required 24-hour timeframe. Despite the facility's policy requiring immediate reporting, staff, including the DON and an LPN, failed to investigate or document the incident. The resident's representative and hospice nurse were the first to notice the wound, but the facility did not take appropriate action, leading to a deficiency in compliance with reporting regulations.
A resident with severe cognitive impairments was found with a bite wound of unknown origin, but the LTC facility failed to investigate the incident thoroughly. Despite concerns raised by the resident's representative and hospice nurse, the staff did not document or report the injury, and the Director of Nursing admitted no investigation was conducted. This resulted in a failure to address potential abuse and ensure the resident's safety.
Failure to Honor Resident Bathing Preferences and Document Shower Provision
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident’s right to self-determination and choice regarding bathing, specifically by not ensuring showers were provided consistent with the resident’s preferences. The resident, an older adult with diagnoses including severe sepsis with septic shock, pneumonia, major depressive disorder, and weakness, was cognitively intact with a BIMS score of 15 and required assistance with several activities of daily living. The MDS documented bathing as not applicable for assistance, while the ADL care plan initiated shortly after admission indicated the resident needed partial to substantial assistance for bathing or showering but did not include the resident’s bathing preferences or specific shower days. The resident’s representative reported that the resident stated staff were busy and not providing showers, and that the resident requested a shower during the week after admission but did not receive one. The representative observed the resident wearing the same clothing on multiple occasions and noted a personal female odor, and the resident expressed a desire to be clean. When the representative requested documentation of completed showers from the DON, the facility was unable to provide it. Review of the CNA bathing task documentation from admission through discharge showed no documented showers during the resident’s stay, and the electronic medical record revealed that the shower preference assessment was not completed upon admission. Staff interviews indicated that residents were scheduled for showers multiple times per week and could choose morning or evening showers, with refusals to be documented and communicated between shifts. A CNA stated that this resident was scheduled for showers three times weekly and sometimes refused due to fatigue after therapy, with refusals to be documented and missed showers potentially made up on subsequent days. An LPN described a process of repeated offers, documentation of refusals, and family notification if a resident refused showers. The DON stated residents were to be offered showers at least twice weekly, that a preference evaluation was part of the admission packet, and that new admissions were to be offered a shower the day after admission, but acknowledged staff reported they forgot to document offers or refusals and that she was unaware of any bathing concerns until after the resident had discharged. These findings collectively show that the facility did not ensure the resident’s shower preferences were assessed, care planned, and carried out in practice, nor consistently documented.
Failure to Provide Safe Assistance During Incontinence Care Resulting in Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to ensure safe assistance and adequate supervision during incontinence care, resulting in a fall with minor injuries. The facility’s Falls – Clinical Protocol policy required identification of residents at risk for falls and assessment and documentation of falls and related factors. Resident #1, an older adult with severe sepsis with septic shock, pneumonia, major depressive disorder, and weakness, was cognitively intact and required substantial to maximal assistance with toileting and other ADLs. A fall risk assessment identified her as a high fall risk, and her fall care plan cited risk factors including respiratory failure, COPD, and chronic pain. The resident’s ADL care plan noted a self-care performance deficit and need for staff assistance, but the bed mobility intervention did not specify the level of assistance or number of staff required. The fall care plan, however, included an intervention that two staff members were to provide incontinence care. On the date of the incident, a CNA was providing incontinence care when the resident rolled out of bed, landing on her lower extremities. The resident reported right shoulder pain, and the nurse observed multiple skin tears on the toes and a right knee abrasion. An IDT note later described that the resident lifted her right leg, her weight shifted, and she rolled left and slid out of bed onto her knees during incontinence care. The resident’s representative reported that the resident stated an unknown CNA kept pushing her to roll over during incontinence care, leading to her falling off the bed, and that a nurse entered and saw the CNA pulling the resident up from the floor by her right arm despite the resident’s complaints of pain. The representative also reported abrasions or bruising on every toe of the resident’s right foot, with bandages applied, and that the facility notified her later that the resident had a fall and was fine, without informing her of injuries. Staff interviews showed inconsistency between the care plan requirement for two-person assistance during incontinence care and staff understanding of the needed level of assistance, with the DON stating the resident required one-person assistance for turning in bed prior to the fall. Review of the electronic medical record revealed no nursing progress notes documenting the fall event on the date it occurred.
Failure to Prevent Serving Allergen-Containing Food Despite Documented Allergy
Penalty
Summary
The deficiency involves the facility’s failure to ensure that food served accommodated a resident’s documented allergy, resulting in the resident being served and ingesting pineapple despite a known pineapple allergy. Facility policy on Food Allergies and Intolerances, revised August 2017, states that residents with food allergies are to be identified upon admission, have allergies documented in the care plan, and be offered appropriate substitutions, with steps taken to prevent exposure to allergens. For the resident involved, the comprehensive care plan initiated in mid-January identified allergies to pineapple and wool, and the care plan report listed pineapple as an allergy and included an intervention for staff to honor food preferences, although it did not document specific food likes and dislikes. The resident, an older adult with diagnoses including severe sepsis with septic shock, pneumonia, major depressive disorder, and weakness, was cognitively intact with a BIMS score of 15 and required set-up or clean-up assistance with eating. On an evening in January, nursing documentation shows that pineapple was present on the resident’s dinner tray even though the resident had a documented pineapple allergy. The progress note states the resident ate two pieces of pineapple before the error was recognized and the pineapple was removed. The resident’s representative reported that the allergy was documented in the medical record and on the meal ticket, yet pineapple was still served, and that the resident became upset and did not understand how this occurred. According to the facility’s own root cause analysis, the dietary aide responsible for serving food did not correctly review the resident’s meal card and failed to note the highlighted pineapple allergy, placing pineapple on the tray as dessert. The CNA delivering the tray identified the pineapple only after the resident had already eaten two pieces. Interviews with the dietary manager, dietary aide, cook, RD, CNA, RN, and DON consistently described a system in which resident allergies are entered into an electronic system, printed on meal tickets, and highlighted so that kitchen and nursing staff can verify trays before service. However, in this incident, staff did not adequately review or follow the meal ticket information, and subsequent resident council notes documented ongoing resident concerns that CNAs were not following meal tickets correctly and were not consistently asking residents for their meal choices. Resident council meeting notes from late January and late February further describe meal service concerns, including reports that CNAs blamed the kitchen for meal mistakes and did not correct issues when errors occurred, and that meal tickets were not being followed correctly by CNAs on a specific unit. These resident reports indicate that, beyond the single documented pineapple incident, residents perceived ongoing problems with adherence to meal tickets and proper verification of meals against documented diets and allergies. The deficiency is thus centered on the facility’s failure, in at least one case, to prevent exposure to a known food allergen despite clear documentation and an established process intended to identify and avoid such allergens.
Failure to Adhere to Infection Control Protocols During Resident Care
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by staff not adhering to established protocols for personal protective equipment (PPE) and wound care. Specifically, staff did not wear gowns when providing direct care to a resident on enhanced barrier precautions (EBP), despite facility policy requiring both gloves and gowns for high-contact care activities involving residents at risk for or colonized with multi-drug resistant organisms (MDROs). Observations showed that a certified nurse aide and two LPNs provided care to a resident on EBP while only wearing gloves, omitting the required gown. Additionally, infection control measures were not followed during wound care procedures. One LPN used scissors from her pocket to cut wound dressing without sanitizing them before use, and another LPN used a retractable tape measure to measure an open wound, then retracted and stored it without sanitization. Wound care supplies were also placed directly on a resident's nightstand among personal items, rather than on a clean surface. Staff interviews confirmed that these actions were inconsistent with facility policy and best practices for infection control.
Failure to Protect Residents from Abuse in Memory Care Unit
Penalty
Summary
The facility failed to protect residents from abuse and neglect, specifically in the memory care-secured unit, where two residents were involved in incidents of resident-to-resident abuse. Resident #6, who had a known history of aggressive behavior, was admitted without a comprehensive assessment or a behavioral management care plan. The facility did not inform staff about Resident #6's history of aggression, which led to an incident where Resident #6 physically assaulted Resident #2, causing severe injuries. The staff did not closely monitor Resident #6's activities, despite observing changes in his behavior, which resulted in the assault on Resident #2. Resident #2, an 89-year-old with severe cognitive impairment and dementia, was unable to protect herself from the assault. She suffered significant injuries, including facial trauma and fractures, requiring hospitalization. The facility's failure to assess and manage Resident #6's behavior and to communicate his history to staff contributed to the incident. Additionally, the facility did not implement effective interventions to prevent resident-to-resident abuse, as evidenced by another incident where Resident #5 physically abused Resident #11. The facility's screening and admission process was inadequate, as it did not ensure the safety and appropriateness of admissions for residents with behavioral needs. The facility did not obtain or communicate sufficient information about Resident #6's history, which could have prevented the incident. The lack of a behavior-focused care plan and interventions for Resident #6, along with the failure to reassess his care needs, created a situation of immediate jeopardy for other residents in the memory care-secured unit.
Removal Plan
- Resident was discharged from the facility.
- Resident was placed on one-to-one monitoring and will continue one-to-one support with a review by the interdisciplinary team.
- The facility will hold admissions until it can review the pre-admission screening tool for residents with known behaviors.
- An ad hoc quality assurance performance improvement (QAPI) meeting will be held after the review of the pre-admission screening tool.
- The abuse policy was reviewed.
- The nurse practice educator/designee educated all staff on the facility abuse policy.
- Facility management staff reviewed the facility assessment on staffing and skills to care for residents with behaviors.
- The facility revised its pre-admission screening intake form to include a history of behaviors and supervision needs by the admissions director.
- The director of nursing educated the admissions team on the pre-admission screening tool and process.
- Residents in the memory support unit will be reviewed by social services and/or nursing/designee for behaviors, wandering, current interventions, and their care plan related to behaviors.
- Staff assigned to the memory support unit will be trained in specific resident care needs upon completion of the review, with training completed prior to their next assigned shift.
- Any admission to the memory support unit will be reviewed by social services and nursing to enter behavior tracking and a baseline care plan to meet the resident's needs.
- The facility assessment was reviewed and revised to include staffing levels for all departments in the memory support unit.
- New hires will receive education on abuse prevention and de-escalating behaviors during onboarding by the nurse practice educator.
- The nursing home administrator will implement a review with the quality assurance performance improvement (QAPI) committee to review and interpret all abuse findings, with all audit findings reviewed at the monthly meeting for at least three months or until the compliance pattern is maintained.
Lack of Hospital Transfer Agreement
Penalty
Summary
The facility failed to maintain a written transfer agreement with at least one local hospital certified by Medicare or Medicaid. This deficiency was identified during a record review and staff interviews. On a specific date, a request was made to the Director of Nursing (DON) and a corporate nurse consultant for the facility's hospital transfer agreement, but they were unable to provide such a document for the area hospital. During an interview, the interim nursing home administrator (INHA) and two corporate nurse consultants confirmed that the facility did not have a hospital transfer agreement. The INHA explained that local hospitals accepted residents based on their availability, and therefore, a formal transfer agreement was deemed unnecessary by the facility.
Failure to Inform and Involve Resident's Representative in Care Planning
Penalty
Summary
The facility failed to ensure that a resident's legal representative was informed and involved in the care planning process. The resident, who had severe cognitive impairment and was unable to participate in care planning, had a legal representative appointed to make decisions on their behalf. However, the facility did not notify the representative in advance of care plan meetings, nor did they inform her of the resident's podiatry and dental appointments or changes in the resident's condition, such as falls. The legal representative reported that she was not informed of a care conference meeting held on a different date than initially scheduled. She only learned about the resident's frequent falls and medical appointments through a voicemail left by the facility after the meeting. Despite being present at the facility daily, the representative was not kept informed of the resident's care and treatment changes, which hindered her ability to participate actively in the resident's care. Interviews with facility staff revealed inconsistencies in the notification process for care conferences and medical appointments. The social services assistant admitted to not notifying representatives of routine medical appointments and only contacting them by phone when there was insufficient time to send a letter. The director of nursing acknowledged issues with scheduling care conferences and emphasized the need for notifying representatives of all scheduled visits and changes in the resident's condition.
Failure to Report and Investigate Injury of Unknown Origin
Penalty
Summary
The facility failed to report an allegation of an injury of unknown origin, specifically a bite wound, to the State oversight agency within the required 24-hour timeframe. The incident involved a resident who was discovered to have a bite wound on the top of his left hand, which was suspected to have been caused by someone other than the resident himself. The facility's policy mandates that such incidents be reported immediately, defined as within two hours for serious bodily injury or within 24 hours for other allegations. However, the facility did not adhere to this policy, as the incident was not reported to the appropriate authorities. Interviews and record reviews revealed that the resident's representative and hospice nurse were the first to notice and report the bite wound. The hospice nurse informed the resident's representative and attempted to contact the facility, leaving a voicemail when unable to reach the memory care unit manager. Despite these efforts, the facility staff, including the Director of Nursing (DON) and Licensed Practical Nurse (LPN) #3, were either unaware of the bite wound or did not take appropriate action to investigate or report the incident. The DON acknowledged hearing about the allegation but did not ensure an investigation was conducted or that the incident was reported. The lack of documentation and follow-up by the facility staff further compounded the issue. The DON could not provide evidence of an investigation or assessment of the resident's injury, and there was no documentation of any nurse's assessment of the bite wound. This failure to investigate and report the injury of unknown origin represents a significant deficiency in the facility's adherence to its policies and regulatory requirements.
Failure to Investigate Alleged Abuse Incident
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving a resident who was found with a bite wound of unknown origin. The resident, who had severe cognitive impairments and was known to wander, was discovered with a bite mark on the top of his wrist. Despite the resident's representative and hospice nurse raising concerns about the injury, the facility staff did not document or investigate the incident as required by their policies. Interviews with staff revealed inconsistencies and a lack of awareness regarding the resident's injury. The resident's representative reported the bite mark to the facility staff, but no one could provide an explanation for how the injury occurred. The hospice nurse also noted the injury and attempted to communicate with the facility, but the staff did not follow up with an investigation or report the incident to the appropriate authorities. The facility's Director of Nursing (DON) acknowledged that no investigation was conducted and that the incident was not reported as an injury of unknown origin. The DON admitted to hearing about the allegation but did not personally assess the resident or ensure that the staff documented the incident. This lack of action and documentation led to a failure in addressing the potential abuse and ensuring the resident's safety.
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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