Villa Manor Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Lakewood, Colorado.
- Location
- 7950 W Mississippi Ave, Lakewood, Colorado 80226
- CMS Provider Number
- 065092
- Inspections on file
- 19
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 11
Citation history
Health deficiencies cited at Villa Manor Care Center during CMS and state inspections, most recent first.
Incomplete COVID-19 Vaccine Education and Documentation: The facility failed to document COVID-19 vaccine education, offers, refusals, or medical contraindications for five reviewed residents. Records for residents with significant medical histories and varying cognitive status showed their COVID-19 vaccination was not up to date, but the EMR did not show that the vaccine was offered or why it was not received. Staff said education was provided verbally and that residents who declined did not sign anything, while one cognitively intact resident stated she did not remember being offered the vaccine and never refused a shot.
Failure to Follow EBP During High-Contact Care: Staff did not consistently wear gowns and gloves while providing direct care to residents on EBP. Observations showed an unidentified staff member assisting a resident with dressing and transfer without a gown, two staff transferring a resident with a foley catheter and colostomy bag without gowns, and RN/CNA staff providing transfers, toileting, and wound-related care to another resident without the required PPE. Interviews confirmed staff knew residents with wounds or indwelling devices were on EBP and that gowns and gloves were required for high-contact care activities.
Resident exposed during shower transport: A cognitively intact resident with quadriplegia and dependence for ADLs was observed being moved through hallways in a shower chair with inadequate covering after bathing. The resident was seen with the back, lower torso, thighs, feet, and later the knees to mid-waist exposed while other residents were present. RN, DON, and CNA interviews stated residents should be fully covered to preserve dignity and privacy.
Failure to Report Alleged Resident Abuse: The facility did not report an allegation of abuse involving two residents to the State Agency or the abuse coordinator. One resident with dementia-related behaviors was reported to have called another resident names and made an obscene gesture, and an RN also observed the gesture but did not report it. The cognitively intact resident said she told the social worker and a unit manager, but staff interviews and record review showed the allegation was not documented as reported.
Fall interventions were not consistently implemented for two residents. One resident with dementia, muscle weakness, and a history of falls was repeatedly observed without a fall mat by the bed and wearing regular socks instead of non-skid socks, despite a care plan calling for both interventions; records also showed multiple unwitnessed falls. Another resident with severe cognitive impairment, heart disease, COPD, and a T11-T12 fracture was observed several times in bed without the fall mat on the floor by the bed, and staff noted they were not aware the mat needed to be placed there.
Failure to Follow Ordered Oxygen Flow Rates: The facility did not ensure ordered respiratory care was carried out for two residents on continuous oxygen. One resident with respiratory failure and CHF was observed multiple times with the concentrator turned off and oxygen not applied, despite an order for 4 LPM via NC. Another resident with emphysema, acute respiratory failure with hypoxia, and pneumonia was observed with the concentrator set at 1 LPM instead of the ordered 4 LPM, and staff acknowledged the order should have been followed.
Expired and discontinued medications were found in two medication carts, including a discontinued methocarbamol order left in a resident’s drawer and an expired guaifenesin tablet on another cart. An LPN said discontinued medications should be removed from the cart and discarded, and the DON stated unit managers were responsible for keeping carts free of expired and discontinued meds.
The facility failed to provide necessary bathing assistance to three residents due to inadequate staffing. Despite the facility's policy to assist residents with ADLs, shower logs and interviews revealed that residents did not receive scheduled showers. Staff reported a shortage of CNAs, impacting their ability to provide care, while management attributed the issue to documentation errors.
The facility failed to provide sufficient nursing staff, resulting in delayed showers and incontinence care for residents. Interviews with CNAs revealed chronic understaffing, with only two CNAs often available for 50 residents, leading to rushed care and unmet needs. Despite management's confidence in staffing levels, grievances and staff accounts highlighted significant issues with timely resident care.
Incomplete COVID-19 Vaccine Education and Documentation
Penalty
Summary
The facility failed to develop and implement policies and procedures related to immunizations for five reviewed residents (#4, #6, #12, #38, and #58). For each of these residents, the medical record did not show that the resident or resident representative was provided education about the benefits and potential risks of the COVID-19 vaccine, and the records also did not document whether the vaccine was refused or not given because of a medical contraindication. The deficiency was identified during record review and interviews with facility staff. Resident #4 was over age 65 and had diagnoses including stroke, CAD, hypertension, hyponatremia, hyperlipidemia, dementia, hemiplegia or hemiparesis, and malnutrition; the MDS showed a BIMS score of 5 out of 15 and that the resident’s COVID-19 vaccination was not up to date, without stating whether the vaccine was offered or why it was not received. Resident #6 was also over age 65 with diagnoses including stroke, anemia, hypertension, diabetes mellitus, hyperlipidemia, dementia, and hemiplegia or hemiparesis; the MDS likewise showed a BIMS score of 5 out of 15 and no documentation of vaccine offer or reason for non-receipt. Resident #12 was over age 65, cognitively intact with a BIMS score of 14 out of 15, and had diagnoses including anemia, hypertension, hyponatremia, hyperlipidemia, aphasia, and hemiplegia or hemiparesis; the MDS stated the COVID-19 vaccination was not up to date but did not document whether it was offered or why it was not received. Resident #38 was over age 65 with diagnoses including CAD, heart failure, hypertension, PVD, GERD, renal failure, arthritis, and respiratory failure; the MDS showed a BIMS score of 15 out of 15 and again did not document whether the COVID-19 vaccine was offered or why it was not received. Resident #38 stated she remembered receiving the flu shot at the facility and receiving a vaccination sheet showing she was due for a COVID-19 vaccine, but she did not remember being offered the vaccine in October 2025 and said she never refused a shot. Resident #58 was over age 65 with diagnoses including CAD, hypertension, heart failure, hyperlipidemia, dementia, fracture, anxiety, and depression; the MDS showed severe cognitive impairment with a BIMS score of 3 out of 15 and did not document whether the vaccine was offered or why it was not received. Staff interviews indicated the COVID-19 vaccine was offered with the flu vaccine in the fall, education was verbal, residents who wanted the vaccine signed up, and those who declined did not sign anything; the DON also stated consent was obtained for residents who received the vaccine, while the immunization documentation reviewed did not include the education or refusal details.
Failure to Follow Enhanced Barrier Precautions During Resident Care
Penalty
Summary
The facility failed to maintain and follow its infection prevention and control program by not ensuring staff wore the required PPE during high-contact care for residents on enhanced barrier precautions (EBP). The report states that EBP requires gown and glove use during activities such as dressing, bathing, transferring, providing hygiene, changing linens, toileting, device care, and wound care for residents with wounds or indwelling medical devices. The facility policy also required standard and transmission-based precautions to prevent the spread of infections. On 3/24/26, an unidentified nursing staff member entered Resident #6’s room, where a sign indicated the resident was on EBP, and assisted with dressing and transferring the resident from bed to chair without donning a gown. The report also documented that Resident #70, who had a foley catheter and colostomy bag, was transferred into a shower chair via mechanical lift by two unidentified nursing staff members wearing gloves but not gowns, and later the same resident was transferred from bed to a mechanical wheelchair by two unidentified staff members who again did not wear gowns. Additional observations showed RN #4 assisting Resident #76 with transfers and toileting without wearing a gown and gloves despite an EBP sign posted on the door. CNA #5 wore gloves but not a gown while assisting Resident #76 with blood pressure measurement and toileting, and an unidentified CNA placed heel protector boots on Resident #76, who had a wound, without wearing a gown and gloves. Staff interviews confirmed that residents with wounds, catheters, ostomy bags, PICC lines, and other devices were considered appropriate for EBP, and multiple staff acknowledged that gowns and gloves should be worn for high-contact care activities.
Resident exposed during shower transport
Penalty
Summary
The facility failed to ensure dignity and respect for Resident #70 by not keeping the resident appropriately covered during transport through the hallway and common areas. Resident #70 was admitted and readmitted with diagnoses including quadriplegia, type 2 diabetes, muscle weakness, contractures of both upper arms, major depressive disorder, and anxiety. The 2/17/26 MDS showed the resident was cognitively intact with a BIMS score of 15/15 and was dependent on staff for showers, toileting hygiene, dressing, oral hygiene, and transfers. During observations, Resident #70 was transported in a shower chair from one shower room to another while covered only with a white bed sheet that exposed the resident's back, lower torso, thighs, and feet, with four other residents present in the hallway. Later, the resident was transported to his room covered with two towels while naked underneath, with visible exposure from the knees to the mid-waist on each side, and four residents were present in the common hallway area. The care plan documented the resident needed assistance from two staff for transfers and shower hygiene. Staff interviews stated residents should be fully covered after showers, that sheets or towels could be used to preserve privacy, and that residents should not be brought through the hall with skin exposed.
Failure to Report Alleged Resident Abuse
Penalty
Summary
The facility failed to report an allegation of abuse involving Resident #85 and Resident #79 to the State Survey and Certification Agency in accordance with state law. The deficiency was identified during record review and staff interviews, and the facility was unable to provide documentation that the allegation had been reported to the State Agency or to the facility’s abuse coordinator. The facility policy reviewed by surveyors stated that staff must report alleged violations of abuse, neglect, exploitation, and misappropriation of resident property without fear of retaliation and within required time frames. Resident #85 was greater than 65 years old and had diagnoses including hypertensive heart disease with heart failure, COPD, congestive heart failure, vascular dementia, and peripheral vascular disease. His MDS showed moderate cognitive impairment with a BIMS score of 12 out of 15, need for substantial to maximum assistance with some ADLs, and verbal behavioral symptoms directed toward others, including threatening, screaming, and cursing. His psychosocial care plan documented labile mood related to dementia with behaviors and a history of isolation and decreased socialization. Resident #79 was greater than 65 years old and had diagnoses including cancer, hypertension, peripheral vascular disease, and renal failure. Her MDS showed she was cognitively intact with a BIMS score of 15 out of 15 and needed supervision with shower transfers. She told surveyors that Resident #85 called her names and made an obscene hand gesture toward her, and said she reported the incident to the social worker and a unit manager. Staff interviews showed an RN observed Resident #85 make an obscene gesture toward Resident #79 and did not report it, and the NHA stated staff had not reported the allegation to him or to the State Agency.
Fall interventions were not consistently implemented for two residents
Penalty
Summary
The facility failed to ensure adequate supervision to prevent accidents for two residents by not consistently implementing their fall interventions. Resident #4 had diagnoses including muscle weakness, dementia, respiratory failure, and a history of falling. His MDS showed he was cognitively intact with a BIMS score of 5 out of 15 and required substantial to maximum assistance with transfers, toileting hygiene, and lower body dressing. His fall care plan included interventions such as non-slip socks, a low bed, and a fall mat next to the bed, but observations showed the fall mat was not consistently in place and he was often wearing regular socks instead of non-skid socks. During observations, Resident #4 was seen in bed without a fall mat next to the bed and wearing regular socks. At one point, his call light was on for several minutes before staff responded, and when staff entered the room, the fall mat was still not placed by the bed. Later, the resident was again observed sitting on the edge of the bed without the fall mat in place and still wearing regular socks. On another observation the next morning, the resident was lying in bed without non-slip socks and the fall mat remained folded behind a chair. Record review showed multiple unwitnessed falls, including falls on 2/22/26, 3/19/26, and 3/24/26, with staff notes describing the resident found on the floor or on his knees near the bed. Staff interviews confirmed that the fall mat and non-skid socks were intended interventions and that nursing staff were responsible for ensuring they were in place. Resident #58 had diagnoses including hypertensive heart disease with heart failure, endocarditis, COPD, restless leg syndrome, and a burst fracture of T11-T12. His MDS showed severe cognitive impairment with a BIMS score of 4 out of 15 and that he needed substantial assistance or was dependent for all ADLs. His fall care plan and Kardex identified a fall mat next to the bed as a safety intervention. However, observations showed the resident in bed without a fall mat on the floor by the bed on multiple occasions, with the mat folded in the corner against the wall. Staff passed by the room without moving the mat into place. An RN stated she was not aware the resident needed the fall mat on the floor when in bed, while the DON stated the mat was intended because of the resident’s prior fall history and fracture diagnosis.
Failure to Follow Ordered Oxygen Flow Rates
Penalty
Summary
The facility failed to ensure respiratory care was provided according to physician orders for two residents receiving oxygen therapy. The report states that oxygen is considered a medication and requires a prescription and continuous monitoring, and the facility’s oxygen policy required oxygen orders to include a specific flow rate. The deficiency involved Resident #4 and Resident #1, both of whom had physician orders for continuous oxygen at 4 LPM via nasal cannula. For Resident #4, the record showed diagnoses including respiratory failure and congestive heart failure, and the resident was receiving oxygen therapy. Observations found the oxygen concentrator next to the resident’s bed turned off, with the nasal cannula connected but oxygen not being administered. This was observed while the resident was in bed, in a wheelchair in the common area, in the kitchen, and when taken to the dining room. The resident’s physician order required oxygen at 4 LPM continuously via nasal cannula, and the MAR showed staff documenting oxygen as being provided even though observations on multiple occasions showed it was not applied. For Resident #1, the record showed diagnoses including emphysema, acute respiratory failure with hypoxia, pneumonia, pulmonary hypertension, and dependence on supplemental oxygen. The resident’s care plan and physician order required continuous oxygen at 4 LPM via nasal cannula. However, observations showed the oxygen concentrator set at 1 LPM while the resident was sitting in her room, and it remained at that setting later in the day. Staff interviews indicated the resident should have been on 4 LPM per the physician order, and there was no documentation of a current titration order changing the oxygen setting.
Expired and Discontinued Medications Left in Medication Carts
Penalty
Summary
Expired and discontinued medications were found stored in medication carts in two of five medication carts observed. On the 100 Hall medication cart, the drawer for Resident #82 contained methocarbamol 500 mg oral tablets even though the order had been discontinued on 1/18/26 after being ordered on 1/13/26 for leg pain. On the 500 Hall medication cart, guaifenesin extended-release tablets were present even though the medication had expired on 3/16/26. Staff interviews confirmed that the discontinued medication should not have remained in the cart and that nurses were responsible for removing discontinued medications and placing them in the basket for discontinued medications in the medication storage room. An LPN stated the expired or discontinued medication should have been discarded, and the DON stated unit managers were responsible for ensuring medication carts were free of discontinued and expired medications, with weekly rounds performed to dispose of them. The DON also stated the medications left in the carts were overlooked.
Inadequate Staffing Leads to Missed Showers for Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene. Specifically, three residents who were dependent on staff for bathing did not receive their scheduled showers. The facility's policy stated that residents would receive assistance as needed to complete ADLs, but this was not adhered to, as evidenced by the shower logs and resident interviews. Resident #1, who was cognitively intact and dependent on staff for bathing, reported that the facility did not have enough staff to meet her needs, resulting in missed showers. The shower logs confirmed that Resident #1 received only a fraction of the scheduled showers over a three-month period. Similarly, Resident #2, who had moderate cognitive impairments and required partial assistance with bathing, also did not receive adequate showers, as confirmed by the shower logs and the resident's representative. Resident #3, who required maximal assistance with bathing, experienced similar issues, although there was some improvement in March 2025. Interviews with staff, including CNAs and an LPN, revealed that the facility had been experiencing a shortage of CNAs, which impacted their ability to provide scheduled showers and other personal care. Staff reported working with insufficient numbers, sometimes caring for a large number of residents alone, which delayed or prevented the completion of scheduled showers. Despite these challenges, the Director of Nursing and the Regional Vice President attributed the missed showers to documentation errors, rather than acknowledging the staffing issues reported by the staff.
Staffing Shortages Lead to Delayed Resident Care
Penalty
Summary
The facility failed to provide sufficient nursing staff to ensure residents received timely care and services, particularly in the areas of scheduled showers and incontinence care. The facility's staffing policy, revised in August 2023, stated that adequate staff would be maintained on each shift to meet residents' needs, but interviews and grievances indicated otherwise. Residents and their families reported delays in receiving showers and incontinence care, with one resident stating it could take up to 45 minutes to receive incontinence care. The facility assessment documented a desired per patient day (PPD) for CNAs of 2.26 hours, but staffing levels were reportedly insufficient to meet this standard. Interviews with CNAs revealed that the facility had been short-staffed for over a year, with instances where only two CNAs were available to care for 50 residents. This shortage led to delays in providing scheduled showers and incontinence care, with CNAs having to prioritize residents with bowel movements over those who were wet. CNAs reported that management did not assist with resident care when short-staffed and that they were often told to do what they could with the available resources. The lack of sufficient staff also resulted in CNAs having to rush through resident care and stay late to complete charting. The Director of Nursing (DON) and the Regional Vice President (RVP) were interviewed and expressed confidence in the facility's staffing levels, attributing missed showers to documentation errors. However, the grievances and staff interviews indicated ongoing issues with staffing and resident care. The RVP acknowledged staff turnover and efforts to increase CNA pay but did not recognize a staffing concern. The facility's failure to provide adequate staffing resulted in residents not receiving necessary care in a timely manner, as documented in the report.
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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