Brookside Inn
Inspection history, citations, penalties and survey trends for this long-term care facility in Castle Rock, Colorado.
- Location
- 1297 S Perry St, Castle Rock, Colorado 80104
- CMS Provider Number
- 065361
- Inspections on file
- 18
- Latest survey
- March 12, 2026
- Citations (last 12 mo.)
- 14 (1 serious)
Citation history
Health deficiencies cited at Brookside Inn during CMS and state inspections, most recent first.
The deficiency centers on failures in transportation safety and fall management that led to serious resident injuries. A resident with dementia and bilateral lower extremity impairments was transported in a wheelchair without foot pedals, seated on a blanket and Hoyer sling, and improperly restrained when the driver misapplied the lap and shoulder belt to avoid disturbing an ostomy bag. During the trip the resident slid forward, struck both legs on a step in the vehicle, and was later found to have bilateral tibial fractures with significant bruising, swelling, and pain. The driver’s training had been informal, passed down from another staff member without documented competencies, van‑specific procedures, or clear emergency protocols, and leadership acknowledged they had not investigated the admitted misuse of the seat belt. Separately, two residents at high risk for falls experienced multiple falls, including one with a facial laceration and maxillary sinus fracture, while care‑planned fall interventions such as scheduled toileting, prompted voiding, monitoring, and assisted transfers were not consistently implemented, and IDT reviews and implementation of recommended interventions were not always timely.
Improper glove use during food preparation. A cook and the regional dietary supervisor were observed handling ready-to-eat foods in the kitchen without changing gloves or performing hand hygiene between tasks. The cook prepared a PB&J sandwich, dinner rolls, and hamburgers while touching utensils, refrigerator doors, packaging, and multiple food items with the same gloves. The regional dietary supervisor also handled packaged lettuce, boiled eggs, ham, and salad ingredients with the same gloves while assembling chef salads.
Facility assessment was incomplete and not facility specific. The NHA and DON acknowledged it did not include staff competencies, training plans, staffing resources, contracts with oxygen, lab, and X-ray vendors, emergency hazard areas, or how policies were evaluated for current standards. It also failed to note that the secured unit was for female residents only and did not identify how a translator would be obtained for non-English speaking residents.
The facility’s QAPI program failed to identify and address repeated abuse-related deficiencies and concerns involving resident care and safety. The record showed multiple citations for F600 abuse prevention across several surveys, and a transportation incident in which a resident was not properly secured in a facility vehicle, resulting in multiple lower-extremity fractures and an IJ finding with actual serious harm.
Failure to follow up on resident council grievances: Residents reported repeated concerns about meal ordering, snack choices, fruit, soups, and tray delivery issues that were discussed in food council meetings but not clearly resolved. Record review showed the concerns were documented in meeting minutes, but there was no evidence of timely written decisions or follow-up with the residents or council on what had been done to address the grievances.
Improper medication storage and labeling were found in the medication room and on multiple med carts. Surveyors observed opened eye drops, insulin, TB serum, and nebulizer meds that were not dated, along with expired meds and supplies such as Flucelvax, suppositories, blood collection items, naloxone, lidocaine patches, and miconazole cream. Staff stated night shift nurses were responsible for routine checks of the med room and carts for expired items.
Residents were not consistently served meals according to their preferences, and staff described a reduced menu with limited alternatives. Several residents said they often did not receive ordered items, were given preset trays instead of requested meals, and were not offered meaningful substitutes such as fresh fruit, soups, or sandwiches outside scheduled meal windows. Food council records showed repeated resident requests for more variety, but the grievance tied to those concerns had no documented follow-up.
The facility failed to follow infection control practices during housekeeping, resident care, and medication administration. Two housekeepers cleaned resident rooms without cleaning all high-touch surfaces, did not follow the required disinfectant dwell time, and used the same gloves after touching contaminated surfaces and resident items. For a resident on EBP with an open wound, urinary catheter, and PICC line, a restorative aide, CNA, and LPN did not consistently wear gowns for high-contact care and did not change gloves or perform hand hygiene after touching surfaces before continuing care. An RN also dispensed oral meds into a bare hand before placing them in a med cup.
Failure to Protect Resident from Verbal Abuse: A resident with severe cognitive impairment and a history of verbal and physical aggression directed racial slurs at another resident who also had severe cognitive impairment and multiple neurologic and psychiatric diagnoses. The abused resident appeared to laugh off the incident, and the facility determined it was not abuse because there was no physical contact and the resident did not seem upset. Surveyors found the comments constituted verbal abuse and that the resident was not kept free from abuse.
The facility failed to ensure two residents were free from involuntary seclusion by not accurately and timely re-evaluating their secure-unit placement. One resident with severe dementia, total ADL dependence, and no wandering or exit-seeking was observed sitting in the same Broda chair position for nearly four hours without self-propelling, while staff said she could not walk or propel herself and never tried to exit-seek. Another resident with dementia and behavioral diagnoses was observed reading, attending activities, and showing no wandering or exit-seeking behaviors, yet staff said she had not been trialed off the unit and the record lacked physician documentation that the locked unit was the least restrictive setting.
Failure to Reevaluate PRN Psychotropic Medication: A resident with vascular dementia, restlessness, agitation, and severe cognitive impairment received PRN lorazepam under an order written for 90 days. The record showed the PRN psychotropic was not reevaluated after the 14-day limit and no physician rationale was documented to justify continued use beyond that period, despite doses being administered during the month.
Failure to Report Alleged Verbal Abuse: A resident with dementia and a history of verbal aggression directed racial slurs at another resident with severe cognitive impairment and multiple neurologic diagnoses. Staff spoke with both residents, and the recipient laughed off the incident, but the facility determined it was not abuse and did not report it to the State Agency, despite the event involving racially targeted verbal abuse.
Failure to reposition and provide timely incontinence care led to pressure injury care deficiencies for two residents. One resident who was dependent for ADLs and at high risk for skin breakdown was left in the same Broda chair position for hours at a time without staff checking for incontinence or repositioning, despite a care plan calling for skin breakdown prevention measures. Another resident with a stage 4 sacral pressure injury, osteomyelitis, contractures, and total dependence for ADLs was observed sitting in the same angled wheelchair position for over four hours without repositioning assistance, even though the wound care note called for pressure-relieving measures, offloading, and repositioning as tolerated.
A facility failed to provide respiratory care as ordered for two residents. One resident with CHF, OSA, and oxygen dependence was repeatedly observed on oxygen at a higher flow rate than ordered, while staff documented a lower rate on the MAR, and her CPAP humidifier chamber was repeatedly left connected with water and condensation despite orders to disconnect, empty, clean, and dry it. Another resident with heart failure and oxygen dependence was observed on oxygen at a higher flow rate than the physician ordered, while the MAR still reflected the ordered lower rate.
Two residents in a facility were subjected to abuse by staff members. One resident was roughly handled by a CNA, causing physical pain and mental anguish, but the facility failed to investigate or report the incident. Another resident was physically abused by an LPN, resulting in bruising, but the facility's investigation did not substantiate the abuse despite evidence. Both residents had severe cognitive impairments, and the facility's actions violated their abuse prevention policy.
A resident with severe cognitive impairments and a history of attempting to get out of bed unassisted was improperly restrained by facility staff using a recliner chair pushed against her bed. The facility's policy requires that restraints only be used for medical treatment, yet the chair was used for staff convenience. Video evidence and staff interviews confirmed the inappropriate use of the chair as a restraint, contrary to the facility's restraint-free policy.
Transportation Safety and Fall Management Failures Leading to Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision to prevent accidents, particularly in relation to transportation safety and fall prevention. One resident with vascular dementia, bilateral lower extremity impairments, and dependence on staff for transfers was transported to an outside appointment in a facility vehicle while seated in a wheelchair without foot pedals. During the trip, the resident began sliding forward in the wheelchair. The transportation driver reported he could not immediately pull over while exiting the highway, and by the time he stopped, the resident had slid further forward so that her knees and legs were resting on a step behind the driver’s seat. The resident subsequently exhibited multiple bruises, abrasions, swelling of both legs, and severe pain. Facility records and later hospital documentation identified bilateral tibial fractures associated with this transport incident. The report details that the wheelchair was secured with a four‑point tie‑down, but the resident’s body was not properly restrained. The driver later demonstrated that he had routed the shoulder portion of the seat belt around the back of the van seat instead of across the resident’s shoulders, and placed the lap portion across the resident’s chest instead of her lap. He acknowledged this was not the proper use of the seat belt and attributed his actions in part to concern about disturbing the resident’s ostomy bag. He also stated that the resident was sitting on a blanket and a Hoyer sling, which he believed contributed to sliding, and that the absence of foot pedals left nothing to stop the resident’s forward movement. The facility’s own transportation policy required that drivers and passengers wear seatbelts and shoulder harnesses any time the vehicle was in motion and that wheelchairs be made secure with straps, but there was no evidence that the seat belt system was applied as intended in this case. The report further identifies systemic issues in transportation training and oversight that contributed to the deficiency. The van driver had been in the role for a little over a month and was trained informally by the central supply coordinator, who herself had been trained years earlier by a prior driver without documented competencies, checklists, or reference to an operations manual. The central supply coordinator reported no additional training or competencies since that initial instruction and was unaware of any policy or procedure for driving emergencies or clear guidance on whom the driver should contact for clinical or mechanical emergencies during transport. The maintenance director, responsible for monthly checks of the van, used a generic medical transport checklist, had no van‑specific training or competencies, and was unsure whether an operations manual was available. The administrator acknowledged that she was not sure what competencies the trainer had when she trained the current driver, that the DON and ADON were not trained on transportation, and that no investigation was completed into the driver’s admitted misuse of the seat belt. Collectively, these actions and inactions led to the transportation‑related accident and constituted a failure to maintain an accident‑free environment and adequate supervision. In addition, the deficiency includes failures related to fall management for two other residents at high risk for falls. One resident with vascular dementia, muscle wasting, difficulty walking, and severe cognitive impairment experienced 16 falls over a defined period, including an unwitnessed fall that resulted in a facial laceration and a maxillary sinus fracture requiring emergency department evaluation. The facility had a fall management policy requiring IDT review of falls and individualized care plan interventions, and the resident’s care plan contained multiple fall interventions such as scheduled toileting, prompted voiding, use of a non‑recording video monitor, and assistance with transfers. However, the report notes that care‑planned fall interventions were not consistently implemented in a timely manner, and surveyor observations during the survey period showed that staff were not consistently following the resident’s fall interventions. The report also notes that the IDT did not consistently review falls in a timely manner or ensure that recommended interventions were implemented. For the high‑risk resident with multiple falls, IDT notes documented repeated unwitnessed and witnessed falls associated with poor safety awareness, failure to use the call light, weakness, and attempts to ambulate or transfer without assistance. New interventions such as occupational therapy evaluations, room relocation closer to staff, and pharmacy review were recommended, but one occupational therapy evaluation was recommended after a fall even though it had already been recommended after a prior fall, indicating delays or gaps in implementation. Another resident with multiple falls had no timely identification and documentation of fall interventions after several falls. These patterns demonstrate that the facility did not ensure timely IDT review of falls or consistent implementation of care‑planned fall interventions, contributing to repeated falls and at least one major injury. Overall, the cited deficiency encompasses the facility’s failure to safely transport a dependent, cognitively impaired resident in accordance with its own transportation safety policy, resulting in bilateral tibial fractures, and its failure to consistently implement and timely review fall prevention interventions for residents at high risk for falls, including residents who sustained multiple falls and a serious injury.
Removal Plan
- Temporarily suspend all facility resident transportation services and transfer transportation to an outside company pending completion of training and validation.
- Immediately remove all staff members assigned transportation responsibilities from transportation duties pending completion of retraining and competency validation.
- Transport residents requiring appointments using medical transportation services through external transportation companies.
- Implement a resident transportation risk assessment tool to identify residents who require special transportation precautions; assess all residents who utilize facility transportation using this tool.
- Implement a comprehensive transportation safety program including: updated Transportation Safety Policy; Transportation Driver Job Description with defined safety duties; Transportation Staff Competency Validation process; Pre-Transport Safety Checklist (reviewed by administrator or designee); Transportation Special Circumstances Protocol; Transportation Incident Investigation Template; Transportation Safety Training Program; and Transportation Safety QAPI Monitoring Process.
- Require wheelchairs to be secured using a four-point tie-down system.
- Require residents to be secured with lap and shoulder seatbelts.
- Verify wheelchair brakes and foot pedals prior to transport by the administrator or designee.
- Confirm resident stability before departure by the administrator or designee.
- Evaluate residents’ medical devices/special medical circumstances individually (e.g., ostomies, indwelling urinary catheters, suprapubic catheters, oxygen equipment, other devices) and implement appropriate precautions prior to transportation as necessary.
- Provide mandatory transportation safety training for all transportation staff (wheelchair securement, restraint placement, medical device accommodations, emergency response); document attendance and validate competency using a checklist, with validation by the maintenance director and clinical liaison/designee as approved by the administrator.
- Complete a Pre-Transport Safety Checklist prior to each transport verifying wheelchair brakes engaged, foot pedals attached, four-point tie-down secured, lap and shoulder restraints applied, medical devices protected, and resident stability confirmed (completed by Maintenance Director and Clinical Liaison/Designee).
- Use a transportation incident ad hoc QAPI tool to ensure structured review of any transportation-related incident (incident description, equipment review, root cause analysis, corrective action planning).
Improper glove use during food preparation
Penalty
Summary
The facility failed to ensure food was prepared, distributed, and served under sanitary conditions in the main kitchen. During observation of lunch meal service, cook #1 prepared a peanut butter and jelly sandwich while wearing gloves, but after opening the walk-in refrigerator door to retrieve jelly, he continued handling bread and assembling the sandwich without changing gloves or performing hand hygiene. He also carried the finished sandwich into the dirty dish area to retrieve a clean plate before sending it to the servers for resident service. Additional observations showed multiple instances of the same food handling practice. Cook #1 used gloved hands while handling butter, brushing it onto dinner rolls, and then used the same gloves to handle the rolls for placement into a steam table bin. The regional dietary supervisor also handled ready-to-eat foods with gloved hands while preparing chef salads, including opening packaging, handling boiled eggs, and placing lettuce, eggs, and ham into salad bowls without changing gloves after touching packaging or moving between tasks. Further observations included cook #1 handling hamburger buns, patties, lettuce, and pickle slices with the same gloves after touching utensils and packaging. He also repeatedly handled buns and patties while assembling hamburgers without changing gloves between tasks. The regional dietary supervisor stated that ready-to-eat foods should be handled with single use/single task gloves and that kitchen staff should change gloves when going from task to task.
Facility Assessment Missing Required Staffing, Contract, and Resident-Specific Details
Penalty
Summary
The facility failed to conduct and document a facility-wide assessment that identified the resources necessary to care for residents competently during day-to-day operations and emergencies. The assessment, last reviewed by the NHA on 5/8/25 and provided during the survey, did not include staff competencies needed for the resident population, a staff training program for new and existing staff, all contracts and agreements for services or equipment, facility resources needed for resident support, or how policies and procedures were evaluated for current professional standards of practice. It also did not identify the areas of a facility-based and community-based risk assessment using an all-hazards approach. The assessment was also not facility specific. Staff interviews confirmed the secured unit housed 19 residents and was for female residents only, but the assessment did not include that detail. The DON stated the facility had contracts with an oxygen company, laboratory company, and X-ray company, but these were not identified in the assessment. The DON also stated the facility admitted non-English speaking residents and used a translation line, yet the assessment did not identify how a translator would be obtained for those residents. The NHA acknowledged the assessment did not include training, staffing plans, contracts, emergency hazards, or specific information about the all-female secured unit.
QAPI Program Failed to Address Repeated Abuse and Transportation Safety Deficiencies
Penalty
Summary
The facility failed to ensure an effective QAPI program was implemented to identify and address compliance concerns related to quality of care, quality of life, and resident safety. The record showed repeated citations for F600 Abuse prevention during the recertification survey on 11/3/22, the recertification survey on 2/8/24, and the abbreviated survey on 3/6/25, with the most recent citation at the G level scope and severity for actual harm that was not immediate jeopardy. The report states the QAPI performance improvement committee failed to identify and address concerns related to quality of life and quality of care. The report also cross-referenced F689 and described a transportation incident involving Resident #106 on 1/30/26, when the facility failed to ensure the resident was secured properly in a facility transportation vehicle. As a result, the resident sustained multiple fractures to the lower extremities. The facility also failed to address concerns regarding transportation staff training and proper fastening of restraints for residents during transportation. The survey found this failure created an immediate jeopardy situation with actual serious harm.
Failure to Follow Up on Resident Council Grievances
Penalty
Summary
The facility failed to provide residents with a response, action, and rationale for grievances raised in resident/family group meetings. The grievance and concern policy stated residents have the right to receive a written decision on a grievance, and that within three days of receiving a grievance the grievance coordinator was to provide an explanation of the finding and proposed remedies to the complainant and aggrieved party. However, residents who regularly attended the resident council and food council meetings reported that concerns brought up in those meetings were not followed up on and continued to recur month after month. During interviews, residents said concerns about staff using ordering tablets incorrectly, lack of healthy snack choices, refusal of fresh fruit, and not receiving soup varieties or homemade soup were repeatedly raised without clear resolution. Record review showed food council minutes documenting concerns about staff communication, fresh fruit, homemade soups, cold room trays, inconsistent room tray delivery times, missing room tray meals, and low sodium soup options. The grievance materials provided by the facility referenced that some concerns had been addressed in meeting minutes, but the record did not show follow-up with the individual residents or the food council as a group regarding what had been done to resolve the concerns after the meetings. Staff interviews confirmed that concerns raised in the food council meetings were not consistently written up as formal grievances and that residents were not brought back a resolution.
Improper Medication Storage and Labeling
Penalty
Summary
The facility failed to ensure that drugs and biologicals were labeled in accordance with accepted professional principles and stored properly in locked medication areas. During review of the medication storage room, surveyors found one vial of TB serum that had been opened but was not dated, along with multiple expired medications and supplies, including Flucelvax pre-filled syringes, hydrocortisone acetate suppositories, blood collection sets, Luer Lock caps, a Vacutainer needle, an enteral feeding tube clog remover, Vacutainer blood collection vials, and blue capped needles. Surveyors also reviewed medication carts on the secure unit, A-Hall, and B-Hall. On the secure unit cart, they found one opened bottle of Refresh Tears that was not dated, a bottle of Drug Buster stored in the same drawer as liquid medications, and one opened foil package of ipratropium bromide and albuterol sulfate ampules that was not dated. On A-Hall, they found one opened bottle of GenTeal tears that was not dated, two acetaminophen 650 mg suppositories lying loose in a small plastic container, one opened vial of lispro insulin that was not dated, and one naloxone nasal spray kit that had expired. On B-Hall, they found two acetaminophen 650 mg suppositories lying loose in a small plastic container, one opened foil package of lidocaine patches, one opened urinary drainage bag package in the bottom drawer, one opened foil package of ipratropium bromide/albuterol sulfate ampules that was not dated, and one tube of miconazole nitrate cream that had expired. The DON stated that night shift nurses were responsible for routinely reviewing the medication storage room and medication carts for expired medications and supplies, and that the pharmacist also completed routine medication cart reviews but did not check the medication storage room for expired items. An LPN stated that nurses were to check expiration dates during medication passes and that night shift nurses were to routinely review the medication room and carts and remove expired medications or supplies from use.
Failure to Honor Resident Meal Preferences and Provide Adequate Menu Alternatives
Penalty
Summary
The facility failed to ensure meals were served according to resident preferences on five of six units, with residents reporting that they were not consistently offered substantive menu alternatives and that requested food items were often unavailable. The Dining and Food Preferences policy stated that residents who refused food or beverage were to be offered an alternate selection of comparable nutritional value in a timely manner, but multiple residents and staff described a meal service process that no longer supported resident choice. Residents reported that the facility had eliminated an always-available menu, reduced menu options, and changed meal ordering so that nursing staff collected orders the day before meals were served, which often resulted in residents receiving preset tray items instead of what they had requested. Several residents described not receiving ordered items or being offered only limited substitutes. One resident said she repeatedly asked for fresh fruit and was told the facility no longer served it, while another resident said she was still hungry after breakfast and had not been offered a snack between meals. That same resident requested a peanut butter and jelly sandwich, but kitchen staff said they were out of sandwiches and she would have to wait until the scheduled snack time. Another resident reported ordering an omelet, sausage, toast, and oatmeal but receiving scrambled eggs, hashbrowns, and oatmeal instead, and said she could not eat hashbrowns. Residents in group interviews said they often did not receive what they ordered, that staff sometimes failed to take meal orders, and that if they did not like the meal served there was nothing else available. Food council and resident council records showed repeated requests for fresh fruit, vegetables, and soups, along with concerns that the alternate menu had been condensed. The minutes documented responses that fresh fruit and vegetables would be purchased when available and in season, and that soups were made fresh and shipped frozen, but one grievance form tied to the food council did not document further follow-up or investigation. Staff interviews confirmed that the kitchen no longer offered the same snacks or menu alternatives as before, that bistro items were only available during scheduled meal times, and that residents who wanted something outside those windows were offered snack items instead. The NHA stated the dietary manager position had been vacant for months and that she had been running the kitchen until an outside dietary company took over shortly before survey.
Infection Control Failures During Housekeeping, EBP Care, and Medication Pass
Penalty
Summary
The facility failed to maintain an infection control program during housekeeping room cleaning in two resident rooms. In one double-occupancy room, a housekeeper performed hand hygiene, put on gloves, and used Sani-Clean disinfectant on the television console, overbed table, and toilet seat, wiping each surface immediately after spraying instead of allowing the disinfectant to remain wet for the required 10-minute dwell time. The housekeeper also did not clean identified high-touch areas in the room, including the individual call lights, bathroom call lights, door knobs, sink, and grab bars. In a second double-occupancy room, another housekeeper performed hand hygiene, put on gloves, and used damp cloths with Sani-Clean to clean surfaces. She sprayed and wiped the toilet, then used the same gloves to clean the TV console, dresser, and overbed table after touching the toilet seat and the resident’s personal items. She did not change gloves or perform hand hygiene between tasks, and she also did not clean the high-touch areas identified in the room, including the call lights, door knobs, sink, and grab bars. The housekeeper wiped the toilet only four minutes after spraying it with disinfectant, rather than waiting the required 10 minutes. The facility also failed to follow infection control practices for residents on enhanced barrier precautions and during medication administration. A resident on EBP had an open sacral wound, an indwelling urinary catheter, and a PICC line. A restorative aide performed range-of-motion exercises in the resident’s room after only donning gloves, without a gown, and did not change gloves or perform hand hygiene after touching the resident’s personal items and bed frame before continuing care. During later incontinence care for the same resident, the restorative aide, a CNA, and an LPN initially entered without gowns, then donned gowns only after prompting. The CNA, restorative aide, and LPN each touched surfaces or moved the bed and then continued incontinence care without changing gloves and performing hand hygiene. Separately, an RN was observed dispensing oral medications from blister packs into her bare hand before placing them into a medication cup, and acknowledged she knew she was not supposed to do that because it would be an infection control issue.
Failure to Protect Resident from Verbal Abuse
Penalty
Summary
The facility failed to ensure that one resident was kept free from abuse when Resident #37 directed racial slurs at Resident #53. The deficiency was based on record review and interviews showing that Resident #37, who had vascular dementia with mood disturbance, depression, cognitive communication deficits, severe cognitive impairment, and a history of verbal and physical aggression, approached Resident #53 near his room and began making racial slur comments toward him. Resident #53 also had severe cognitive impairment, aphasia, hemiplegia and hemiparesis, vascular dementia, major depressive disorder, and cerebral infarction. Resident #37’s record showed a pattern of behavioral issues, including yelling, calling people names, racial comments toward residents of color, inappropriate sexual comments, and physical aggression toward staff. His behavior care plan identified that he could be verbally aggressive, easily irritated, and had made racial comments toward residents of color. The record also documented prior incidents of yelling obscenities at other residents and making inappropriate comments and touching toward staff. Despite these documented behaviors, the report states there was no further follow-up documentation related to the incident in which Resident #37 directed racial slurs at Resident #53. Resident #53’s record documented that after the incident he laughed, shook his head, gave a thumbs up, and later chuckled and waved his hands when asked if he was upset. Staff interviews indicated that when residents had verbal or physical behaviors, they would separate them, redirect them, and notify nursing staff. However, the facility determined the incident was not abuse because Resident #53 did not appear upset and there was no physical contact. Survey findings concluded that Resident #53 was subjected to verbal abuse when Resident #37 used racial slurs directed at him, and the facility failed to protect him from that abuse.
Inaccurate secure-unit placement reviews for two residents
Penalty
Summary
The facility failed to ensure that two residents were free from involuntary seclusion by not accurately and timely re-evaluating whether their placement in the secure unit remained appropriate. The report states that the facility’s policy required secure unit placement only when specific criteria were met and that placement should end when the condition or behavior justifying it had diminished or the resident no longer met criteria. For both residents, the record lacked documentation from the primary care physician showing that the locked unit was the least restrictive reasonable setting to protect the resident and assure health and safety. Resident #85 had diagnoses including cerebrovascular disease, hypertensive heart disease with heart failure, hypertension, falls, and dementia. The 2/3/26 MDS showed severe cognitive impairment with a BIMS score of 3, total dependence for ADLs, and no physical behavioral symptoms directed toward others. During a continuous observation of the secure unit, the resident sat in the same Broda chair position at the dining table for nearly four hours, was fed by staff, received a magazine, had a hospice nurse visit, was given a doll and a sensory apron, and did not attempt to self-propel or wander. Staff interviews stated the resident was unable to walk or propel herself, never attempted to exit-seek, and could not communicate her needs. The wandering risk assessment documented no wandering in the prior three months and incorrectly stated she could move herself in her wheelchair. Resident #29 had diagnoses including non-Alzheimer’s dementia with behavioral, psychotic, mood, and anxiety disturbances, hypertension, and a history of fractures and TIA. The 1/6/26 MDS showed moderate cognitive impairment with a BIMS score of 9 and dependence on staff for ADLs. The resident told the surveyor she did not like living in the secure unit and did not know the door passcode or why she was there. Observations showed she attended activities outside the secure unit, was returned to the unit, spent time reading in the common area, and later received incontinence care in her room; during the observation she exhibited no wandering, exit-seeking, or aggressive behaviors. The wandering risk evaluation documented no wandering in the prior six months and only occasional following of instructions and redirection, while the nurse practitioner note described her as calm and cooperative. Staff stated she had not been trialed off the unit for three days to evaluate whether transition out of the secure unit was appropriate, and that she had not exhibited exit-seeking behavior.
Failure to Reevaluate PRN Psychotropic Medication
Penalty
Summary
The facility failed to adequately monitor the use of a psychotropic medication for one resident, Resident #85, who had vascular dementia, restlessness, agitation, and severe cognitive impairment. The resident’s March 2026 physician orders included lorazepam 0.5 mg by mouth every four hours as needed for dementia with behaviors, restlessness, and agitation for 90 days, ordered on 2/2/26. The order was written for longer than the 14-day limit for PRN psychotropic medications and did not include a physician-documented rationale for continuing the medication beyond that limit. Resident #85’s psychotropic medication care plan identified the resident as receiving psychotropic medications for vascular dementia and behaviors, with interventions to administer medications as ordered and monitor for side effects. The resident received PRN lorazepam doses on 2/21/26 and 2/26/26, but the record contained no documentation that the physician reevaluated the PRN lorazepam after 14 days or documented a rationale to justify continued use beyond the 14-day limit. The DON acknowledged that PRN psychotropic medications should be prescribed for 14 days and then reevaluated unless a rationale for longer use is documented.
Failure to Report Alleged Verbal Abuse
Penalty
Summary
The facility failed to report an alleged incident of verbal abuse to the State Survey and Certification Agency after one resident directed racial slurs toward another resident. The abuse reporting policy stated that if abuse was suspected, the administrator would initiate an investigation and, if abuse was confirmed, notify the State Agency within 24 hours. Surveyors found that the facility did not report the incident because staff and leadership determined it was not abuse after speaking with the residents involved. Resident #37 had vascular dementia with mood disturbance, depression, and cognitive communication deficits, and was assessed as severely cognitively impaired with a BIMS score of 5. His behavior care plan documented verbal aggression, racial comments toward residents of color, physical aggression toward staff, and threats toward staff. A progress note documented that he was found yelling racial slurs at Resident #53, who was redirected away from the area. No further follow-up documentation related to the incident was available, and the facility was unable to provide an investigation because it had determined the event did not constitute abuse. Resident #53 had aphasia, hemiplegia and hemiparesis, vascular dementia, major depressive disorder, and cerebral infarction, and was also assessed as severely cognitively impaired. Documentation showed he was near his room when Resident #37 approached him and began making racial slur comments. Staff later asked Resident #53 about the incident, and he laughed, shook his head, gave a thumbs up, and said he was okay. The social worker also documented that Resident #53 chuckled and waved his hands when asked if he was upset. During interviews, the director of operations, social services director, and nursing home administrator stated the facility did not report the incident because there was no physical contact and they believed Resident #53 was not harmed, despite the verbal slurs directed toward his race.
Failure to Reposition and Provide Timely Incontinence Care for Residents With Pressure Injuries
Penalty
Summary
The facility failed to provide necessary services consistent with professional standards of practice to promote healing of pressure injuries and prevent additional pressure injuries for two residents. One resident, who was dependent on staff for ADLs and assessed as high risk for skin breakdown, was observed sitting in the same Broda wheelchair position for long periods without staff attempting to reposition her or check her for incontinence. During one continuous observation, she remained at the dining room table from 11:40 a.m. until 3:37 p.m., and during another observation she remained in the same position from 8:45 a.m. until 1:28 p.m. before being taken for incontinence care. Her care plan identified her as high risk for skin breakdown and included monitoring for repositioning and following facility protocols for prevention and treatment of skin breakdown. Staff interviews confirmed that the resident was incontinent and needed assistance for incontinence care, but the CNA task list did not include repositioning. The RN stated the resident was at high risk for skin breakdown and that not providing incontinence care for four hours or more was a long time. The DON stated that residents at high risk for skin breakdown should receive interventions such as repositioning, hydration, and barrier cream, and acknowledged that sitting long hours in the same position could increase the risk for pressure injuries. The DON also stated she did not know why staff did not provide incontinence care and repositioning for long periods of time. A second resident had a stage 4 sacral pressure injury, osteomyelitis of the sacral and sacrococcygeal vertebrae, cerebral palsy, profound intellectual disabilities, contractures, and was dependent on staff for all ADLs. He used a wheelchair with a ROHO cushion and had an air mattress. During observation, he was seen sitting at an angle in his wheelchair in the common area and remained in the same position for over four hours without repositioning assistance. Staff later transferred him to bed, provided incontinence care, and repositioned him onto his right side. The wound care physician noted the resident had an unavoidable stage 4 sacral pressure injury and recommended pressure-relieving measures, offloading, and repositioning as tolerated, but the care plan did not document how often he should be repositioned or how the ROHO cushion should be monitored and maintained.
Failure to Follow Oxygen and CPAP Orders
Penalty
Summary
The facility failed to provide respiratory care consistent with physician orders and professional standards for two residents receiving oxygen therapy and, for one resident, CPAP care. Resident #42 had diagnoses including CHF, type 2 DM, OSA, depression, and dependence on supplemental oxygen. She was observed multiple times receiving oxygen via nasal cannula from a concentrator set at 4 LPM, while the physician order in the record was for 3 LPM. The record also showed staff documenting oxygen administration at 3 LPM on the MAR during the same period, and there was no documentation that the physician had been notified of the higher observed flow rate. Resident #42 also had a CPAP order requiring the humidifier chamber to be disconnected, emptied, wiped with a disinfectant wipe, dried, and stored out of direct sunlight each day shift. During repeated observations, the humidifier chamber remained connected to the CPAP machine, contained water, and had visible condensation on the chamber walls. The resident stated nursing staff were responsible for cleaning the CPAP machine, and a roommate was observed rinsing the humidifier chamber in the bedroom sink. Staff interviews confirmed the chamber should have been disconnected and cleaned, and the DON acknowledged the resident’s care plan did not reflect the CPAP use, cleaning, and maintenance needs. Resident #16 had chronic right heart failure, a history of pulmonary embolism, and dependence on supplemental oxygen, with severe cognitive impairment and total dependence for many ADLs. The physician order called for oxygen at 2 LPM via nasal cannula, but repeated observations showed the concentrator set between 3 and 3.5 LPM. The MAR documented oxygen at 2 LPM despite the higher observed setting. Staff interviews confirmed the oxygen flow rate was not consistent with the physician order, and the DON acknowledged the resident was not receiving oxygen as ordered.
Failure to Protect Residents from Abuse by Staff
Penalty
Summary
The facility failed to protect two residents from abuse by staff members. Resident #2 was subjected to physical abuse by a CNA who roughly repositioned her, causing physical pain and mental anguish. Despite the family reporting the rough treatment to the facility, no investigation was initiated, and the incident was not reported to the state agency. The facility's policy required such allegations to be promptly investigated, but this was not adhered to, leading to a deficiency in protecting the resident from abuse. Resident #2, who had severe cognitive impairments and required assistance with daily activities, was admitted to the facility with a diagnosis of dementia with severe agitation. Her family installed a hidden camera in her room due to concerns about her treatment. The camera captured the CNA handling Resident #2 roughly, which was reported to the facility staff, including the DON. However, the staff did not take appropriate action to investigate or report the incident, violating the facility's abuse prevention policy. Additionally, Resident #1 was physically abused by an LPN who grabbed her arm, resulting in bruising. The incident was observed by a CNA, but the facility's investigation concluded that the abuse was unsubstantiated, despite evidence to the contrary. Resident #1, who also had severe cognitive impairments, was unable to recall the incident. The facility's failure to substantiate the abuse and take appropriate action further highlights the deficiency in protecting residents from abuse.
Improper Use of Physical Restraints for Resident
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints imposed for staff convenience and not required to treat medical symptoms. Specifically, the facility did not prevent the use of a recliner chair as a physical restraint for a resident with severe cognitive impairments and a history of attempting to get out of bed unassisted. The facility's policy mandates that restraints should only be used when necessary for medical treatment, and behavioral interventions should be exhausted prior to restraint application. The resident, who was over 65 years old and diagnosed with dementia with severe agitation, was found on multiple occasions with a recliner chair pushed up against her bed, preventing her from getting out of bed. The resident's family had installed a hidden camera in her room, which captured these instances. The family expressed concerns about the facility's treatment of the resident, noting that the staff often complained about the resident's attempts to get out of bed unassisted. The video evidence showed a CNA pushing the recliner chair against the bed and handling the resident roughly, which the family interpreted as a method to keep the resident in bed. Interviews with facility staff, including the NHA and DON, confirmed that the use of the recliner chair in this manner constituted a physical restraint. The staff acknowledged the resident's impulsivity and hallucinations, which led to her attempts to get out of bed. Despite these challenges, the facility's actions were not aligned with their policy of maintaining a restraint-free environment, as the recliner chair was used to restrict the resident's movement without exhausting other behavioral interventions.
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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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