Lakeside Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Wheat Ridge, Colorado.
- Location
- 6270 W 38th Ave, Wheat Ridge, Colorado 80033
- CMS Provider Number
- 065273
- Inspections on file
- 18
- Latest survey
- March 26, 2026
- Citations (last 12 mo.)
- 2
Citation history
Health deficiencies cited at Lakeside Post Acute during CMS and state inspections, most recent first.
A resident with bipolar disorder, PTSD, traumatic brain injury, and moderate cognitive impairment alleged that an LPN and CNA were rough and sexually abusive during incontinence care, stating the LPN aggressively rolled him, caused his head to hit the wall, and repeatedly inserted a finger into his anus despite his protests. The facility’s investigation relied on staff statements and lack of observed rectal trauma, did not interview the roommate, and did not explore why staff continued care after the resident’s abuse allegation. The resident also reported ongoing rough transfers, inadequate repositioning in a wheelchair causing pain and bruising, and lack of assistance with proper positioning for meals, which was corroborated by observation of poor positioning, a bruise on his arm, and food spilled on his shirt. Although the care plan noted a history of false allegations and required care in pairs and investigation of voiced concerns, it lacked a specific focus on the resident’s PTSD and did not address his repeated reports that staff’s incontinence care and handling were rough and abusive.
Two residents engaged in a verbal and physical altercation in the smoking area, resulting in one resident being struck, scratched, and burned with a cigarette. No staff were present during the incident, and another resident had to seek help. The affected resident had a history of depression, anxiety, and paraplegia, while the other had a care plan for potential aggression. The facility's lack of supervision and incomplete witness interviews contributed to the substantiated abuse.
A resident with a history of mental illness and substance dependence eloped twice from a facility due to inadequate supervision. Initially deemed not at risk for elopement, the resident left unsupervised when a receptionist failed to notice her following another person out. Despite being placed on 15-minute checks, the resident eloped again the same day when a nurse buzzed her out without checking the camera. The resident was found 29 hours later and taken to the hospital per the guardian's request.
A resident with multiple medical conditions was improperly discharged AMA from a facility without adequate documentation or notification to their legal representative. The facility relied on a behavioral contract for the discharge, failing to document unmet needs or notify relevant agencies. The NHA admitted to not following proper procedures, contributing to the deficiency.
Two residents in a facility experienced significant medication errors. One resident, with schizoaffective disorder and bipolar disorder, missed doses of clozapine due to the facility's failure to send necessary lab results to the pharmacy, resulting in self-harm. Another resident received an incorrect dosage of an antibiotic for nearly a year due to a failure in updating medication orders after a physician's recommendation. The facility did not follow its policy on medication shortages and failed to conduct proper medication reconciliation.
The facility failed to properly store and label beverages, air-dry cooking utensils, discard dented cans, and use correct sanitizing test strips. Observations showed undated beverages in unit refrigerators, moisture between stacked pans, dented cans stored with other goods, and incorrect sanitizing solution testing. Staff interviews confirmed these deficiencies, highlighting risks of food-borne illnesses and cross-contamination.
The facility failed to maintain an effective infection control program, with deficiencies observed in housekeeping and wound care practices. Housekeeping staff did not properly disinfect high-touch surfaces, and wound care procedures lacked adherence to infection control protocols. An LPN and an RN were observed failing to maintain clean working areas and perform necessary hand hygiene, increasing the risk of infection transmission.
The facility failed to maintain a safe and functional environment, with issues such as a cracked entrance walkway, non-functional handicapped door opener, and cluttered hallways. Common areas were obstructed by debris and equipment, posing trip hazards. Residents and staff reported ongoing maintenance issues, with the maintenance director acknowledging a backlog of repairs.
A resident in an LTC facility, who was cognitively intact and required assistance with mobility and dressing, reported that staff frequently entered her room without respecting her privacy. During an observation, an activities assistant entered the resident's room without knocking while personal care was being provided, which upset the resident. The assistant was aware of the facility's policy to knock before entering but failed to do so, citing previous complaints from the resident about loud knocking disturbing her sleep.
A facility failed to update a care plan for a resident with confrontational behaviors. Despite being cognitively intact, the resident exhibited behaviors that led to a police intervention. The care plan, last revised in February, did not include interventions for these behaviors. Staff interviews confirmed the resident's tendency to initiate confrontations, and the DON acknowledged the need for an updated care plan.
A resident, who was an unsupervised smoker, repeatedly smoked in an undesignated area at the front of the facility, contrary to the facility's smoking policy. This area lacked proper disposal for cigarette butts and posed a fire hazard due to a nearby wooden fence. Staff were aware of the resident's actions but were unsure who permitted it, while the NHA acknowledged allowing the resident to smoke there.
A resident receiving dialysis care did not have their pre-dialysis assessment section consistently completed on communication forms, as required by facility policy. Despite being scheduled for dialysis three times a week, the forms were not filled out on several occasions, leading to incomplete communication with the dialysis center. Staff interviews revealed lapses in responsibility for completing these forms.
A resident in a LTC facility did not receive timely dental services after losing his dentures, affecting his ability to eat. Despite a dentist's recommendation for new dentures months prior, the facility failed to schedule follow-up appointments or document actions taken. Staff interviews revealed awareness of the issue, but no steps were documented to address the resident's dental needs, resulting in a deficiency.
Failure to Thoroughly Investigate and Address Allegations of Sexual and Rough, Abusive Care
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and document allegations of sexual abuse and rough, abusive care toward a resident. The facility’s abuse policy required that all reports of resident abuse be thoroughly investigated and documented. An investigation dated 2/24/26 addressed an allegation that a resident was sexually abused during incontinence care, but the investigation did not include interviewing the resident’s roommate about what he might have seen or heard during the alleged incident. The investigation concluded the allegation was unsubstantiated based on lack of physical trauma and staff statements, and it attributed the resident’s report to cognitive decline and terminal agitation, despite the resident’s clear and consistent account during the survey interview. The resident involved was under age 65 with diagnoses including bipolar disorder, anxiety, depression, PTSD, and traumatic brain injury. A recent MDS showed moderate cognitive impairment (BIMS 12/15), aggressive behavior, and delusions, and the resident was dependent on staff for toileting, transfers, and bed mobility, using a manual wheelchair. During the facility’s investigation, the resident reported that while yelling for help after a bowel movement, a CNA entered and began care, and then an LPN took over. The resident stated he did not want the LPN to provide care, tried to swat him away, and that the LPN grabbed his hands, rolled him aggressively causing his head to hit the wall, and inserted a finger into his anus four times while wiping, despite the resident yelling for him to stop. Staff statements conflicted with the resident’s account regarding who provided care and what occurred, and the facility did not investigate why staff did not stop care and have another staff member take over when the resident alleged abuse during the episode. The resident continued to report that staff were rough and that their approach to care felt abusive, including prior rough transfers by the same LPN and improper positioning and repositioning by other staff that caused pain and bruising. On the survey date, the resident described ongoing rough care, lack of staff responsiveness to his requests, and feeling that no one listened to or believed him. He reported that staff did not assist him to sit up properly for breakfast, resulting in difficulty eating and spilled food on his shirt. Observation during the interview showed the resident slouched and slumped to the left in his wheelchair, with his left arm hanging over the side, a bruise on his upper arm where the armrest was pressing, and dried oatmeal on his shirt from the morning meal. The resident’s care plan documented a history of false allegations and required care in pairs, investigation of all concerns voiced, and a calm, slow approach, but there was no specific care plan focus addressing his PTSD or his allegations of rough or abusive incontinence care, and the facility did not pursue his ongoing reports of rough and abusive treatment during personal care.
Failure to Prevent Resident-to-Resident Physical Abuse in Smoking Area
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident in the smoking patio area. During the incident, a verbal altercation escalated when one resident made inappropriate comments and moved his electric wheelchair toward the other, who responded by flicking a lit cigarette, spitting, grabbing the resident's arm, digging fingernails into the skin, and striking the resident in the face, causing his glasses to fall. There were no staff members present during the altercation, and another resident had to leave the area to get help. The initial assessment by a registered nurse documented minor scratches and a small burn, which the resident declined treatment for at the time. A subsequent assessment noted a burn mark consistent with a cigarette burn that was not initially observed. The resident who was the victim of the abuse had a history of depression, anxiety, and paraplegia, requiring substantial assistance with activities of daily living. His care plan included interventions for verbal aggression and agitation, but there was no indication of behaviors that would have predicted the escalation to physical abuse. The assailant, also cognitively intact, had a care plan noting a potential for anger and aggression if provoked, with interventions for monitoring and de-escalation. However, staff interviews indicated that neither resident was known for physical aggression, and the incident was unexpected by those familiar with their behaviors. The facility's policy required supervision and interventions to prevent abuse, but at the time of the incident, there was no staff supervision in the smoking area, and the camera in that area was not functioning. Witness interviews revealed that not all potential witnesses were interviewed as part of the investigation. The lack of staff presence and incomplete witness interviews contributed to the failure to prevent and fully investigate the abuse incident, resulting in a substantiated finding of resident-to-resident physical abuse.
Resident Elopement Due to Inadequate Supervision
Penalty
Summary
The facility failed to provide adequate supervision and facility-assisted devices to prevent the elopement of a resident diagnosed with bipolar disorder, adult failure to thrive, cocaine dependence, and alcohol dependence. Upon admission, the resident was evaluated and deemed not at risk for elopement or wandering. However, the resident had an emergency court-appointed guardian who requested that the resident not leave the facility without supervision due to her mental illness and substance-seeking behaviors. On the morning of January 10, 2025, the resident left the facility unsupervised when a receptionist buzzed someone out the front door and failed to notice the resident following behind. The resident was located over two hours later by the guardian near a homeless shelter approximately five miles from the facility. Despite being placed on 15-minute checks upon her return, the intervention proved ineffective as the resident eloped a second time the same day. This occurred when a nurse buzzed the resident out the facility door without checking the camera to see who was being buzzed out. The second elopement resulted in the resident being missing for almost 29 hours before being found by a staff member on the side of the road in a downtown area. The staff member notified the nursing home administrator and the police, who then transported the resident to the hospital per the guardian's request. The facility's failure to ensure staff were aware of which residents required supervision when leaving the facility led to these incidents, creating a situation with the likelihood of serious harm to the resident's health and safety.
Improper Discharge Process for Resident
Penalty
Summary
The facility failed to ensure a proper discharge process for a resident, leading to a deficiency in discharge planning. The resident, who was under 65 years old and had multiple medical conditions including end-stage renal disease and hypertension, was discharged against medical advice (AMA) without adequate documentation or notification to the resident's legal representative. The facility's policy required that residents not be discharged without a valid reason and that they be informed of their rights, including the right to appeal. However, the facility did not adhere to these policies in the case of this resident. The resident had a history of leaving the facility and not returning as scheduled, which led to the signing of a behavioral contract. This contract stipulated that if the resident did not return on time, they would be discharged AMA. On one occasion, the resident left the facility with medications for an overnight pass but did not return as expected. The facility attempted to contact the resident but ultimately discharged them AMA when they did not return by the agreed time. The facility did not document the resident's unmet needs or attempts to meet those needs, nor did they notify the ombudsman or state agencies, as they believed the discharge was AMA. Interviews with the nursing home administrator (NHA) revealed a lack of understanding of the proper discharge procedures. The NHA admitted to not documenting critical information, such as the resident's medication status or the conversation about the discharge. The NHA also acknowledged that the facility did not offer to retrieve the resident or provide their medications post-discharge. The failure to follow proper discharge protocols and the reliance on a behavioral contract as a basis for discharge contributed to the deficiency identified in the survey.
Medication Errors Lead to Resident Harm and Incorrect Dosage Administration
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, affecting two residents. Resident #4, diagnosed with schizoaffective disorder and bipolar disorder, did not receive her prescribed antipsychotic medication, clozapine, for two consecutive days. This occurred because the facility did not send the required complete blood count (CBC) laboratory results to the pharmacy, which was necessary for the medication refill. As a result, Resident #4 experienced increased anxiety and self-harmed by burning her forearm with a cigarette, leading to blisters that required medical attention. The facility's policy on medication shortages and unavailability was not followed. Staff failed to notify the attending physician or the nursing supervisor about the medication unavailability and did not document the missed doses in the resident's medical records. Interviews with the nursing staff revealed a lack of communication and documentation regarding the medication shortage, contributing to the significant medication error. Resident #38 was also affected by a medication error. The facility did not update the resident's antibiotic medication order following an infectious disease physician's recommendation to reduce the dosage. Consequently, the resident received an incorrect dosage of the antibiotic cephalexin for nearly a year. The facility failed to conduct a medication review and reconciliation after the resident's appointment with the infectious disease physician, and there was no documentation of an individualized care plan for antibiotic stewardship and infection monitoring.
Deficiencies in Food Storage, Preparation, and Sanitization
Penalty
Summary
The facility failed to maintain proper food storage and labeling practices in its unit refrigerators. Observations revealed that beverages, including milk and juice, were not dated or labeled, which is against the Colorado Retail Food Establishment Rules and Regulations. Interviews with the dietary manager and a licensed practical nurse confirmed that nursing staff were responsible for labeling and dating opened items, and the lack of proper labeling could lead to food-borne illnesses. In the main kitchen, the facility did not adhere to proper drying procedures for cooking utensils and pans. Observations showed that metal pans were stacked with moisture between them, contrary to the facility's Kitchen Sanitation policy and state regulations that require air-drying to prevent cross-contamination. Interviews with dietary staff indicated a lack of adherence to these procedures, which could attract harmful bacteria. The facility also failed to discard dented food cans, which were found during a kitchen tour. According to USDA guidelines, dented cans can harbor dangerous bacteria, yet they were stored with other canned goods. Additionally, the facility used incorrect test strips for sanitizing solutions, leading to inaccurate concentration levels. The dietary manager acknowledged the use of wrong test strips and the absence of proper documentation for sanitizing solution testing, which is crucial for maintaining hygiene standards.
Infection Control Deficiencies in Housekeeping and Wound Care
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by multiple deficiencies observed in housekeeping and wound care practices. Housekeeping staff did not adhere to proper cleaning techniques, particularly in disinfecting high-touch surfaces in resident rooms. Observations revealed that housekeepers used a Swiffer duster instead of disinfectant solutions on high-touch areas such as call lights, bed controls, and light switches. Additionally, the cleaning process did not follow the recommended sequence from cleanest to dirtiest areas, leading to potential cross-contamination. In the area of wound care, the facility's staff did not follow infection control protocols during and after wound care procedures. An LPN was observed providing wound care in a shower room without establishing a clean working area for supplies and treatment. The LPN failed to perform hand hygiene between glove changes and did not place a barrier pad under the resident's leg, resulting in wound drainage contaminating the floor and wheelchair foot pedals. Furthermore, the LPN did not clean the shower room floor or the resident's foot pedals after the procedure, increasing the risk of infection transmission. Another incident involved an RN providing wound care to a resident in their room. The RN did not replace a soiled chucks barrier pad or incontinence brief before changing the wound dressing, compromising the cleanliness of the working area. The RN also failed to provide a clean surface for the wound care supplies, which could lead to contamination. These actions demonstrate a lack of adherence to established infection control policies and procedures, contributing to the facility's failure to prevent the spread of infection.
Facility Fails to Maintain Safe and Functional Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations revealed significant issues with the physical environment, including a cracked and uneven main entrance walkway, cluttered hallways, and missing light covers. The front concrete sidewalk had a large hole, causing difficulties for residents and visitors, particularly those using wheelchairs. Additionally, the handicapped door opener was non-functional, creating accessibility challenges for residents. The facility's common areas and recreational spaces were not adequately maintained. Sidewalks and patios were cluttered with debris, hoses, and disassembled equipment, posing trip hazards. The recreation room was obstructed by an extension cord, limiting access to amenities. The flooring outside the rehabilitation gym was uneven, with gaps that could cause trips, especially for residents with mobility aids. The back parking lot was used as a dumping ground for broken equipment and trash, visible from inside the facility, and the landscaping was overgrown with weeds. Interviews with residents and staff highlighted ongoing issues with maintenance and repairs. Residents expressed concerns about the long-standing disrepair of the entrance sidewalk and the broken handicapped door opener. The maintenance director acknowledged the backlog of repairs and the need for a dumpster to clear the accumulated junk. The nursing home administrator was aware of the maintenance challenges but had not yet addressed the specific issues raised in the report.
Failure to Ensure Resident Privacy During Personal Care
Penalty
Summary
The facility failed to ensure personal privacy for a resident during personal care, as observed in the case of a resident who was cognitively intact and required assistance with mobility and dressing. The resident expressed concerns about staff frequently entering her room without respecting her privacy, particularly during personal care. On one occasion, a certified nurse aide (CNA) knocked and entered the room appropriately, but an activities assistant (AA) entered without knocking while personal care was being provided, which upset the resident. The activities assistant, who had been in her position for two months, admitted to not knocking before entering the room, despite being aware of the facility's policy to knock and wait for a response. The assistant mentioned that the resident had previously complained about loud knocking disturbing her sleep, but this concern was not documented or reported. The nursing home administrator confirmed the facility's policy of respecting residents' rights to privacy and dignity, emphasizing the importance of knocking before entering a resident's room.
Failure to Update Care Plan for Resident's Confrontational Behaviors
Penalty
Summary
The facility failed to develop and revise a comprehensive care plan for a resident with confrontational behaviors. The resident, under 65 years old, was admitted with diagnoses including chronic respiratory failure, chronic pain syndrome, bipolar disorder, major depressive disorder, and diabetes mellitus. Despite being cognitively intact, the resident exhibited confrontational behaviors, as documented in a nursing progress note. The note detailed an incident where the resident was found in another resident's space, yelling and using foul language, which escalated to the involvement of law enforcement. However, the resident's care plan, which was last revised in February 2023, did not include interventions to address these behaviors. Interviews with facility staff, including an LPN and the DON, confirmed the resident's tendency to initiate confrontations and use accusatory language. The DON acknowledged that the care plan should have been updated following the incident to include strategies for managing the resident's escalating behaviors. The NHA also recognized the need for a care plan with person-centered approaches to address the resident's confrontational behaviors, indicating a lapse in updating the care plan to reflect the resident's current needs.
Resident Smoking in Undesignated Area Creates Fire Hazard
Penalty
Summary
The facility failed to ensure that a resident, who was an unsupervised smoker, adhered to the designated smoking areas as per the facility's smoking policy. The resident, who was cognitively intact and required moderate assistance with personal care, was observed multiple times smoking in an area that was not designated for smoking. This area was located at the front of the facility, where the resident extinguished cigarettes on the ground and discarded the butts between a concrete slab and a wooden fence, creating a potential fire hazard. Staff interviews revealed that both a CNA and an RN were aware of the resident's smoking habits in the undesignated area but were unsure who permitted it. The NHA acknowledged allowing the resident to smoke in the undesignated area and recognized the potential fire hazard due to the lack of an ashtray and the presence of a wooden fence. Despite the facility's policy, the resident continued to smoke in the undesignated area, leading to a deficiency in maintaining a safe environment free from accident hazards.
Incomplete Pre-Dialysis Communication for Resident
Penalty
Summary
The facility failed to ensure that a resident receiving dialysis care was provided with services consistent with professional standards of practice. Specifically, the facility did not consistently complete the pre-dialysis assessment section on the dialysis communication forms for the resident. The facility's policy required that nursing staff send a dialysis communication to the dialysis center every time a resident was scheduled for dialysis, which was not adhered to in this case. The resident, who was cognitively intact and had diagnoses including end-stage renal disease, was scheduled for dialysis three times a week. However, the pre-dialysis section of the communication forms was not completed on multiple occasions, as observed in the resident's records from May to July 2024. Interviews with staff revealed that the responsibility for completing these forms was not consistently fulfilled, with LPNs and the DON acknowledging lapses in the process. This lack of adherence to protocol resulted in incomplete communication with the dialysis center regarding the resident's pre-dialysis status.
Failure to Provide Timely Dental Services for Resident
Penalty
Summary
The facility failed to provide timely dental services for a resident who required new dentures. The resident, who was cognitively intact and independent in oral hygiene and eating, reported that his dentures went missing a few months ago, which affected his ability to eat certain foods. Despite the resident's report and the dentist's recommendation for new dentures made in October 2023, the facility did not schedule any follow-up appointments or document any actions taken to address the resident's dental needs. The facility's policy required referral for dental services within three days for lost or damaged dentures, but this was not adhered to in this case. Interviews with staff revealed that the social service director was aware of the missing dentures, and there was an assumption that the facility was waiting for insurance approval. However, there was no documentation to support this, and the nursing home administrator confirmed that no steps had been taken to obtain new dentures for the resident. The resident's medical record lacked documentation of coordinated care for dental services, and the facility did not ensure the resident received the necessary dental care, resulting in a deficiency in providing routine and emergency dental services.
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.
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.
A resident with dementia but intact cognition, who depended on staff for ADLs, had a dementia medication (donepezil) discontinued following a pharmacist’s recommendation and a physician’s order. Facility policy required notifying the resident, consulting the physician, and informing the resident’s representative when treatment was altered, including discontinuation of medications. However, there was no documentation that the resident or representative was informed of the recommendation or the discontinuation, and the representative later reported learning of the change about two months afterward and being very upset. The DON acknowledged that the representative had not been notified at the time of the medication change.
A resident with MDRO had concurrent physician orders for contact precautions and Enhanced Barrier Precautions, but the care plan did not specify the required isolation type, and no isolation signage or PPE was posted at the room. CNAs and an LPN were unclear about the resident’s MDRO status and whether PPE was required, with some believing precautions were no longer needed and others unsure what happened to prior isolation signs after a room change. The LPN discovered two conflicting isolation orders in the electronic record and had not yet contacted the DON or physician for clarification, while the DON later confirmed the resident had MDRO in sputum and that PPE should have been used, yet the facility’s process for placing and maintaining isolation signage and communicating precautions to staff had not been effectively carried out.
Surveyors found that the facility failed to keep call lights within reach for multiple residents, including cognitively intact and cognitively impaired individuals with conditions such as COPD, CKD, dysphagia, cerebrovascular disease, epilepsy, blindness, cervical fracture, and Huntington’s disease. Observations showed residents with soiled hands unable to summon help, residents in bed or in wheelchairs with call lights on the floor, under beds, on distant furniture, or behind them, and residents unaware of their call light’s location. Care plans for these residents required a safe environment and reachable call lights, but staff did not consistently position the devices so residents could independently request assistance.
The facility failed to timely report two abuse allegations between two roommates, despite a policy requiring immediate internal reporting and external reporting within strict timeframes. In the first incident, a CNA heard yelling, entered the room, and observed one resident hitting the other; although the CNA reported this to a nurse, management was not informed until days later, and the incident report to the State Agency was submitted late. In the second incident, an LPN overheard a resident yelling aggressive, threatening statements at the roommate, intervened, and offered a room change, but did not notify the abuse coordinator, resulting in the verbal abuse allegation not being reported to the State Agency until it was discovered during surveyor review.
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.
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 Notify Resident Representative of Discontinued Dementia Medication
Penalty
Summary
The facility failed to notify a resident’s representative of a significant medication change, specifically the discontinuation of donepezil, as required by its own Resident Change of Condition/Status policy. That policy, dated 4/11/25, states the facility must inform the resident, consult with the physician, and notify the resident’s family member or legal representative when there is a change requiring notification, including alterations in treatment such as new treatments or discontinuation of current treatments. The policy further notes that even when residents are cognitively competent, the physician must be contacted and the representative notified, particularly when a family has requested to be informed of significant health status changes. Resident #6, an older adult with dementia and frontal lobe/executive function deficits, was cognitively intact per a recent MDS (BIMS score 14/15) and dependent on staff for ADLs. A pharmacist note dated 10/30/25 recommended deprescribing donepezil due to lack of demonstrated efficacy and potential side effects; this recommendation was signed by the physician on 12/22/25, and the physician’s order shows the donepezil was discontinued on 1/7/26. Record review revealed no documentation that the facility communicated with the resident or the resident’s representative about either the pharmacist’s recommendation or the actual discontinuation of the medication. The resident’s representative reported she was not contacted prior to the discontinuation and only learned of it approximately two months later, which upset her. The DON confirmed in interview that the representative was not notified when the medication was discontinued, despite the facility’s policy and the resident’s capacity to understand medication changes.
Failure to Clarify and Communicate MDRO Isolation Precautions
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program for a resident with a history of multidrug-resistant organism (MDRO) infection. The facility’s MDRO policy required systems to designate residents colonized or infected with MDROs, implement Contact Precautions (CP) for targeted MDROs, and use Enhanced Barrier Precautions (EBP) when appropriate. For this resident, the computerized physician orders included an order for contact precautions related to MDRO (GI) and a separate order for EBP with gown and glove use during all high-contact care due to MDRO. The resident’s comprehensive care plan did not specify what type of isolation precautions were required, and there was no clear documentation in the care plan to guide staff on the ordered precautions. Surveyors’ observations showed that, despite these orders, there were no EBP or contact precaution signs on the resident’s door or surrounding area during multiple checks. Staff interviews revealed confusion and lack of awareness regarding the resident’s MDRO status and required precautions. One CNA stated staff previously wore gown and gloves in the resident’s room but believed the resident no longer had MDRO and that PPE was only needed when the resident had a cold, even though the resident still required EBP. Another CNA recalled that the resident initially had isolation signage and PPE at the door, but after the resident changed rooms, she did not know what happened to the signs or PPE and was unsure what precautions were currently in place, though she believed the resident had MDRO in urine and wore gown and gloves when assisting in the bathroom. An LPN initially reported that PPE was not required for this resident and was unaware of any infection, noting that no alerts appeared on the MAR or TAR and no information was given in report about precautions. Upon later review of the electronic orders, the LPN identified two active isolation orders—one for EBP and one for contact precautions related to MDRO (GI)—and stated she did not know which to follow and had not yet contacted the DON or physician for clarification. The DON later confirmed that the electronic record indicated MDRO in the sputum and that staff should have been wearing PPE during care, and also stated that the facility’s process was for the housekeeping director to place isolation signage and PPE on doors and that signage and PPE should follow the resident when rooms are changed. At the time of the survey, there was no signage or PPE at the resident’s door, and staff had not received clear communication about the resident’s required isolation precautions, resulting in failure to implement the ordered infection control measures.
Failure to Keep Call Lights Within Reach for Multiple Residents
Penalty
Summary
The deficiency involves the facility’s failure to ensure that call lights were accessible to multiple residents as required by facility policy and individual care plans. The facility’s “Answering the Call Light” policy directed staff to ensure the call light system was accessible to residents when in bed, on the toilet, in the shower or bathing facility, and from the floor. Despite this, surveyors observed several instances where residents’ call lights were not within reach, and residents were unable to independently summon assistance. These observations occurred across multiple rooms and residents and were corroborated by record reviews showing that care plans required reachable call lights. One resident with chronic obstructive pulmonary disease, chronic kidney disease, and dysphagia, who was cognitively intact, was found in her room requesting assistance while lying partially on top of her call light, which she could not reach. She had feces covering her palm and fingers and stated she had already used a napkin to clean herself; the soiled napkin was on her lunch plate. Her call light was not turned on and was not accessible, and no staff were observed nearby until another resident activated their own call light to alert staff. This resident’s ADL and fall care plans required a safe environment, prompt response to requests for assistance, and a workable, reachable call light. Another resident with a history of cerebrovascular disease, dysarthria, cognitive communication deficit, muscle weakness, gait abnormalities, and repeated falls, and who was moderately cognitively impaired, was observed twice with her call light out of reach. On one occasion, she was in bed with a distressed facial expression while her call light cord hung from the far corner of a dresser drawer, beyond her reach. On another occasion, she was asleep in bed while her call light was under a blanket on top of her wheelchair, approximately four feet away on the opposite side of the bedside dresser. Although staff reported that she could use her call light and sometimes slept with it in her hand, observations showed it was not consistently within reach. Her ADL care plan instructed staff to encourage her to use the call light for assistance. Additional residents were also observed without accessible call lights. One resident in a wheelchair next to his bed did not know where his call light was until he located it under the bed; he attempted but was unable to retrieve it from the floor with a reaching device and reported that it sometimes fell off the bed. Another cognitively intact resident requiring moderate ADL assistance was twice observed in her wheelchair with her call light either on the bedside table behind her or on the bed, both times out of her reach, even though her fall risk care plan required a safe environment with a reachable call light. A younger resident with epilepsy, cerebral infarction affecting the right dominant side, blindness, and high fall risk was observed with his call light lying on the floor underneath the bed and out of reach, despite a care plan intervention to ensure the call light was within reach. Another younger resident with a cervical fracture and Huntington’s disease, who required moderate ADL assistance, was found with his call light on the floor under the bed and out of reach; he stated he could use the call light but did not know where it was. These findings collectively demonstrate that the facility did not reasonably accommodate residents’ needs and preferences by ensuring call lights were accessible as required by policy and care plans.
Failure to Timely Report Resident-to-Resident Physical and Verbal Abuse Allegations
Penalty
Summary
The deficiency involves the facility’s failure to timely report two separate abuse allegations between roommates to the State Agency and other required authorities, contrary to its own abuse reporting policy. The facility’s policy on Abuse, Neglect, Exploitation or Misappropriation – Reporting and Investigating, revised September 2022, required that all suspicions of abuse, neglect, exploitation, misappropriation, or injury of unknown origin be reported immediately to the administrator and other officials, and then to state and other external agencies within two hours if abuse or serious bodily injury was involved, or within 24 hours if not. Despite this, an incident of physical abuse that occurred on 1/30/26 and a separate incident of verbal abuse that occurred on 2/13/26 between the same two residents were not reported within the required timeframes. The first incident involved a resident with moderate cognitive impairment, lower extremity impairment, and a history of verbal behavioral symptoms directed toward others, and a cognitively intact roommate with severe visual impairment, hemiparesis, and no documented prior behavioral symptoms. On 1/30/26 at approximately 9:00–9:37 p.m., a CNA heard yelling in their shared room and, upon entering, observed one resident hitting the other. The CNA separated the residents and reported the situation to the nurse. However, there was no contemporaneous nursing documentation of the altercation on 1/30/26, and facility management was not made aware of the incident until 2/2/26 at 5:00 p.m. When the incident was finally investigated on 2/2/26, nursing notes and interviews documented that one resident had punched the other three times in the arm during an argument after being cursed at and threatened, and that the alleged victim reported not feeling scared and declined a room change. The incident report to the State Agency, which was due within 24 hours of the 1/30/26 event, was not submitted until 2/2/26 at 6:42 p.m., and was marked late. The second incident involved verbal abuse between the same two residents on 2/13/26. A behavior note documented that an LPN, while walking past the room, heard one resident yelling aggressively and inappropriately at the roommate, stating "I hate you, shut your stupid mouth and I will (expletive) you up." The LPN entered the room, informed the resident that the behavior was inappropriate, and the resident stated he hated his roommate and did not want to remain in the room. The LPN offered a room change, and the resident agreed, with plans to discuss the change with the interdisciplinary team and notify the resident’s representative. This verbal altercation, however, was not reported to the facility’s abuse coordinator (the NHA) at the time and therefore was not reported to the State Agency until 4/21/26, after surveyors identified the issue during the survey. The NHA later acknowledged he had not been made aware of the 2/13/26 incident and that, given the prior physical altercation between the same residents, there should have been heightened sensitivity and timely reporting of any further incidents between them.
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