Riverdale Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Brighton, Colorado.
- Location
- 2311 E Bridge St, Brighton, Colorado 80601
- CMS Provider Number
- 065378
- Inspections on file
- 24
- Latest survey
- April 22, 2026
- Citations (last 12 mo.)
- 7
Citation history
Health deficiencies cited at Riverdale Post Acute during CMS and state inspections, most recent first.
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 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.
The facility failed to protect residents from resident-to-resident physical abuse and did not implement preventive behavioral interventions after two separate altercations on a men’s secured unit. In one event, a cognitively intact resident with dementia and a history of frequent aggressive behaviors struck another severely cognitively impaired resident in the face with a soda can, causing a skin tear and bruising, yet his care plan was only updated with immediate de-escalation actions and no new preventive strategies. In another event, a resident with severe dementia and a known history of physical and verbal aggression toward staff made contact with another resident’s head after a verbal exchange in the hallway, but his care plan did not address aggression toward other residents and was not revised with interventions to prevent recurrence. CNAs reported they were only instructed to keep the involved residents separated and were not given additional techniques, and an LPN stated she had not been informed about recent altercations, demonstrating that staff were not consistently informed or guided on preventive measures following these abuse incidents.
Surveyors found that medication and treatment carts were repeatedly left unlocked and unattended, including one treatment cart near the front entrance containing wound care supplies and prescription medications. On another occasion, an RN left a medication cart unlocked in a common area with a prefilled insulin syringe and multiple labeled medication cups containing different residents’ medications stacked on top of each other, including one cup with an unknown medication. Staff later confirmed that carts were expected to remain locked when not in use and that prepouring medications was not permitted, but these practices were not followed.
An LPN performed wound care for a resident without following basic infection control practices, including failing to perform hand hygiene before accessing the treatment cart, handling wound care supplies, and changing gloves. The LPN placed supplies and wound care scissors on an unsanitized bedside table, removed a soiled dressing from an open wound, then used the same contaminated gloves to open a sterile saline bottle and set it on the unclean surface. After removing the soiled gloves, the LPN again skipped hand hygiene before donning clean gloves, used saline and gauze to clean the open wound, and then used unsanitized scissors from the soiled table to cut antimicrobial dressing that was applied directly to the wound, and later to cut Velcro from an ace bandage applied over the resident’s arm and brace.
The facility failed to prevent falls and ensure safe transfers for three residents, leading to multiple falls and injuries. A resident with dementia and an unsteady gait experienced several falls due to inconsistent implementation of fall interventions. Another resident, requiring a mechanical lift for transfers, was improperly transferred by a single CNA, resulting in a fall. A third resident, needing a Hoyer lift, was involved in incidents where the lift protocol was not followed, leading to falls. These deficiencies highlight the facility's failure to adhere to care plans and safety protocols.
The facility failed to maintain safe food storage and sanitary kitchen conditions. Refrigerators were above safe temperatures, health shakes lacked expiration labels, and expired food was found. The kitchen had missing tiles, standing water, and a dirty ice machine filter. Staff interviews revealed unclear responsibilities for maintaining these standards.
The facility's binding arbitration agreement did not include provisions for the selection of a neutral arbitrator agreed upon by both parties or for a mutually convenient venue, as required by policy. Instead, the agreement specified that arbitration would be conducted by a contracted provider with the arbitrator chosen from their list, and the hearing held in the facility's county. Staff confirmed that residents were not given the opportunity to participate in selecting the arbitrator or venue.
A facility failed to provide a dignified dining experience by not adhering to residents' dietary preferences and using disposable cups for beverages. A resident on a puree diet did not receive the ordered menu items, and residents on the Aspen unit were served drinks in paper and styrofoam cups instead of plastic ones. Staff interviews revealed a lack of clarity regarding these practices.
A facility failed to protect residents from abuse, with incidents involving sexual and physical aggression. One resident was observed masturbating in a shared room, while another incident involved a physical altercation between two residents. A third incident saw a resident attempting to kick another in the dining room. Despite documented histories of inappropriate behavior, the facility's investigations were incomplete, and incidents were not reported as required. Care plans were not adjusted to prevent recurrence, and the facility's response was inadequate.
The facility failed to provide residents with mechanically altered diets as prescribed, leading to incorrect meal preparations that did not match dietary orders. Observations revealed that residents received meals inconsistent with their dietary needs, such as receiving crisp tostada shells instead of pureed beef tostadas and fruit crisps instead of peach slices. Staff interviews indicated a lack of training in the new IDDSI standards, contributing to the errors.
Three residents did not have comprehensive care plans addressing their specific needs, including supplemental oxygen use, PICC line management, and insomnia. One resident with schizoaffective disorder and vascular dementia lacked care plan interventions for oxygen and PICC line care, while two others with dementia and insomnia had no care plan focus on their sleep issues, despite being prescribed medications for insomnia. Staff confirmed these omissions during interviews.
The facility did not ensure that three residents or their representatives received a thorough explanation of the binding arbitration agreement or provided documented acknowledgement of understanding before signing. Interviews revealed that these individuals did not recall signing or understanding the agreement, and staff could not provide evidence of proper explanation or acknowledgement.
The facility failed to maintain proper infection control by not ensuring housekeeping staff followed hand hygiene protocols, neglected cleaning high-touch surfaces, and used improper cleaning techniques in resident bathrooms, including sharing toilet brushes between rooms. Additionally, staff did not implement Enhanced Barrier Precautions for a resident with a PICC line, with no PPE available and inconsistent understanding among staff about when EBP was required.
The facility did not ensure necessary maintenance and cleanliness in resident rooms, bathrooms, dining areas, and hallways, resulting in damaged furniture, water damage, pest presence, and unaddressed repair needs. Residents reported unresolved requests for cleaning and missing room furnishings, while staff interviews revealed a lack of awareness and follow-through on maintenance issues.
A cognitively intact resident with a history of inappropriate sexual behavior was witnessed by a CNA masturbating in another resident's room. The DON was informed, and the resident was relocated to a secured unit. However, the incident was not reported to the State Survey Agency as required, leading to a deficiency in compliance with state reporting requirements.
Resident meal tickets containing protected health information, including names and diet orders, were left unsecured in the kitchen and dining room, allowing a resident's representative to access and review them. Staff confirmed that such information should remain confidential and not be accessible to guests.
A resident with multiple chronic conditions and cognitive intactness was admitted with a physician's order for full code status, but the facility did not document the resident's refusal to complete a MOST form or any discussion of resuscitation preferences in the care conference notes or electronic medical record. Staff interviews and record reviews confirmed the absence of required documentation regarding the resident's resuscitation choices.
A resident with a PICC line for IV antibiotics did not have a physician's order for routine dressing changes, and there was no documentation that the dressing was changed for several weeks after insertion. The care plan lacked interventions for PICC line maintenance, and observations showed the dressing was soiled and pulling away from the skin. Staff interviews revealed the order for dressing changes was not obtained until prompted by surveyors.
A resident with multiple chronic conditions and wounds was not weighed upon admission as required by facility policy, and there was no consistent documentation of attempts to obtain weights or monitor nutritional status. Despite orders for weekly weights and staff acknowledgment of the need for follow-up when a resident refused, the EMR lacked evidence of these actions, resulting in inadequate monitoring of the resident's nutrition needs.
A resident with moderate cognitive impairment and a history of malnutrition and eating disorder was observed self-administering tube feedings without staff supervision or a documented assessment of her ability to do so safely. Care plans and physician orders did not authorize self-administration, and staff interviews confirmed that no formal evaluation had been completed. This resulted in a failure to ensure appropriate care and oversight for the resident's enteral nutrition.
A facility exceeded the acceptable medication administration error rate, with an LPN administering an incorrect dose of omeprazole via PEG tube and applying a lidocaine patch to the wrong shoulder for a resident with GERD and shoulder pain. The errors were attributed to not double-checking physician's orders and misunderstanding the resident's position during care.
A resident with advanced dementia and multiple medical conditions did not have hospice nursing and CNA visit notes, care plans, or other required hospice documentation accessible to facility staff. Staff interviews confirmed that hospice documentation was missing from the resident's binder and not uploaded to the EMR, hindering effective care coordination.
The facility did not post a complete and accessible list of contact information for all required State agencies and advocacy groups, including missing mailing and email addresses and certain agency contacts. Several alert and oriented residents reported not knowing how to file a complaint, and staff interviews revealed confusion over responsibility for maintaining these postings.
The facility failed to maintain a functioning alarm on the door to the secured patio, compromising resident safety. Observations showed the alarm was broken, allowing residents to potentially exit unnoticed. Staff interviews revealed a lack of training and communication regarding the alarm issue, which had persisted for months. The DON and NHA were unaware of the problem until the survey, indicating a breakdown in internal communication.
The facility failed to control a fly infestation in the kitchen and dining areas, with flies entering through an unscreened open door. Residents expressed discomfort, and staff acknowledged the unsanitary conditions despite efforts to address the issue.
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 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 Implement Preventive Measures After Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident-to-resident physical abuse and to implement preventive measures after incidents. Facility policy states residents have the right to be free from abuse, including physical abuse, and that the abuse prevention program must protect residents from abuse by anyone, including other residents, and implement measures to address factors that may lead to abusive situations. Despite this, the facility did not develop or update behavioral care plans with preventive interventions following two separate resident-to-resident altercations on the men’s secured unit, and staff were not provided with new techniques beyond immediate separation of the involved residents. In the first incident, a cognitively intact resident with dementia and a history of frequent physical and verbal behavioral symptoms struck another resident in the face with a soda can in the men’s secured unit dining area. The victim, who had severe cognitive impairment, dementia with behavioral disturbance, and no documented behavioral symptoms on the most recent MDS, sustained a skin tear and bruising near the left eye. The facility’s investigation confirmed that the assailant resident made contact with the victim’s face using a soda can after a conflict over trash, and that the contact constituted substantiated abuse. The behavioral care plan for the assailant was revised only to reflect that an altercation had occurred and that staff de-escalated his aggressive mood by returning him to his room, but it did not include any new preventive interventions to avoid recurrence of aggression toward other residents. In the second incident, a resident with severe vascular dementia, behavioral disturbance, and a history of physical and verbal aggression toward staff made contact with another resident’s head in the hallway after both became verbally aggressive. The victim had moderate cognitive impairment, dementia with behavioral disturbance, bipolar disorder, and no prior documented behavioral symptoms on the MDS, and reported that the other resident cursed at him and then hit him, causing the aggressor to fall. The facility’s investigation acknowledged that the aggressive resident had a history of behaviors that could be triggered by feeling rushed, loss of control, unfamiliar staff, changes in routine, or unmet needs, and that without appropriate interventions his behaviors could escalate and place him and others at risk. However, there were no updates to the aggressive resident’s behavioral care plan to address aggression toward other residents, and no new interventions were added to prevent further recurrence. Staff interviews confirmed that CNAs were only told to keep the involved residents separated and were not given additional prevention techniques, and an LPN reported not being informed about recent altercations on the unit, limiting her ability to monitor and separate residents at risk of conflict.
Unlocked Carts and Unattended Prepoured Medications Left in Common Area
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards. Over multiple days, a treatment cart located near the front entrance was observed unlocked and unmonitored by nursing staff for extended periods. The contents of this treatment cart included wound care supplies and prescription medications, yet it remained accessible when no nurse was present. The facility was unable to provide a medication storage policy when requested during the survey. On another occasion, a medication cart was observed unlocked and unattended by the assigned RN. On top of this cart, surveyors observed a prefilled insulin syringe and several paper medication cups labeled with different residents’ names, each containing medications. These cups were stacked so that the bottom of one cup was in contact with another resident’s medications, and there was also a plastic medication cup containing an unknown medication at the top of the stack. These medications were left on the cart in a common area without the medication nurse in sight, and the RN later stated she had left the cart to go into the supply room. Staff interviews confirmed that both treatment and medication carts were expected to be locked when not being accessed and that prepouring medications was not allowed, but these expectations were not followed in the observed instances.
Failure to Follow Hand Hygiene and Aseptic Technique During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow proper infection prevention and control practices during wound care for a resident. During an observed wound care procedure, an LPN did not perform hand hygiene before opening the treatment cart, touching wound care supplies, or bringing those supplies and the physician’s wound care order into the resident’s room. The LPN placed wound care supplies and wound care scissors on the resident’s bedside table without sanitizing the table surface or the scissors. The LPN then donned gloves without prior hand hygiene and removed the resident’s soiled wound dressing, which had yellow discharge. With the same soiled gloves, the LPN opened a bottle of sterile saline and set it on the unclean bedside table, again without performing hand hygiene. After handling the saline bottle, the LPN removed the soiled gloves but did not perform hand hygiene before reaching into a box of clean gloves and donning a new pair. The LPN then poured saline on gauze to clean the resident’s open wound and picked up the unsanitized scissors from the soiled bedside table to cut antimicrobial dressing material, which was placed directly onto the open wound. The LPN did not sanitize the scissors before using them to prepare the dressing. The LPN continued the wound care by applying ointment, a foam-covered bandage, an ace wrap, and a hard plastic brace, and then used the same unsanitized scissors to cut off Velcro from another ace bandage applied over the brace and the resident’s arm. These actions occurred despite CDC guidance that failure to perform appropriate hand hygiene is a leading cause of health-care-associated infections and spread of multiresistant organisms.
Failure to Prevent Falls and Ensure Safe Transfers
Penalty
Summary
The facility failed to ensure that three residents remained as free from accidents as possible, leading to multiple falls and injuries. Resident #97, who was at risk for falls due to dementia, hearing impairment, and an unsteady gait, experienced several falls resulting in head injuries. Despite having a fall care plan in place, the facility did not implement new interventions after each fall until after the third incident. Even after introducing a soft helmet as an intervention, the facility did not ensure the resident wore it consistently, leading to further falls and injuries. Resident #37, who required a mechanical lift and two staff members for transfers due to hemiplegia and dementia, was improperly transferred by a single CNA without the use of a mechanical lift. This resulted in the resident being lowered to the floor during a transfer, contrary to the care plan and facility policy. The fall investigation revealed that the resident tripped over oxygen tubing and a floor mat, indicating a lack of adherence to the care plan and safety protocols. Resident #47, who required a Hoyer lift for all transfers due to multiple sclerosis and a history of traumatic brain injury, was involved in two incidents where the lift protocol was not followed. In one instance, the resident fell during a shower transfer when a CNA attempted to transfer him without the Hoyer lift, resulting in the resident hitting his head. In another incident, the resident was assisted to the floor during a transfer due to weakness, despite the care plan requiring the use of a Hoyer lift. These incidents highlight the facility's failure to adhere to established care plans and transfer protocols, leading to preventable falls and injuries.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in its food storage and preparation areas, as observed in the main kitchen and unit nourishment refrigerators. The nourishment room refrigerators were not kept at safe temperatures, with recorded temperatures consistently above the acceptable cold holding temperature of 41°F. Health shakes stored in these refrigerators were not labeled with pull or expiration dates, despite instructions to use the thawed product within 14 days. Additionally, expired food items, such as a turkey pot pie, were found in the freezer, indicating a lack of proper monitoring and removal of outdated products. The main kitchen environment was also found to be unsanitary. Observations revealed missing and damaged coving tiles behind the ice machine, which led to standing water pooling on the floor. The ice machine's aluminum filter was covered in brown debris, and a large section of the kitchen floor was missing tiles, exposing rough concrete. These conditions suggest a failure to adhere to professional standards for maintaining clean and sanitary food preparation areas. Interviews with staff, including the Director of Nursing (DON), Certified Nurse Aides (CNAs), the Dietary Director (DD), and the Nursing Home Administrator (NHA), revealed a lack of clarity and responsibility regarding the maintenance of refrigerator temperatures and cleanliness of the kitchen. The NHA was unaware of the unsanitary conditions and the lack of proper cleaning assignments for the ice machine filter. The dietary department was identified as responsible for monitoring refrigerator temperatures and expired products, but there was no evidence of corrective actions taken to address the deficiencies.
Arbitration Agreement Lacks Required Neutrality and Venue Provisions
Penalty
Summary
The facility failed to ensure that its binding arbitration agreement contained all required components as outlined in its own policy and federal regulations. Specifically, the agreement did not include language that allowed for the selection of a neutral arbitrator agreed upon by both parties, nor did it provide for the selection of a venue that was convenient to both parties. The agreement instead specified that arbitration would be administered by a contracted provider, with the arbitrator selected from a list provided by that provider, and that the hearing would be held in the county where the facility is located. This process did not allow residents or their representatives to participate in the selection of the arbitrator or venue, as required. Interviews with facility staff confirmed these omissions. The admission coordinator stated that the arbitration agreement did not inform residents of their right to speak with federal, state, or local surveyors or ombudsman, and that such information was only included in a separate admission agreement. The admission coordinator also confirmed that there was no language in the arbitration agreement regarding the selection of a venue by both parties. These findings demonstrate that the facility's arbitration agreement did not meet the required standards for neutrality and convenience for both parties.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure that residents prescribed a puree diet received meals according to their preferences and prescribed diet orders. Specifically, Resident #26 did not receive the menu items he ordered, such as a cheeseburger, and instead was served mashed potatoes and puree meat. The resident's representative reported difficulty in finding the puree diet menu and noted that the resident often had to guess what he was eating. Observations during meal service confirmed discrepancies between the menu and the food served, with the puree test tray not matching the documented diet modification spreadsheet. Additionally, the facility did not provide residents on the Aspen unit with non-disposable beverage cups during meals. Observations showed that residents were served beverages in paper and styrofoam cups instead of plastic cups, which was inconsistent with the practice on the men's secured unit. Staff interviews revealed a lack of clarity regarding the reason for this discrepancy, with both a CNA and an LPN indicating that the kitchen consistently sent paper cups for the women's secured unit without a clear explanation. The facility's dietary director and nursing home administrator acknowledged the practice of pureeing leftover food from previous meals for residents on a puree diet. However, they were unaware of any concerns regarding the puree food items prior to the survey. The dietary director also indicated that staff had been educated to serve residents their preferred puree options, such as a puree burger, if requested. Despite this, the facility's failure to adhere to residents' dietary preferences and provide appropriate dining materials resulted in a deficiency in treating residents with respect and dignity.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect several residents from abuse, as evidenced by multiple incidents involving inappropriate and harmful interactions between residents. One incident involved a resident who was observed masturbating in the shared room of two female residents. Despite the presence of a care plan addressing the resident's history of sexually inappropriate behavior, the facility did not conduct a thorough investigation or implement effective interventions to prevent recurrence. The facility's documentation was incomplete, lacking interviews with other residents or staff, and the incident was not reported to the State Agency as required. Another incident involved a physical altercation between two residents in a hallway. One resident attempted to pass by another, resulting in a physical confrontation. Although staff intervened and no injuries were reported, the facility did not substantiate the incident as abuse, despite evidence of aggressive behavior. The care plans for both residents indicated a history of behavioral issues, yet no changes were made to address the risk of future altercations. A third incident involved a resident who attempted to kick another resident in the dining room. The assailant had a documented history of physical aggression, and staff were unable to redirect him effectively. The facility's investigation concluded that the incident did not constitute abuse, despite witness statements indicating otherwise. The resident was eventually discharged to the hospital due to his inability to be redirected, but the facility's response to the incident was inadequate in preventing harm to other residents.
Failure to Provide Mechanically Altered Diets as Prescribed
Penalty
Summary
The facility failed to ensure that residents who were prescribed mechanically altered diets received food prepared according to their diet orders. Specifically, residents who required puree and mechanical soft diets were not provided with meals that matched their dietary needs as indicated on their meal tray cards. The facility's policy stated that diet orders should match the terminology used by the food and nutrition services department, and the dietitian, nursing staff, and attending physician should regularly review the need for prescribed therapeutic diets. During meal service observations, it was noted that residents received meals that did not align with their dietary requirements. For instance, a resident with a mechanical soft-ground texture order received a crisp, fried tostada shell instead of a pureed beef tostada. Another resident received a fruit crisp instead of peach slices. Additionally, a puree plate served to a resident included peas, which should not have been pureed, and the puree meat had small visible lumps, indicating it was not of the correct consistency. Interviews with staff revealed that the facility was in the process of transitioning to the International Dysphagia Diet Standardisation Initiative (IDDSI) standards, but the staff had not yet been fully trained. The dietary director acknowledged that the modified diet textures were incorrect and that residents were at risk for choking if modified textures were served incorrectly. The dietary director also noted that the facility had not yet transitioned to using IDDSI levels, which contributed to the confusion and errors in meal preparation.
Failure to Develop Comprehensive Care Plans for Oxygen, PICC Line, and Insomnia
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, resulting in unmet needs related to supplemental oxygen, PICC line management, and insomnia. For one resident with schizoaffective disorder, vascular dementia, and cellulitis, the care plan did not address the use of supplemental oxygen or the maintenance and monitoring of a PICC line, despite physician orders and ongoing treatments for these conditions. Interviews with the resident, their representatives, and staff confirmed the absence of these critical interventions in the care plan, even though the resident required continuous oxygen and had a PICC line for IV antibiotics. Two other residents, both with dementia and additional diagnoses including insomnia, were also found to have incomplete care plans. Their care plans did not include any focus or interventions related to their insomnia, despite both being prescribed medications such as trazodone and melatonin specifically for sleep issues. Staff interviews confirmed that sleep patterns were being tracked and that insomnia was a known issue, but this was not reflected in the residents' care plans. The facility's policy requires that care plans be comprehensive, person-centered, and updated as residents' conditions change. However, record reviews and staff interviews revealed that these requirements were not met for the three residents in question, as their care plans lacked necessary interventions for significant medical and behavioral needs identified through assessments and physician orders.
Failure to Ensure Residents Understood Binding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement was thoroughly and accurately explained to residents and/or their representatives prior to signing, as required by facility policy. Specifically, three residents or their representatives signed the arbitration agreement without evidence that the terms and implications were explained in a manner they could understand, and without documented verbal acknowledgement of understanding. The facility's policy requires that the agreement be explained in consideration of language, literacy, and learning preferences, and that staff document a verbal acknowledgement of understanding, not just a signature. Interviews with the affected residents revealed that they did not recall signing the arbitration agreement or understanding its purpose. Staff interviews indicated that the admissions coordinator read the agreement aloud to residents or their responsible parties, but the facility was unable to provide documentation that residents or their representatives acknowledged understanding the agreement. Record review confirmed that the required documentation of understanding was missing for the identified residents.
Infection Control Lapses in Housekeeping and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program across all units, as evidenced by multiple observed lapses in housekeeping and staff practices. Housekeeping staff did not consistently follow appropriate hand hygiene protocols, such as sanitizing hands between glove changes, and were observed contaminating clean gloves by touching personal items like keys. High-touch surfaces in resident rooms, including door knobs, light switches, and call lights, were not cleaned or sanitized as required. Additionally, improper cleaning techniques were used in resident bathrooms, such as using the same toilet scrub brush for multiple rooms and cleaning from dirty to clean areas and back, which is contrary to recommended procedures. Staff interviews revealed a lack of clarity and consistency in infection control practices. The housekeeping supervisor acknowledged that only one toilet scrub brush was available per unit and expressed a desire for each room to have its own brush, indicating current practices did not meet expected standards. The supervisor also confirmed that high-touch surfaces should be cleaned daily, but observations showed this was not being done. Housekeeping staff were not consistently sanitizing their hands between glove changes, and the same cleaning tools were used across multiple rooms, increasing the risk of cross-contamination. The facility also failed to implement Enhanced Barrier Precautions (EBP) for a resident with a peripherally inserted central catheter (PICC). Staff did not wear gowns or gloves during high-contact care activities with this resident, and there was no personal protective equipment (PPE) available in or outside the resident's room. Interviews with nursing and restorative staff indicated confusion about when EBP was required and inconsistent application of these precautions. The infection preventionist and DON provided differing accounts regarding the resident's need for EBP, with the DON stating EBP was only in place during active medication administration through the PICC line, while the infection preventionist indicated EBP should be used for any resident with an indwelling device.
Failure to Maintain Safe, Sanitary, and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as required by its own Safe and Homelike Environment policy. Observations revealed multiple areas in disrepair, including nine dining room chairs with ripped and peeling seat cushions, and four dining room tables with scratched and peeling surfaces exposing the underlying particle board. In the Mountain View hallway, rotted wood was found along the bottom of a double doorway frame, and the ceiling near the exit sign showed water spots and was bowing downward. Resident rooms and bathrooms were found with significant maintenance and cleanliness issues. One room had raised and rough patches on the wall, holes, scuff marks, and trash on the floor. Another room had dried liquid spills and a yellow chunky substance splattered on the wall, while a third room had a large hole in the wall with peeling paint and broken plaster. Bathrooms were observed with hard water staining, separated baseboards, corrosion, water damage, and evidence of a leaking toilet. In one bathroom, a towel was placed on the floor, and when lifted, 15 to 20 gnats were observed. Additional issues included missing curtains, broken heating vents, and toilet tank lids that did not fit, leaving openings into the tank. Interviews with residents indicated that some were unable to see trash baskets or wall conditions, and requests for cleaning (such as removal of a dead moth) were not fulfilled. One resident reported that curtains had been removed and not replaced, contributing to a cold room environment. Staff interviews revealed that the nursing home administrator was unaware of the maintenance concerns, and the maintenance director had not received work orders or been made aware of specific issues in certain rooms. The maintenance director acknowledged ongoing repair needs but cited the age of the building and competing priorities as reasons for delays.
Failure to Report Potential Sexual Abuse Incident
Penalty
Summary
The facility failed to report an incident of potential sexual abuse involving a resident to the State Survey Agency (SSA) as required by state law. The facility's policy mandates that all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property be identified, investigated, and reported within the timeframes required by federal requirements. However, in this case, the facility did not adhere to these requirements. The incident involved a 65-year-old resident who was cognitively intact and had a history of inappropriate sexual behavior. On a specific date, a CNA witnessed the resident masturbating in another resident's room while the other residents were asleep. The CNA relocated the resident and informed him that such actions were not permissible. The Director of Nursing (DON) was notified and spoke with the resident, who agreed to relocate to an all-male secured unit. Despite these actions, the facility did not report the incident to the SSA. Interviews with the DON and the Nursing Home Administrator (NHA) revealed that the incident was not reported to the SSA because the NHA consulted with a clinical consultant who advised that the incident was not considered abuse. The NHA acknowledged that any allegations of abuse should be reported to the SSA within 24 hours, but in this case, the incident was not reported, leading to a deficiency in compliance with state reporting requirements.
Failure to Secure Resident Meal Tickets and Protect Confidential Information
Penalty
Summary
Facility staff failed to maintain the confidentiality of resident medical records by leaving resident meal tickets, which contained protected information such as resident names and physician-prescribed diet orders, in unsecured locations within the main kitchen and dining room. During meal preparation and service, these meal tickets were observed on both sides of the serving counter and on top of the steam table, making them easily accessible to anyone in the area. A resident's representative was seen picking up and looking through the meal tickets in both locations, searching for a specific resident's meal ticket. Staff interviews confirmed that the meal tickets contained protected information, including resident names, room numbers, and diet orders, and that guests should not have access to them. The dietary director acknowledged that resident privacy was not maintained in this instance, and the nursing home administrator stated that this issue had not been previously brought to his attention. The regional clinical resource noted that while staff were trained on resident privacy, it was unclear if meal tickets were specifically included in that training.
Failure to Document Resident's Resuscitation Preferences and MOST Form Refusal
Penalty
Summary
The facility failed to accurately document a resident's resuscitation preferences and refusal to complete a medical orders for scope of treatment (MOST) form upon admission. The resident, who was over 65 years old and had multiple diagnoses including COPD, chronic respiratory failure, diabetes, opioid dependence, history of blood clots, hypertension, and pressure ulcers, was cognitively intact and dependent on care for hygiene and bed mobility. Despite a physician's order for full code status being present, there was no documentation in the care conference summary or progress notes indicating that the resident's resuscitation choices or refusal to sign the MOST form were discussed or recorded. Staff interviews revealed that the DON stated the resident declined to initiate a MOST form at admission and that this was supposedly documented in care conference notes. However, a review of the care conference notes and the electronic medical record did not show any documentation of the resident's declination or discussion of resuscitation choices. The RCR confirmed that, in the absence of a completed MOST form, the default order would be for full code status. An email from the RCR further confirmed the lack of documentation regarding the resident's refusal or discussion of resuscitation preferences.
Failure to Obtain Orders and Provide Routine PICC Line Maintenance
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice regarding the maintenance of a peripherally inserted central catheter (PICC) line. Specifically, the facility did not obtain a physician's order for routine PICC line dressing changes until several weeks after the line was placed, and there was no documentation that the dressing had been changed from the time of insertion until the order was obtained. The resident's care plan also lacked any focus or interventions related to the PICC line or its maintenance. The resident, who was over 65 years old and had diagnoses including schizoaffective disorder, vascular dementia, and cellulitis, was admitted with a PICC line for IV antibiotics. Interviews with the resident and her representatives confirmed that the PICC line was placed for antibiotic administration. Observations revealed that the PICC line dressing was visibly soiled, pulling away from the skin, and the date on the bandage was mostly washed away, indicating it had not been changed as required. The resident reported that the dressing had not been changed for several days, and staff interviews indicated uncertainty about the presence of a physician's order for dressing changes. Record review showed that while there were orders for PICC line placement, radiographs, and flushing, there was no order for dressing changes until it was added during the survey. Staff interviews confirmed that the order for weekly dressing changes was not in place until prompted by the survey, and there was no documentation of dressing changes in the electronic medical record during the relevant period. This failure to follow professional standards and obtain necessary orders resulted in the deficiency.
Failure to Monitor and Document Resident Weight Upon Admission
Penalty
Summary
The facility failed to ensure that a resident with multiple medical conditions, including COPD, chronic respiratory failure, type 2 diabetes, opioid dependence, hypertension, and pressure ulcers, received appropriate monitoring of nutritional status upon admission. Although facility policy required residents to be weighed upon admission and at intervals determined by the interdisciplinary team, there was no documented admission weight for the resident, nor were there consistent attempts to obtain a weight as required. The only recorded weight was from a prior hospital stay, and the resident's usual body weight was unknown. The care plan and physician orders indicated the need for weekly weights, but the electronic medical record did not show evidence of these weights being taken or of repeated attempts to weigh the resident, except for a single documented refusal during the nutritional risk assessment. Staff interviews revealed that weighing residents upon admission was standard protocol, and that if a resident refused, further follow-up by nursing staff was expected. A CNA reported difficulty weighing the resident due to the need for two staff members and the resident's discomfort, but there was no documentation in the medical record of these attempts or refusals beyond the initial assessment. The lack of documented efforts to obtain the resident's weight and monitor for trends, as well as the absence of recorded weights in the medical record, resulted in a failure to meet the resident's nutritional monitoring needs as outlined in facility policy.
Failure to Assess and Supervise Resident Self-Administering Tube Feedings
Penalty
Summary
The facility failed to ensure that a resident with a feeding tube received appropriate assessment and supervision while self-administering tube feedings. The resident, who was under 65 years old and had diagnoses including moderate protein-calorie malnutrition, an eating disorder, and adult failure to thrive, was observed independently administering her own bolus tube feedings on multiple occasions without staff present. The resident had a moderate cognitive impairment and required supervision or assistance for most activities of daily living, though she was independent with eating. Review of the resident's care plans and physician orders indicated that she required enteral nutrition and that staff were to check tube placement and provide supervision for safety. The care plans also noted that the resident was private and refused staff assistance with tube feedings, but there was no documented assessment confirming her ability to safely self-administer her feedings. Additionally, there were no physician orders authorizing the resident to self-administer her tube feedings. Interviews with staff, including an LPN and the DON, confirmed that the resident did not allow staff to administer her feedings and that no formal assessment had been completed to determine her competency in self-administration. Both staff members stated that supervision should have been provided during feedings and that a physician's order was necessary for self-administration. The lack of assessment, documentation, and supervision constituted a failure to provide appropriate care and services for the resident with a feeding tube.
Medication Administration Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication administration error rate below five percent, as required by professional standards and regulations. During observations, it was found that the medication error rate was 6.06%, with two errors identified out of 33 opportunities. Specifically, an LPN administered only 20 mg of omeprazole to a resident via PEG tube, instead of the prescribed 40 mg dose. Additionally, the same LPN applied a lidocaine patch to the resident's right shoulder, contrary to the physician's order to apply it to the left shoulder. These actions were directly observed during medication administration. Interviews with the LPN revealed that the errors occurred due to a misunderstanding of the resident's position and a failure to double-check the medication dosage. The LPN acknowledged administering only one capsule of omeprazole instead of two and placing the lidocaine patch on the wrong shoulder. The DON confirmed that physician's orders should be double-checked during medication administration. The resident involved had a history of GERD and required medication via PEG tube, as well as topical pain management for shoulder pain.
Failure to Maintain Accessible Hospice Documentation for Resident
Penalty
Summary
The facility failed to ensure that hospice agency notes regarding the care of a resident receiving hospice services were easily accessible to facility staff, which impeded effective coordination of care. According to the contract between the facility and the hospice provider, both parties were required to maintain complete, detailed, and readily available clinical records for each hospice patient. However, review of the resident's records revealed that the hospice binder only contained documentation from the hospice social worker and lacked nursing notes, CNA visit documentation, the hospice plan of care, and other required records. Additionally, the resident's electronic medical record did not contain any hospice provider progress notes. Interviews with staff confirmed that hospice staff were expected to place visit notes in the hospice binder and communicate care provided to facility staff, but this was not consistently done. The LPN and CNAs reported that hospice CNA visit notes were missing from the binder, and some hospice staff did not always communicate the care provided. The DON and regional clinical resource also acknowledged that the hospice binder should contain comprehensive documentation, including visit summaries and care plans, but these were absent for the resident in question. The resident involved was an elderly individual with respiratory failure, vascular dementia, and adult failure to thrive, who was dependent on staff for most activities of daily living and had significant cognitive impairments.
Incomplete and Inaccessible Posting of State Agency and Advocacy Group Contact Information
Penalty
Summary
The facility failed to post, in an accessible and understandable manner, a complete list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups as required. Observations revealed that while some information, such as the abuse coordinator, ombudsman contact, state agency phone number and website, and residents' rights, was posted in the lobby, the postings did not include the mailing and email addresses of the State Agency or contact information for adult protective services, the state licensure office, and the Medicaid fraud control unit. Additionally, the information that was posted was not in a readable font size or placed in an area with ease of access for residents. Interviews with six alert and oriented residents who regularly attended resident council meetings indicated that none of them knew how to file a complaint with the State Agency. Staff interviews revealed a lack of clarity regarding responsibility for maintaining the postings, with the social services director stating she occasionally updated ombudsman information but was not responsible for the main postings, and the nursing home administrator acknowledging responsibility but unable to locate information regarding the Medicaid fraud control unit.
Failure to Maintain Functioning Door Alarm in Secured Unit
Penalty
Summary
The facility failed to ensure that the alarm on the door to the outside secured patio was functioning properly, leading to a deficiency in maintaining a safe environment free from accident hazards. Observations revealed that the alarm on the back door of the all-male secured unit was broken and did not audibly alert staff when the door was opened. This door, which was not visible from the nurse's station and lacked camera surveillance, provided direct access to a courtyard with uneven surfaces. The malfunctioning alarm allowed residents to potentially exit the facility unnoticed, posing a significant safety risk. Interviews with staff members, including several CNAs, indicated that the alarm had not been functioning for several months, and staff had not been trained on how to set or reset the egress door in the secured unit. The CNAs reported that they had to manually monitor the door to prevent residents from exiting unsupervised, which was challenging given the number of residents and the layout of the unit. The staff also mentioned that the previous maintenance director had been informed of the issue, but no action was taken to fix the alarm. The DON and NHA were unaware of the broken alarm until the survey, highlighting a communication breakdown within the facility. The lack of a functioning alarm system and inadequate staff training on the door's security features contributed to the deficiency. The facility's failure to address the alarm issue in a timely manner compromised the safety and supervision of residents in the secured unit.
Fly Infestation in Kitchen and Dining Areas
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a fly infestation in the kitchen and dining room areas. Observations revealed that the back door of the kitchen, which led to the area where trash dumpsters were kept, was open and lacked screens, allowing flies to enter the kitchen and dining room. Several flies were observed in the kitchen during meal preparation and in the dining room during meal service, landing on tables and residents. Interviews with residents highlighted their dissatisfaction with the fly problem. One resident expressed discomfort with flies landing on her while eating, and another resident was observed carrying a fly swatter to combat the flies during meals. Residents reported that they had complained about the issue to management, but the problem persisted, affecting their dining experience. Staff interviews confirmed the ongoing issue with flies. A dietary aide mentioned that the kitchen door was left open to allow steam to escape, contributing to the fly problem. The dietary manager acknowledged the unsanitary conditions caused by the flies and the potential for food contamination. Despite efforts such as using insect zappers and hiring an exterminator, the facility had not resolved the infestation, partly due to its location in a cattle community.
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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