Citations in Colorado
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Colorado.
Statistics for Colorado (Last 12 Months)
Financial Impact (Last 12 Months)
Latest Citations in Colorado
Two residents with cognitive impairment and high fall risk did not receive adequate supervision or effective, individualized fall prevention interventions. Despite care plans outlining measures such as non-skid footwear, anti-rollback wheelchair brakes, and frequent safety checks, observations and staff interviews revealed that these interventions were not consistently implemented or tailored to the residents' needs. Audits and documentation failed to confirm the effectiveness or appropriateness of the interventions, resulting in repeated falls.
A resident with hepatic encephalopathy and other conditions did not receive multiple doses of prescribed medications, including Xifaxan, due to the facility's failure to have the medications available. Despite the resident's family providing a supply of Xifaxan, the medication was not administered as ordered, and there was no documentation that the provider was notified of the missed doses. Medication administration records and staff interviews confirmed that several medications were missed because they were not delivered from the pharmacy.
A resident with multiple respiratory and cardiac conditions had a MOST form indicating a wish for CPR, but facility staff incorrectly documented the code status as DNR in the EMR, care plan, MAR, and report sheet. When the resident was found unresponsive, staff relied on the incorrect report sheet information and did not initiate CPR or contact EMS, resulting in the resident's wishes not being honored.
A nurse performed a PICC line dressing change for a resident without following professional standards, including turning away from the sterile field, leaving the line exposed, not cleaning the site for the recommended duration, failing to measure catheter length, and not wearing a protective gown. The nurse had not received facility-specific training or demonstrated competency in PICC line care, and neither of the two nurses on staff had been trained in PICC line management.
A facility failed to ensure proper infection prevention and control by not implementing enhanced barrier precautions (EBP) during high-contact care activities for a resident with a PICC line. Staff did not wear gowns as required during a dressing change and incontinence care, despite clear signage and CDC guidance. Interviews revealed gaps in staff understanding and adherence to EBP protocols.
A resident with multiple chronic conditions was given warfarin twice daily instead of the prescribed once daily due to a failure to discontinue a previous order and inaccurate documentation of INR results. This led to the resident receiving excessive doses of the anticoagulant over several days, with staff not updating the MAR with current INR values or completing scheduled INR testing.
Surveyors found that the facility did not maintain a safe, clean, and comfortable environment, with persistent odors of urine and feces, unclean floors, stained linens, and unrepaired damage in resident rooms and common areas. Residents and their representatives reported frequent unpleasant odors and visible cleanliness issues, while staff interviews revealed confusion about cleaning responsibilities and inconsistent maintenance practices.
Two residents did not receive their scheduled pain medications, including Oxycontin and oxycodone, within the prescribed time frames as documented in the MARs. In several instances, medications were administered late or missed entirely, despite physician orders and professional standards requiring timely administration. Both residents reported ongoing pain and noted that delays in medication administration affected their comfort.
Two residents with significant cognitive impairment and complex medical needs did not have their representatives consistently involved in care plan development, as required. Representatives reported not being invited to or having difficulty scheduling care conferences, and facility records confirmed a lack of documented conferences and incomplete contact attempts over several months.
A resident's designated representative was not notified of multiple significant changes in the resident's condition, including facial swelling, urgent dental care, leg edema, loose stools, and bruising, despite facility policy requiring such notifications. The resident was cognitively impaired and unable to communicate, and staff interviews confirmed these events should have triggered notification and documentation.
Failure to Implement Effective Fall Prevention Interventions for High-Risk Residents
Penalty
Summary
The facility failed to ensure that two residents at high risk for falls received adequate supervision and effective, person-centered interventions to prevent repeated falls. For one resident with a history of stroke, dementia, anxiety, and unsteadiness, the care plan included multiple interventions such as reminders to use the call light, non-skid footwear, and keeping personal items within reach. However, observations revealed that the resident's glasses and hearing aids were out of reach, the call light signage was difficult to read due to poor contrast, and the resident's wheelchair lacked proper identification. Documentation did not confirm whether the resident understood how to use the call light or if interventions were tailored to her cognitive abilities. Additionally, there was no evidence of pharmacy review specific to fall prevention, and the responsible party was not consistently involved in developing or updating fall prevention strategies. Another resident with severe cognitive impairment, muscle weakness, and a history of falls was also not provided with all required safety interventions. Although the care plan called for anti-rollback brakes on the wheelchair and other fall prevention measures, observations showed that the anti-rollback brakes were not installed as required. Staff interviews indicated a lack of awareness regarding the need for these safety devices, and progress notes documented multiple falls after the intervention was recommended but not implemented. The care plan included frequent checks and reminders, but these were not always carried out or documented as effective. Audits and performance improvement plans were in place to monitor fall prevention interventions, but these did not consistently assess the residents' specific needs or the effectiveness of interventions. For example, audits failed to evaluate whether residents could read reminder signs, reach their call lights, or use them effectively. There was also a lack of follow-through on therapy recommendations and incomplete documentation of resident preferences and abilities. As a result, the facility did not consistently implement or monitor person-centered, effective fall prevention interventions for the affected residents.
Failure to Provide Physician-Ordered Medications Due to Unavailability
Penalty
Summary
The facility failed to provide physician-ordered medications as prescribed for one of the sampled residents. Specifically, the facility did not have the medication Xifaxan, which is used to treat hepatic encephalopathy, available for administration to the resident on multiple occasions. The medication was not available in the facility from the pharmacy between the time the initial supply ran out and the refill was delivered, resulting in missed doses. Additionally, other medications such as lotilaner ophthalmic solution and midodrine were also not administered as ordered due to unavailability from the pharmacy. The resident involved had diagnoses including hepatic encephalopathy, hepatitis C, and hepatomegaly, and was cognitively intact at the time of the incident. Interviews with the resident and her representative revealed that the representative had brought in a supply of Xifaxan from the previous facility and left it with the nursing staff. Despite this, the medication was still not administered as ordered on certain dates, and there was no documentation that the provider group was notified when the medication was unavailable. Staff interviews confirmed that the resident's family provided a supply of Xifaxan and that the facility experienced delays in obtaining the medication from the pharmacy, partly due to insurance approval issues. Nursing staff were expected to notify the provider if a medication was unavailable, but there was no record of such notification for the missed doses. The medication administration records and nursing progress notes documented multiple missed doses of Xifaxan, lotilaner ophthalmic solution, and midodrine due to lack of availability.
Failure to Honor Resident's Advance Directive Due to Documentation Errors
Penalty
Summary
The facility failed to ensure that a resident's right to formulate and have their advance directive honored was upheld. Upon admission, the resident, who had a history of acute and chronic respiratory failure with hypoxia, interstitial pulmonary disease, pulmonary hypertension, COPD with acute exacerbation, and pneumonia, had a Colorado Medical Orders for Scope and Treatment (MOST) form completed and signed by the resident's representative and a nurse practitioner. This form clearly indicated the resident's wishes to receive CPR in the event of cardiac or respiratory arrest. However, the facility incorrectly transcribed the resident's code status as 'Do Not Resuscitate' (DNR) in the electronic medical record (EMR), care plan, medication administration record (MAR), and nurses' report sheet, which conflicted with the signed MOST form. When the resident was found unresponsive and without vital signs by a CNA and subsequently assessed by an LPN and an RN, staff did not initiate CPR or contact emergency medical services. The LPN and RN both relied on the information from the nursing report sheet, which incorrectly listed the resident as DNR, rather than referencing the MOST form or the EMR for the accurate code status. As a result, the resident's expressed wishes for resuscitation were not honored, and no resuscitative efforts were made prior to the physician pronouncing death. Interviews with staff confirmed that the nurses did not check the MOST form binder or the EMR to verify the resident's code status at the time of the incident. Instead, they relied on outdated or incorrect information from the report sheet. The facility's failure to ensure accurate and consistent documentation of the resident's advance directives directly led to the staff not attempting resuscitation, contrary to the resident's documented wishes.
Failure to Follow Professional Standards During PICC Line Dressing Change
Penalty
Summary
The facility failed to ensure that services provided met professional standards of quality during a peripherally inserted central catheter (PICC) line dressing change for one resident. During the observed procedure, the registered nurse (RN) turned his back on the sterile field multiple times, left the resident's room to obtain additional supplies after removing the PICC line dressing—leaving the line exposed—and did not follow the recommended cleaning technique or duration for the insertion site. The RN also failed to measure the length of the catheter to monitor for migration and did not wear a protective gown as required. These actions were not in accordance with established professional guidelines for PICC line care. Record review revealed that the RN had not completed training or demonstrated competency in PICC line dressing changes at the facility. Interviews with the RN, the director of nursing (DON), and the infection preventionist (IP) confirmed that neither of the two nurses currently working at the facility had received training for PICC line management. The RN admitted to lacking formal training at the facility and expressed a desire for education, attributing his errors during the procedure to nervousness and unfamiliarity with the facility's protocols.
Failure to Implement Enhanced Barrier Precautions During High-Contact Care Activities
Penalty
Summary
The facility failed to maintain and follow its infection prevention and control program, specifically regarding the implementation of enhanced barrier precautions (EBP) for residents with indwelling medical devices. According to CDC guidance, EBP requires the use of gowns and gloves during high-contact resident care activities for residents with wounds or indwelling devices, regardless of known colonization with multidrug-resistant organisms (MDROs). The facility's policy addressed standard transmission-based precautions but did not mention or address EBP, despite signage indicating EBP requirements on a resident's door. During observations, a registered nurse (RN) was seen performing a peripherally inserted central catheter (PICC) line dressing change for a resident who was admitted for antibiotic treatment and IV management. The RN wore gloves and a mask but failed to don a protective gown as required by EBP. Additionally, a certified nurse aide (CNA) assisted the same resident with transferring and incontinence care but did not wear a gown, only gloves, despite the resident being on EBP due to the presence of an IV line. Interviews with the involved staff revealed a lack of understanding and adherence to EBP protocols. The CNA believed that only gloves were necessary for personal care and did not recognize the need for a gown when assisting with transfers or incontinence care for a resident with an indwelling device. The RN acknowledged forgetting to wear a gown during the dressing change. The infection preventionist confirmed that both staff members should have used gowns and gloves for these high-contact activities, as required by EBP.
Significant Medication Error in Warfarin Administration and Monitoring
Penalty
Summary
A significant medication error occurred when a resident with a history of hypertension, kidney disease, diabetes, stroke, and left-sided paralysis was administered warfarin, a blood-thinning medication, twice daily instead of the prescribed once daily at bedtime. The resident was admitted from the hospital with orders for warfarin and regular INR (international normalized ratio) monitoring to manage stroke risk. The initial physician's order specified warfarin 1 mg in the morning, with daily INR monitoring for dose adjustments. After an INR result was communicated to the physician, a new verbal order was given for warfarin 1.5 mg to be administered once daily in the evening, along with instructions to document the most recent INR and schedule the next INR test. However, the verbal order did not include discontinuation of the previous morning dose, resulting in the resident receiving both the morning and evening doses of warfarin from August 28 to September 9. During this period, facility nurses failed to update the medication administration record (MAR) with the most recent INR result from August 26, instead repeatedly documenting an outdated hospital INR result from August 22. The scheduled INR test for August 29 was not completed, and the error in warfarin administration continued until a subsequent INR test on September 10 revealed an elevated level of 4.5. The facility's medication administration policy required medications to be given as prescribed and for staff to contact the prescriber if a dosage appeared inappropriate or excessive. The anticoagulation protocol also required the use of a warfarin flow sheet to track dosage and response. Despite these policies, the failure to discontinue the prior warfarin order, lack of accurate INR documentation, and omission of scheduled INR testing led to the resident receiving excessive doses of warfarin over a prolonged period.
Failure to Maintain a Safe, Clean, and Comfortable Environment
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in three of five units. Multiple observations and interviews revealed persistent odors of urine and feces in common hallways, resident rooms, and dining areas. Residents and their representatives reported frequent and strong smells of urine and feces, with some stating that the odors were so strong they had to cover their mouths and noses. Additionally, representatives noted issues such as broken blinds, missing lights, and sticky or stained floors in resident rooms and common areas. Direct observations by surveyors documented stained footprints, sticky and stained floors, dried feces in resident rooms, spills left uncleaned for hours, and cracks in floors and walls. Used linens and water pitchers were left in common areas for extended periods, and cleaning was observed to be incomplete, with crumbs and stains remaining under tables and on surfaces. Handrails and baseboards throughout the facility were scratched, chipped, and marked, and some repairs appeared to be temporary or incomplete. The facility's cleaning and maintenance practices were inconsistent, with unclear responsibilities between housekeeping and nursing staff regarding the cleaning of bodily fluids and spills. Staff interviews confirmed confusion about cleaning responsibilities and the frequency of deep cleaning. Housekeeping staff did not always clean under tables or mop common areas, and nursing staff were sometimes responsible for cleaning spills, but there was uncertainty about the cleaning solutions used and the condition of cleaning equipment. Maintenance issues, such as cracked floors and missing lights, were sometimes delayed due to communication problems and staff turnover. The facility's own policy required a sanitary, orderly, and comfortable environment, but observations and interviews indicated that these standards were not consistently met.
Failure to Administer Pain Medications Timely per Physician Orders
Penalty
Summary
The facility failed to ensure that two of five sampled residents received medication administration in accordance with professional standards and physician orders. Specifically, the facility did not administer scheduled pain medications, including Oxycontin and oxycodone, within the prescribed time frames for both residents. The medication administration records (MARs) showed multiple instances where medications were given outside the allowed one-hour window before or after the scheduled time, and in one case, a dose was missed entirely. One resident, who had diagnoses including fibromyalgia, neuropathy, and chronic pain, was cognitively intact and relied on scheduled opioid medications to manage severe pain. The MARs indicated that her Oxycontin doses were administered late on several occasions, sometimes by more than an hour past the scheduled time. The resident reported experiencing high levels of pain and noted that her pain medications were not always given on time, although she could not recall specific dates. Another resident, with diagnoses including dementia, chronic kidney disease, and chronic pain, also received scheduled pain medications. The MARs for this resident documented several late administrations of oxycodone, with one dose not administered at all. This resident expressed a desire not to experience any pain and stated that delayed administration of her pain medication resulted in increased discomfort. Staff interviews confirmed that the medications were not administered within the required time frames and acknowledged the importance of timely medication administration as per physician orders.
Failure to Involve Representatives in Care Plan Development
Penalty
Summary
The facility failed to ensure that residents and their representatives were given the opportunity to participate in the development and implementation of person-centered care plans for two residents out of a sample of twelve. Both residents were cognitively impaired, with BIMS scores of zero, and required significant assistance with daily activities. For one resident, the representative reported only being invited to the initial care conference upon admission and had not been invited to any subsequent conferences for several months, despite attempts to contact social services. Documentation confirmed that no care conferences had occurred for this resident between July and December, except for a voicemail left during the survey period. For the second resident, the representative stated difficulty in scheduling care conferences and could not recall the last time one was held. The facility's records indicated that the representative did not attend the last documented care conference due to unsuccessful contact attempts, and there was no evidence of any further care conferences in the following months. Staff interviews confirmed that the facility was behind in scheduling both initial and quarterly care conferences for all residents, including the two in question, and that documentation of contact attempts was expected but not consistently completed.
Failure to Notify Resident Representative of Significant Change in Condition
Penalty
Summary
The facility failed to notify a resident's designated representative of significant changes in the resident's condition, as required by facility policy. The policy states that the responsible party must be informed of any change in the resident's condition and the steps being taken, with all attempts at notification documented in the nursing progress notes. However, record review and interviews revealed that the representative was not notified of several notable changes, including facial swelling, an urgent dental visit, leg edema, loose stools, and bruising on the knee and face. The resident involved was cognitively impaired, with a BIMS score of zero, and required maximal assistance with daily activities. The medical record showed multiple incidents: a limp and mild bruising on the left knee, facial swelling and dental issues requiring urgent referral, right periorbital ecchymosis, and episodes of loose stools and leg edema. In each case, there was no documentation that the resident's representative was informed of these changes or the interventions ordered by physicians, despite the facility's policy and the resident's inability to communicate his needs. Interviews with staff, including RNs and regional clinical resources, confirmed that bruising, black eye, edema, and loose stools are considered changes of condition that require notification of the physician, DON, and the resident's representative. Staff acknowledged a gap in documentation regarding who was notified when a change of condition occurred. The resident's representative also reported not being informed about these significant health events, emphasizing the importance of communication due to the resident's inability to advocate for himself.
Some of the Latest Corrective Actions taken by Facilities in Colorado
- Established cross-verification of new admission orders with hospital discharge orders to ensure transcription accuracy and resolve discrepancies with the attending physician (J - F0760 - CO)
- Required primary physician review of every new admission order set against the resident’s history and physical to confirm accuracy before implementation (J - F0760 - CO)
- Directed consultant pharmacists to review all new admissions for high-risk medications, interactions, contraindications, and duplicate therapies, with communication of any concerns to facility leadership (J - F0760 - CO)
- Re-educated all licensed nurses on medication-administration and reconciliation policy, emphasizing documentation of verification sources, two-nurse order checks, and clarification of stop dates for long-term medications (J - F0760 - CO)
- Mandated completion of medication-reconciliation training before any licensed nurse may work on the floor, including those returning from leave or hired through agencies (J - F0760 - CO)
- Uploaded required medication-reconciliation education to the agency nursing platform and blocked shift confirmation until training is completed (J - F0760 - CO)
Failure to Administer Prescribed HIV Medication Due to Transcription Error
Penalty
Summary
The facility failed to ensure that a resident with a diagnosis of HIV received the physician-prescribed antiretroviral medication, Biktarvy, upon admission. Instead, the admitting nurse transcribed the order incorrectly, listing only one component of the medication, tenofovir alafenamide, rather than the full combination therapy required for effective HIV treatment. There was no documentation or recall as to why the order was changed, and neither the facility pharmacist nor the medical director reviewed or corrected the order prior to its implementation. As a result of this transcription error, the resident received only tenofovir alafenamide for several months, rather than the complete Biktarvy regimen. When the order for tenofovir expired, it was not renewed, and the resident subsequently received no HIV medication for a period of time. Throughout this period, the facility's nursing staff, pharmacist, and medical director failed to identify or address the omission, despite regular medication reviews and the resident's ongoing need for antiretroviral therapy as documented in the care plan and physician orders. The deficiency was discovered when the resident was sent to a hospital for routine HIV viral load testing, which revealed a significantly elevated viral load, indicating a lack of effective HIV treatment. The hospital physician noted that the resident's medication list from the facility did not include Biktarvy, and the resident was subsequently restarted on the correct medication. Interviews with facility staff confirmed that the resident was cooperative with care and did not refuse medications, and that the error was not identified until the hospital visit. The facility's failure to administer the prescribed medication as ordered resulted in a significant medication error and actual harm to the resident.
Removal Plan
- Resident #1's medication list was printed and reviewed with the facility physician for accuracy.
- The hospital's infectious disease office was contacted regarding follow-up appointment recommendations for lab monitoring.
- The DON or designee will prioritize reviewing current residents who are receiving clinically significant medications such as insulin, anticoagulants, cancer agents, antivirals, and medications for multiple sclerosis or Parkinson's, focusing on order accuracy.
- The DON/designee will review all remaining residents.
- The DON or designee reviewed all resident orders with a discontinuation date using the order listing report to ensure accuracy.
- Facility Medication policy was reviewed by the NHA, the DON, and the medical director.
- New admission orders will be reviewed against the discharge orders to ensure transcription accuracy. Any discrepancies identified will be clarified with the attending physician.
- The primary physician will review new admission orders in conjunction with the history and physicals to ensure accuracy.
- Consultant pharmacists will complete a review of new admissions for clinically significant risk. This review will include assessment of high-risk medications, potential interactions, contraindications, missing indications, and duplicate therapies. Any concerns identified will be communicated to the facility.
- The LPN who may not have transcribed the original order correctly was re-educated via phone by the assistant director of nursing (ADON). Education included the facility's policy regarding medication administration and reconciliation guidelines of noting who medications were verified with and any changes made during reconciliation.
- The staff development coordinator (SDC) or designee re-educated all licensed nurses on the facility's medication administration and reconciliation policy. Education included documenting who was verified for each medication, noting any changes made during reconciliation, completing a two-nurse verification of order accuracy, and clarifying when a long-term medication has a stop date.
- Any nurse who has not yet received the education will not work the floor until training is completed.
- Licensed nurses who have not worked have been terminated.
- Licensed nurses on a leave of absence will be educated upon their return and prior to working on the floor.
- Licensed nurses were unable to be reached by the SDC or designee and will not be scheduled to work until the required education is completed.
- The SDC/designee will educate agency licensed nurses on the facility's policy regarding medication administration and reconciliation guidelines. Education was uploaded to the agency portal.
- The agency platform requires the agency nurse to complete training before they can confirm the shift.
- The regional director of clinical services notified the pharmacy account representative of the error. A meeting has been scheduled with the pharmacy to review the error in detail and establish an ongoing plan for medication monitoring.
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