Facility Fails to Support Resident Dignity and Autonomy
Summary
The facility failed to provide an environment that supported and enhanced the dignity, self-worth, sense of satisfaction, and control over the lives of residents residing on the second and third floors. Observations and interviews with residents and staff revealed practices that disregarded residents' quality of life and were inconsistent with the facility's Resident Rights policy. Residents reported restrictions on their day-to-day lives, such as limitations on meeting without staff at Resident Council, accessing personal funds, moving freely within the facility, choosing dining options, having visitors, participating in social activities, and communicating privately by phone and mail. Observations confirmed these restrictions, showing that staff were not responsive to call lights, contributing to residents feeling neglected. Residents lacked access to information on outside assistance and survey results. Specific incidents included residents being limited to one soda per day, having to use plastic cutlery, and being restricted to certain floors. Residents expressed feelings of being jailed, trapped, and angry due to these limitations. Interviews with residents further highlighted their concerns, such as the inability to make private phone calls, restricted visitation hours, and limited access to personal funds. Some residents reported feeling trapped and unable to leave their floors without an escort. The facility's practices created an immediate jeopardy situation with the likelihood of serious harm if not immediately corrected.
Removal Plan
- Residents will be asked before each Resident Council whether they would like staff to attend the meeting or not. Residents are able to meet without staff present.
- A new Resident Council Form was implemented to include the question about staff attendance and the resident's response. The resident's response will be documented in the minutes of each Resident Council Meeting.
- Resident Council Meeting Minutes will be reviewed during QAPI to ensure compliance.
- Postings were updated with the correct contact information and are located in each neighborhood at wheelchair level.
- Postings will be monitored by the Leadership Team to ensure they are in place and at the proper level.
- Survey Results Binder is located in the Front Lobby on the first floor, containing surveys. Residents have access to the Survey Results independently.
- NHA or designee will update the binder with all annual and complaint surveys moving forward and ensure that the binder is in place.
- Resident #8's care plan was updated to include guardian input and court-ordered placement stipulations regarding movement throughout the community.
- A Resident Preferences Interview was conducted with Resident #8, and her care plan was updated to reflect her preferences.
- Resident #8's preferences will be updated as needed, and the community will maintain contact with resident's guardians for further care plan revisions and as needed.
- All residents are encouraged to eat in the dining areas. If a resident chooses to eat in their rooms, a room tray will be provided.
- The kitchen is open. If a resident misses a meal, they can request food or a tray during these times.
- Snacks are available in the neighborhoods.
- Dining Services will be reviewed with the Food Committee.
- Residents can purchase and/or request soda any time they wish. Residents on the second floor will have soda served to them in a disposable cup for safety.
- The use of disposable cups for soda will be discussed during the second floor Resident Council meetings.
- There is a cordless phone at the Nurses' Station in each neighborhood, available to all residents for private conversations.
- There are also stationary resident phones located throughout the community, and a private phone in the Town Hall Room on the first floor.
- The use of cordless phones will be discussed during the Resident Council Meetings for each neighborhood.
- Residents on the second floor will utilize plastic cutlery for safety. This information is located in the Resident Handbook for all admissions to the second floor.
- The use of plastic cutlery will be discussed during the Resident Council Meetings for the second floor.
- Visiting hours are twenty-four hours per day. Visitors may be asked to leave items in a locker if there are concerns about contraband.
- All responsible parties were notified of the visiting hours policy.
- Elevator operates and residents have access to it at all times.
- Elevator availability will be discussed during the Resident Council Meetings in each neighborhood.
- The facility will continue to follow the CDPHE directed plan regarding safe smoking.
- Resident smoking abilities are assessed, and care plans are updated accordingly.
- Mail is delivered if/when received from the USPS, and will be delivered by the Leader on Duty.
- The community follows regulations regarding resident's personal needs accounts, ensuring access to $100.00 ($50.00 for Medicaid residents) in cash within a reasonable period.
- Assessments and behavior care plans are developed and created on a resident-specific and individualized basis.
- A Resident Preferences Questionnaire has been completed, and residents have been interviewed regarding all of the above topics.
- All above items will be reviewed in QAPI and Safety Committee.
Penalty
Resources
Below are regulatory guidelines relevant to this citation:
A resident experienced multiple leg fractures after a fall, resulting in a significant change in condition and non–weight-bearing status. Although the MDS reflected that it was important for the resident to participate in group activities, favorite pastimes, and church services, the activity care plan was not revised after the injury to address her new limitations. The existing plan listed numerous preferred activities such as resident council, food committee, religious services, music, gardening, and in-room pursuits, but no new individualized interventions were added, and documentation showed only two 1:1 visits after her return from the hospital. The resident reported she could no longer get into her wheelchair, attend council or church, or join groups she enjoyed, and stated that activity staff did not visit often, while the Director of Recreation confirmed she had not attended groups since the injury and that in-room social visits were not consistently documented, resulting in a decline in activity participation and social isolation.
A resident with multiple medical conditions, including a femur fracture, gout, COPD, and HTN, activated the call light for incontinence care but remained in a soiled brief for over 40 minutes while lunch was served. A CNA entered the room without knocking, turned off the call light, initially ignored the resident, and stated she could not provide peri-care because the roommate was eating. The CNA later claimed she had been told not to provide such care when someone in the room was eating, while the CN and DSD denied giving such instructions and referenced expectations for immediate response and use of privacy curtains. Review of the facility’s dignity policy and the DON’s statements confirmed that required practices for prompt toileting assistance, respect, and privacy were not followed.
A deficiency occurred when the facility failed to ensure hot water was available in resident rooms for showers, preventing a warm and comfortable bathing experience for multiple residents. One cognitively impaired resident, fully dependent for personal care, had no documented showers or baths for an extended period despite a scheduled bathing routine, and her family had filed a grievance about the lack of hot water. Two cognitively intact male residents, one with paraplegia and one with cirrhosis and diabetes, reported that their room showers had only cold or lukewarm water for weeks; they often refused showers when hot water could not be found, sometimes accepting sponge or bed baths instead, and one refused to bathe in other residents’ rooms. Staff and the Maintenance Director confirmed ongoing hot water problems on one wing, acknowledged that management was aware, and described workarounds such as using other rooms with hot water, obtaining hot water from common areas, or pouring basins of hot water over residents in their own showers, which did not consistently meet the facility’s policy to provide comfortably tempered shower water.
The facility failed to ensure residents had access to warm water for bathing and showers, resulting in at least one resident receiving a cold bed bath during a winter storm and another receiving a cold shower when hot water was unavailable. A resident with fractures and chronic diastolic heart failure, who required substantial assistance with bathing, reported taking a cold bed bath when the facility lost power and had no warm water. Staff, including a SW, CNA, LVN, housekeeping staff, and supervisors, described ongoing problems with cold water on one hall, residents refusing showers, and staff transporting residents to other halls or carrying hot water between showers. A surveyor measured the shower water at 71°F on the affected hall, and the area maintenance specialist later found the hot water temperature had been turned down and that required weekly water‑temperature logs had not been completed for several weeks, despite a policy requiring water temperatures of 100–110°F and resident rights to care that promotes quality of life.
Two residents with complex medical needs experienced repeated delays in staff response to call lights, with documented wait times far exceeding the facility's 5-minute expectation. Both residents reported long waits, and call light logs confirmed multiple instances of extended response times, indicating staff did not meet the facility's standard for timely care.
A resident with upper extremity impairment and cognitive intactness was not assisted with her dentures before breakfast, despite her care plan indicating a need for substantial help. The CNA who served her breakfast was unaware of the resident's dentures, and the DON acknowledged the importance of this assistance for proper nutrition.
Failure to Revise Activity Care Plan After Significant Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received ongoing opportunities to participate in meaningful activities consistent with her interests and preferences following a significant change in condition. The resident experienced a fall on 02/18/26, was sent to a local emergency room for pain in both legs, and diagnostic radiology revealed an anterior apex angulated fracture of the distal left femur with impaction and an impaction and comminuted anterior apex angulated fracture of the distal right femur metaphysis, with osteopenia noted. She was hospitalized for these fractures and returned to the facility on 02/24/26. A subsequent MDS with an ARD of 02/27/26 documented a significant change in status and indicated that it was important for the resident to do things with groups of people, participate in her favorite activities, and attend church services. Record review showed that the resident’s activity care plan, originally initiated in 2020 and revised multiple times through 03/03/2025, contained numerous interventions reflecting her preferences, including in-room visits, participation in food committee and resident council, church and religious services, group singing and cooking, gardening, pet visits, listening to religious/bluegrass/country music, watching TV and keeping up with the news, and engaging in favorite activities such as church, sewing, cooking, reading, and gardening. The care plan also noted her use of a wheelchair and need for accommodations for visual impairments. However, there were no new or revised activity interventions added to address her new non–weight-bearing status and functional limitations after the fractures, and no changes to the activity care plan were documented following the significant change in condition. During interview, the resident, who had decision-making capacity and a BIMS score of 15, reported that prior to the fall she had been able to stand, pivot, and walk with therapy, and that she had been active in resident council, church, and social activities. She stated that since her return from the hospital she could not get into her wheelchair, could not attend resident council meetings or church, and could not participate in the group activities she enjoyed. She reported that activity staff did not visit her very often and became tearful while describing her situation. The Director of Recreation confirmed that the resident had not attended group activities since returning from the hospital, was non–weight-bearing for 10 weeks, and that anything done with her was now in-room. The Director of Recreation also stated that the resident did not receive one-to-one visits “per se” and that social visits were not documented. Surveyors identified that only two one-to-one visits had been documented since the resident’s return from the hospital and that there was a significant decline in her activity participation without corresponding revisions to her care plan, which led to the finding of failure to provide consistent, individualized activity interventions and ongoing opportunities for meaningful activities.
Failure to Provide Timely Incontinence Care and Maintain Resident Dignity
Penalty
Summary
The deficiency involves the facility’s failure to provide timely incontinence care and to honor a resident’s dignity and comfort. Resident 1, who had diagnoses including a left femur fracture, gout, COPD, hypertension, and a history of falling, reported that she activated her call light at 11:00 AM because she needed a diaper change. She stated that a CNA brought her lunch at 11:30 AM but refused to assist with the diaper change. At 11:41 AM, the resident was observed in bed stating she had been waiting since 11:00 AM for incontinence care. At 11:43 AM, while the surveyor was present, the resident again activated her call light. CNA 1 entered the room in less than a minute without knocking or announcing her presence, turned off the call light, ignored the resident, checked only on the roommate, and was about to leave the room until the visibly distressed resident requested assistance, stating she would not eat while soiled. CNA 1 told the resident she could not change the diaper because the roommate was eating. In a subsequent interview, CNA 1 stated she had been on lunch break from 10:40 AM to 11:20 AM, believed another staff member had answered the earlier call light, and claimed she had been instructed by the DSD not to provide peri-care if someone in the room was eating, and that the charge nurse had told her she could not do it. The charge nurse denied instructing CNA 1 not to change the resident and stated she had told CNA 1 to pull the privacy curtain and assist with the diaper change. The DSD denied ever instructing staff to delay care due to a roommate eating and stated staff were expected to attend to residents’ needs immediately and use privacy curtains during personal care. Review of the facility’s “Dignity” policy showed requirements that residents be treated with dignity and respect, that staff knock and request permission before entering rooms, promote and protect privacy, and promptly respond to toileting requests. The DON acknowledged that the policy was not followed when staff did not provide necessary personal care and left the resident in a soiled diaper for more than 40 minutes, in violation of facility standards and CMS regulations.
Failure to Provide Hot Water for Resident Showers and Maintain Comfortable Bathing Conditions
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with hot water in their own showers, resulting in an inability to ensure a warm and comfortable bathing experience for multiple residents over an extended period. For one cognitively impaired female resident with a history of stroke, vascular dementia, and total dependence on staff for personal care, record review showed she was scheduled for bathing three times weekly, but there were no showers, baths, or sponge baths documented in her medical record for nearly a month. Her care plan listed showers/baths as not applicable, and a grievance from her family reported no hot water to provide a shower or bath, with no documentation of how this concern was resolved. When water temperatures were tested in her room, the shower measured 94°F and the sink 77°F after running for three minutes. A cognitively intact male resident with paraplegia, type 2 diabetes, and a need for maximal assistance with showering/bathing reported that there had been no hot water in his room for 2–3 weeks. His care plan did not identify his showering/bathing needs. ADL documentation showed a mix of refusals, full body baths, and one shower during the review period. He stated that if staff could not find hot water, he refused showers, and although staff suggested he shower in another resident’s room, he declined because he wanted to shower and change in his own room. He reported accepting sponge baths multiple times when staff could find hot water, but expressed a preference for showers with clean hot water in his own room. Temperature checks in his room showed both the shower and sink at 80°F after running for three minutes. Another cognitively intact male resident with cirrhosis, type 2 diabetes, and a need for assistance with personal care was documented as requiring two staff for bathing/showering and having set-up assistance for showering. ADL records showed frequent showers earlier in the month and a full body bath later, but he reported he was only taking showers once a week because the water was too cold. He stated staff were aware of the cold water, and when he refused showers due to the temperature, staff simply accepted the refusal; he sometimes accepted bed baths because they were warmer, and at other times took cold showers when he could not tolerate going without. Temperature checks in his room showed shower water at 80°F and sink water at 77°F after three minutes. Staff interviews confirmed ongoing hot water problems affecting multiple rooms on one wing, including those of the three residents. The Maintenance Director reported fluctuating water temperatures since the end of December, acknowledged that most rooms on one wing were affected, and stated that all facility management, including the Administrator, were aware of the lack of hot water. CNAs described that some rooms had hot water and some did not, and that they were taking residents without hot water to other residents’ rooms of the same gender or to empty rooms with hot water, if available. They also reported using hot water from the dining room sink or coffee machine for bed or basin baths, and one CNA described filling containers with hot water from another room and pouring them over residents in their own showers to simulate a shower. Staff stated that some residents refused to bathe in other residents’ rooms or refused bed baths when hot water was not available. The DON, who was new to the facility, acknowledged that residents should be showered every other day, that hot water availability varied by room and day, that Resident #1’s family had complained about hot water and showers, and that moving shower locations could be confusing for residents with dementia. The facility’s bath/shower policy required adjusting water to a comfortable temperature before turning the stream toward the resident, which was not consistently achievable due to the lack of hot water in affected rooms.
Failure to Ensure Warm Water for Resident Bathing and Showers
Penalty
Summary
The deficiency involves the facility’s failure to provide residents with warm water for bathing and showers, resulting in cold bed baths and showers for at least two residents. One resident, an older female with fractures of the right tibia and fibula and chronic diastolic heart failure, had an admission MDS showing moderate cognitive impairment and a need for substantial assistance with bathing and total assistance with lower body dressing. Her care plan indicated she required two staff for bathing and that staff could provide a sponge bath when a full bath or shower could not be tolerated. She reported that during a winter storm, when the facility lost power and did not have warm water, she received a cold bed bath because she wanted to feel clean. A social worker reported that the Hall A shower water was cold and stated she discovered this when she stayed in the facility over a winter storm weekend and attempted to take a shower. She said she did not think the facility was aware of the cold water until she tried to shower. On observation, the Hall A shower water was run for approximately three minutes and measured 71°F, never reaching the recommended 100–110°F. The social worker stated that six residents resided on Hall A and were using Hall B and D showers until the water was fixed, without specifying a timeframe for repair. An anonymous resident reported receiving a cold shower because the facility did not have hot water. Multiple staff interviews showed ongoing awareness of hot water problems on Hall A (and at times Hall B) without consistent resolution or documentation. A CNA stated she knew the Hall A shower water was cold for 1–2 months, had reported it to maintenance and the DON, and that no one was taking showers in the Hall A shower room. Housekeeping staff and the housekeeping supervisor reported hearing CNAs complain about cold water, residents refusing showers, and staff having to take residents to other halls or carry hot water from one shower to another. An LVN reported that Hall A did not have hot water on and off, that residents had complained about not having hot water for hot beverages or to sponge off at their sinks, and that residents were taken to other halls for showers. The ADON and DON both stated that staff were expected to report water temperature issues immediately and ensure comfortable water temperatures, and the administrator acknowledged concerns with water not getting as hot as it should. When the area maintenance specialist was interviewed, he stated he was not aware that Hall A water was running cold and noted that the prior maintenance man had been terminated. On testing with the facility’s thermometer, the Hall A shower water measured 98.7°F and the sink water was warm, and he stated that somehow the hot water temperature had been turned down. He presented temperature logs and stated the expected range was 100–110°F, but the last recorded weekly temperature checks were dated more than a month earlier, with no logs documented since. Facility grievance records over a several‑month period did not show any complaints about water temperature. The facility’s resident rights policy required care in a manner and environment that promotes or enhances quality of life, and a facility checklist required weekly testing and logging of hot water temperatures in resident rooms and showers to ensure they remained between 100°F and 110°F, but these checks were not documented as completed during the period when residents and staff reported cold water and residents received cold baths and showers.
Failure to Respond Promptly to Call Lights
Penalty
Summary
The facility failed to ensure prompt response to call lights for two residents, resulting in unmet resident needs. For one resident with multiple complex diagnoses, including cerebral infarction, hypertensive heart disease, anxiety disorder, major depressive disorder, muscle weakness, urinary retention, bowel incontinence, and hemiplegia, both interviews and call light logs confirmed repeated delays in staff response. The resident reported that call lights took a long time to be answered, and direct observation showed a call light remaining on for 15 minutes before staff responded. Review of call light logs revealed multiple instances where the call light was left on for extended periods, ranging from 17 to 54 minutes on various dates. Another resident, diagnosed with Parkinson's disease and assessed as cognitively intact, also reported waiting up to half an hour or more for call light responses. Review of this resident's call light event log showed numerous occasions where the call light remained on for periods ranging from 18 to 46 minutes. Both residents' experiences were corroborated by documentation and interviews, confirming that staff did not meet the facility's stated expectation of responding to call lights within 5 minutes. The facility's policy, last revised in August, requires staff to respond to call lights in a timely manner, with the Executive Director and a Registered Nurse both confirming the expectation of a 5-minute response time. Despite this policy, the documented delays in responding to call lights for these two residents demonstrate a failure to meet the established standard of care.
Failure to Assist Resident with Dentures Prior to Meals
Penalty
Summary
The facility failed to provide necessary assistance with the use of dentures for one resident who was cognitively intact but had significant upper extremity impairment and required substantial or maximal assistance for oral hygiene, including inserting and removing dentures. The resident's care plan identified a self-care performance deficit and risk for decline in activities of daily living due to generalized weakness, carpal tunnel syndrome, and macular degeneration. The nutritional assessment confirmed the resident had dentures. On the morning of the observed incident, the resident was found in bed without dentures and stated that no one had assisted her with them that morning, despite requesting help from staff around 8:30 a.m. The denture cup was observed on the dresser, unused. A CNA who assisted the resident with breakfast reported not noticing the absence of dentures and was unaware the resident had them. The DON confirmed the importance of offering dentures to the resident, acknowledging that without them, the resident would be unable to chew food. The facility's policy required staff to provide appropriate support and assistance with activities of daily living, including dining, for residents unable to perform these tasks independently and in accordance with the care plan.
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