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 facility failed to provide appropriately fitting incontinence briefs for three residents. Two residents were incontinent and one had an indwelling urinary catheter; all three had large body sizes and needed briefs larger than 2 XL, but only 2 XL briefs were available. A resident reported that the briefs were too small and tight and that she had skin shearing on her buttock, while the CNA and Central Supply Director confirmed the size limitation.
Failure to Maintain Comfortable Room Temperatures: Three residents reported hot, uncomfortable rooms, with one stating the HVAC was not working and another saying the heat made her sweaty and less energetic. CNA staff also heard complaints about the rooms being hot. The RMD measured the affected rooms at 80.9 degrees F and 81.3 degrees F, while other rooms were in the low-to-mid 70s, and stated the HVAC was not cooling those rooms properly. The DON acknowledged that some rooms were not being cooled adequately.
A resident with PTSD, depression, and anxiety was placed in a room arrangement that required sharing a bathroom with male residents. After a naked male resident entered her room through the shared bathroom, she called police, stated she felt terrified and unsafe, and told staff she had a history of sexual assault. Staff confirmed the bathroom was shared with male residents and that the arrangement was not supposed to occur.
A resident with stroke-related left-sided weakness, hemiplegia, and dependence for transfers and toileting was moved into a remodeled room before the bathroom was ready. Staff took the resident to larger bathrooms on the hall because the room bathroom lacked a grab bar, and the resident reported embarrassment, difficulty with diarrhea, and an accident while waiting for assistance. Interviews showed the DON, Administrator, and Maintenance Director were not aware the room was not fully prepared when the resident moved in.
Delayed Provision of Bed Side Rails: A cognitively intact resident with Parkinson's disease, restless leg syndrome, rheumatoid arthritis, and chronic pain requested bed side rails to help with bed mobility and repositioning. Therapy documented that the resident would lay in bed if rails were available, but the request was not communicated or acted on promptly, and the bed did not have side rails when observed. Staff later stated side rails are usually installed the same day a request is made, and the DON acknowledged the delay should not have taken so long.
A resident who was cognitively intact activated a call light during breakfast to request assistance with toileting and reported waiting approximately 1.5 to 2 hours before staff responded. Facility call light records confirmed the call was activated and not answered for over two hours. Staff interviews indicated that management had communicated expectations that call lights be answered within about 15–20 minutes, but this expectation was not met in this instance, resulting in a prolonged delay in meeting the resident’s expressed need for assistance.
Incontinence Products Not Available in Appropriate Sizes
Penalty
Summary
The facility failed to ensure that residents were provided appropriately fitting incontinence products for three residents. Resident 1 was cognitively intact, dependent on two staff for daily care needs including toileting, frequently incontinent of urine, and weighed 414 pounds. Her care plan noted that she had an indwelling urinary catheter. During interview, she stated that she had skin shearing on her buttock because the briefs she was made to wear were too small and too tight, and that she had not had the proper sized briefs since the facility changed owners. She reported being required to wear a size 2 XL brief even though she needed at least a 4 XL brief. Resident 4 was cognitively impaired, incontinent of urine and bowel, and weighed 247 pounds; observation showed her sitting in a wheelchair with a large rotund abdomen. Resident 11 was cognitively intact, required staff assistance with activities of daily living, weighed 250 pounds, and had an indwelling urinary catheter; observation showed her sitting up in bed with a large rotund abdomen. A nurse aide confirmed that Residents 1, 4, and 11 all required briefs larger than size 2 XL, but those sizes were not available. The Central Supply Director and Nursing Home Administrator confirmed that the largest brief size the corporate office would permit to be purchased was 2 XL.
Failure to Maintain Comfortable Room Temperatures
Penalty
Summary
The facility failed to ensure resident rooms were maintained at a comfortable temperature for three sampled residents. Resident 1 was admitted with ESRD requiring dialysis, type 2 DM, and cellulitis of both legs, and had intact cognitive skills for daily decision making. Resident 2 was admitted with heart failure and dementia and had moderately impaired cognitive skills for daily decision making. Resident 3 was admitted with a stage four pressure ulcer of the sacrum, DM, and generalized muscle weakness, and the MDS was not yet fully completed. During interviews, CNA 1 stated that Resident 1, Resident 2, and Resident 3 had complained that their rooms were hot. Resident 3 stated her room felt hot and very uncomfortable, that she got sweaty in bed, and that she felt like the facility did not care about her. Resident 2 stated her room felt hot and very uncomfortable, that it made her feel less energy and sweaty. Resident 1 stated the HVAC was not working, that her room was hot and very uncomfortable, that she felt helpless because she could not do anything about it even though she had reported it to the facility, and that she could not sleep well sometimes because the room was hot. On observation, the Regional Maintenance Director measured Resident 1 and Resident 2's room at 80.9 degrees F and Resident 3's room at 81.3 degrees F, while other rooms measured 74.6 degrees F and 73 degrees F. The RMD stated the affected rooms were hotter than other rooms and that the HVAC was not in proper working condition since it was only properly cooling some rooms. The facility policies reviewed stated maintenance service includes maintaining the heat/cooling system, that staff provide a comfortable temperature in a homelike environment, and that the facility must care for residents in a manner and environment that promotes maintenance or enhancement of quality of life. The DON stated some rooms were not being cooled adequately.
Failure to Protect Resident With PTSD From Shared Bathroom Arrangement With Male Residents
Penalty
Summary
The facility failed to provide the necessary care to maintain the psychosocial well-being of one resident with diagnoses including depression, anxiety disorder, and PTSD when she was placed in a room arrangement that required her to share a bathroom with male residents. The resident had a BIMS score of 15 and was cognitively intact. On 5/19/2026, she called the police after a naked person entered her room, and the police requested that the resident who entered her room be moved to another room to prevent further incidents. During interview, the resident stated that around 4:00 a.m. on 5/19/2026 she woke up and found a naked man standing in front of her bathroom door and facing her at the end of her bed. She stated she was terrified, unable to move, thought she would be killed, and cried during the interview while describing that she had been abducted by two men and sexually assaulted in the past. She stated she did not feel safe at the facility after the incident. Staff interviews confirmed the bathroom was shared with male residents, that the resident was not supposed to share the bathroom with male residents, and that the resident's PTSD and history of domestic violence were known to social services. The facility policy stated that resident needs and preferences shall be accommodated, including adaptations to the bedroom and bathroom.
Resident Moved to Room Before Bathroom Was Ready
Penalty
Summary
The facility failed to ensure the resident received care that allowed him/her to achieve the highest practicable well-being when the resident was moved into a remodeled room before the bathroom was fully ready for use. The resident had a history of stroke with left-sided flaccidity, hemiplegia, hemiparesis, diabetes, high blood pressure, a prior fall with fractured pelvis and brain bleed, and required substantial to maximum assistance with dressing, hygiene, transfers, and toileting. The care plan directed staff to follow OT/PT/ST recommendations, use a sling on the left arm before transfers, and provide one or two staff assistance for transfers and toileting, with the resident preferring the bedside commode or bedpan. After the room move, the resident could not use the bathroom in his/her room because a grab bar had not been installed and staff were taking the resident to the larger bathrooms on the 100 or 200 halls to toilet. The resident reported that this was especially difficult when having diarrhea, that he/she had waited for staff and had an accident, and that it was embarrassing not to be able to clean up after toileting. Observation showed a bedpan in a plastic bag on the floor in the room bathroom, tools in the bathroom, and no bedside commode in the bathroom. The resident stated no one had told him/her when the bathroom would be fixed. Interviews showed staff were not aware the bathroom was not ready when the resident was moved. The DON said the room was normally made completely ready before a resident moved in and was not aware the grab bar had not been installed. The Maintenance Director gave conflicting information about when the grab bar was requested and said it had not yet been installed. Multiple staff members stated they were taking the resident to the larger bathrooms because the resident’s room bathroom lacked a grab bar or was not usable, and several were unaware of the issue until that week. The DON and Administrator stated they were not aware the room was not ready and said they would not have moved the resident if they had known.
Delayed Provision of Bed Side Rails
Penalty
Summary
The facility did not ensure that R25 received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial wellbeing when requested side rails for bed mobility were not provided in a timely manner. R25 was admitted with diagnoses including Parkinson's disease, restless leg syndrome, rheumatoid arthritis, and chronic pain, and his BIMS score of 15 indicated he was cognitively intact. During interview, R25 stated he had asked for side rails to help him get into bed, reposition himself, and move around in bed, and he reported he could not get into bed without them. Survey observation confirmed that his bed did not have side rails at that time. Record review showed the PT discharge summary documented that R25 reported he would lay in bed if he had bed rails to assist him with rolling and scooting. Therapy staff stated they had requested side rails from maintenance on 4/27/26 so R25 could have increased independence with bed mobility and had also discussed the need with nursing. However, maintenance staff reported they were unaware of the request, and environmental services stated she was only notified on 5/6/26 and then transferred a bed with side rails into R25's room. Nursing leadership acknowledged that once a request is made, side rails are usually installed the same day and stated R25's side rails should have been addressed sooner.
Failure to Respond Timely to Resident Call Light for Toileting Assistance
Penalty
Summary
Facility staff failed to respond to a cognitively intact resident’s call light within a reasonable time, resulting in a documented delay of over two hours. The resident, who had been admitted earlier in the month, reported that during breakfast he activated his call light to request assistance with toileting and waited approximately 1.5 to 2 hours before staff responded. Facility records from the call light system on the same date showed the call light was activated at 6:22 AM and not answered until 2 hours and 23 minutes later. During interviews, a CNA stated that management had communicated an expectation that call lights be answered in about 15 minutes, and the Administrator stated that staff had been told they should ideally answer call lights within 20 minutes of activation. The facility’s failure to respond to the resident’s call light in a timely manner was cited under WAC 388-97-1060(1) for not honoring resident preferences, choices, values, and beliefs, and placed residents at risk of unmet care needs and diminished quality of life.
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