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F0600
G

Resident Subjected to Mental Abuse During Administrator-Led Drug Sting

Pueblo, Colorado Survey Completed on 04-03-2025

Penalty

Fine: $36,569
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from mental abuse and anguish when the nursing home administrator (NHA) orchestrated a drug purchase involving the resident. The resident, who had developmental disabilities, dementia, depression, anxiety, and schizophrenia, was approached by the NHA after staff found a pipe used for methamphetamines in his possession. The NHA asked the resident to participate in a sting operation to identify the source of drugs within the facility, providing him with $20 to purchase methamphetamines from another resident while the NHA observed. The NHA then confiscated the drugs and pipe and notified the police. The resident reported feeling compelled to participate in the drug purchase to prove he was not a drug dealer, and subsequently experienced fear, discomfort, and mental anguish. He expressed concerns about being arrested or discharged from the facility, and reported that staff referred to him as a drug dealer. The resident also stated that he was not informed of the potential consequences of participating in the sting operation, and that he was unhappy with the counseling services provided afterward, as they were not conducted in a private setting and did not address his emotional needs. The facility's own abuse prevention policy required residents to be free from all forms of abuse, including mental abuse, and mandated immediate investigation and support for affected residents. However, there was no documentation of an internal investigation into the incident, and the resident's care plan did not reflect interventions related to the incident. Interviews with staff confirmed awareness of the NHA's actions, but no further investigation or support was documented for the resident involved.

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