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F0603
D

Failure to Prevent Involuntary Seclusion for Resident with Behavioral Symptoms

La Jara, Colorado Survey Completed on 07-24-2025

Penalty

No penalty information released
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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 ensure a resident's right to be free from involuntary seclusion not required to treat medical symptoms. According to record review and staff interviews, a resident with dementia and depressive episodes, who required supervision for activities of daily living and had memory problems, was told by staff to return to her room or was taken to her room as a response to her behaviors. The care plan for this resident did not include interventions involving sending her to her room as a behavioral management strategy. Nursing progress notes documented that the resident was asked to eat lunch in her room due to her behavior in the dining room, which included yelling and taunting other residents, and was told by staff that if she was not nice, she had to go to her room. Staff interviews revealed that an LPN would tell disruptive residents they would be removed from activities or returned to their rooms, making decisions based on the situation. The DON confirmed that the facility did not have a policy allowing staff to send residents to their rooms as a disciplinary action and stated that if residents were redirected, they should be offered alternative activities or interventions rather than being sent to their rooms. The facility's policy emphasized residents' rights to be free from involuntary seclusion and to be treated with dignity and respect.

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