Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Colorow Care Center during CMS and state inspections, most recent first.
Unsafe Hand Hygiene Practices During Meal Service: Surveyors observed multiple kitchen staff handling ready-to-eat foods, plates, utensils, thermometers, and meal trays without proper hand hygiene before gloving, after touching their face or clothing, and after contact with contaminated surfaces. A cook picked up a resident diet card from the floor and placed it on a meal tray, while a dietary aide handled food and plates with gloved hands and without washing hands. Record review showed one dietary aide did not attend the hand hygiene in-service.
The facility failed to resolve multiple resident grievances in a timely and acceptable manner. Residents and a resident council reported long call light wait times, including delays overnight and during shift change, and the concerns remained unresolved despite staff discussions and documentation. Two other residents had grievances about missing money and personal items, but the investigations were incomplete or lacked follow-up with the resident or representative.
Infection control failures were observed during housekeeping and med pass activities. A housekeeper cleaned resident room toilets and moved between tasks without proper hand hygiene, handled trash and then continued cleaning, and did not allow disinfectant to remain on toilet surfaces. An RN picked up a dropped tablet from the floor with bare hands and continued med administration without hand hygiene. The facility also had multiple heavily soiled sink drains and buildup in common area, staff, therapy, and resident room sinks, and its water management plan did not document steps for other opportunistic pathogens.
A resident with severe dementia, hallucinations, delusions, and chronic pain, who was independent with mobility and at risk for wandering, was struck in the face by another cognitively impaired resident known to exhibit verbal and physical aggression and to be highly protective of her room. An RN heard a commotion, saw the victim outside the aggressor’s room, and attempted to intervene but witnessed the aggressor hit the victim before reaching them, resulting in a lip laceration and bruise. The aggressor’s care plan noted use of a doorway stop sign or closed door and the need to redirect others away from her room, but she often refused these measures. At the time of the incident, only one CNA and one nurse were on the memory care unit due to an unfilled CNA call-in, and staff reported it was difficult to manage when two CNAs were not present. The facility investigation substantiated the event as abuse and identified that both residents may have had increased pain contributing to agitation before the altercation.
Failure to Provide Written Notice of Room and Roommate Changes: A resident with cognitive impairment, chronic respiratory failure, adult failure to thrive, and stroke history was moved multiple times, but the facility did not document that she or her representative received written notice of the room or roommate changes. The resident said she was not given verbal or written notice before the moves, and the record only showed verbal consent from representatives for maintenance-related room changes.
A resident with paraplegia, muscle weakness, chronic pain syndrome, and other diagnoses had an order for an alternating pressure mattress set at 150 pounds of pressure and checked every shift. Surveyors found the mattress repeatedly set at 350 pounds of pressure while nurses signed the TAR as if it were correctly set and functioning. Staff were unsure of the ordered setting, relied on maintenance or a DME vendor, and the resident reported discomfort and a recent mattress failure that left her on the metal frame.
A resident with cognitive impairment and agitation struck another resident following an episode of verbal agitation and intrusion into personal space. Staff were not present to witness the incident, and both residents had known behavioral triggers that were not fully addressed in their care plans. The event occurred without injuries, but the lack of supervision and incomplete care planning led to a failure to prevent physical abuse.
Multiple residents with severe cognitive and behavioral impairments were subjected to physical abuse by another resident with a history of unpredictable and escalating aggression. Despite individualized care plans and staff interventions, repeated altercations occurred in common areas, resulting in physical harm such as bruises and a skin tear. Staff and facility investigations confirmed the incidents, citing environmental overstimulation and challenges in redirecting the aggressive resident as contributing factors.
A resident was subjected to physical restraints without a documented medical necessity, in violation of regulations requiring that restraints only be used for medical treatment.
Multiple residents with cognitive impairments and behavioral issues were involved in repeated physical altercations, including pushing, slapping, and falls, with staff and other residents witnessing the events. Care plans did not consistently identify abuse risk or include timely interventions, and measures such as frequent checks did not prevent further incidents. Injuries and behavioral triggers were not always clearly documented or addressed, resulting in ongoing resident-to-resident abuse.
A resident with severe dementia and multiple care needs was found to have bruising and discoloration on her arms, which was documented by nursing staff on two occasions. Despite facility policy requiring immediate reporting and investigation of injuries of unknown origin, there was no evidence that the cause of the bruising was investigated or that abuse was ruled out. The NHA and DON were unaware of the injuries until after the fact, and no timely action was taken to determine how the injuries occurred.
A resident was hospitalized after being administered another resident's medications, including pregabalin and metoprolol, leading to cardiac dysrhythmia, hypotension, and bradycardia. The error occurred due to a failure in adhering to medication administration standards.
The facility failed to store, prepare, distribute, and serve food in a sanitary manner, including improper labeling of food items, incorrect cleaning of thermometers, and failure to maintain appropriate temperatures in refrigerators and freezers. Cold foods were not held at 41°F or below before serving residents.
The facility failed to address grievances regarding call light response times, leading to significant delays in care. Despite consistent complaints from residents over several months, the facility did not document or implement effective interventions. Staff interviews revealed a lack of proper follow-up and accountability in the grievance process.
The facility failed to protect three residents from physical abuse by another resident with severe cognitive impairment and behavioral disturbances. Incidents included slapping and hitting, which were not prevented despite existing care plans and interventions.
The facility failed to provide an environment free from accident hazards and ensure residents received adequate supervision and assistance to prevent accidents for two residents. One resident did not have a timely baseline fall care plan, and another experienced multiple falls due to inadequate fall interventions and lack of anti-tip brakes on her wheelchair.
The facility failed to maintain the emergency response equipment in safe operating condition, including an unsecured oxygen cylinder and expired medical supplies on the emergency response cart. The RN was not trained on the use of the oxygen cylinder, and the facility lacked a comprehensive policy and checklist for the emergency response cart.
Unsafe Hand Hygiene Practices During Meal Service
Penalty
Summary
The facility failed to ensure food was stored, prepared, distributed, and served under sanitary conditions in the main kitchen during lunch meal service. Surveyors observed multiple instances of staff not performing hand hygiene before donning gloves, after touching contaminated surfaces, and after touching their face, clothing, or other potentially contaminated items while preparing resident meals and handling food items. During the observation, the dietary manager assembled chef salads without performing hand hygiene before putting on gloves, then later handled an onion bag and the walk-in refrigerator door handle without first cleaning her hands after removing a glove from the floor. A dietary aide placed gloves on without hand hygiene, touched her pants and apron pockets, used a thermometer on food, touched her nose and glasses, and handled plates and food items without washing her hands. Another dietary aide sniffed and touched her nose, then retrieved adaptive equipment plates and handled food items and supplies without hand hygiene. The cook touched the eating surfaces of plates while plating ready-to-eat food, picked up a resident diet card from the floor and placed it on a meal tray without wiping it down, and continued plating food without washing her hands. The dietary aide preparing a grilled cheese sandwich touched the food with her gloved hand, removed the sandwich from the pan, placed it on a plate, and cut it while holding it steady with her gloved fingers. Record review showed one dietary aide did not attend the hand hygiene in-service, and staff interviews confirmed that hand hygiene was expected after task changes, after touching contaminated items, and after picking something up from the floor.
Unresolved resident grievances for call light delays and missing belongings
Penalty
Summary
The facility failed to ensure that resident grievances were resolved in an acceptable and timely manner for four of five residents reviewed for grievances. The grievance policy stated that grievances were to be responded to promptly and in writing, and that the grievance investigation report was to be filed with the administrator within five working days of receipt. Survey review found unresolved concerns involving long call light wait times and missing personal belongings. Resident #67, who had COPD, diabetes with neuropathy, CHF, chronic respiratory failure, and moderate cognitive impairment, reported that call lights were not being answered in a timely manner, especially after 6:00 p.m. and during shift change. The grievance record showed the resident complained that long call light waits were occurring and that no one showed up for work. Although the facility documented review of call light times and discussed the concern with the resident, the resident later told surveyors that the long wait times continued and nothing had changed. Resident #26, who had diabetes with circulatory complications, morbid obesity, CHF, depression, and intact cognition, reported that she was vomiting overnight, had only one RN on the hall, remained soaked for hours, and activated her call light without getting help. The grievance record showed a call light remained on for longer than 48 minutes, but the documented investigation did not address the allegation that she was left soaking wet for three hours after requesting assistance. The resident council also filed a grievance about long call light wait times during the night, and the form indicated the concern was not resolved. Staff interviews confirmed that call light delays were an ongoing issue discussed in meetings and that night shift staffing could be difficult. In addition, missing belongings grievances were not resolved for two residents. Resident #39, who had a stroke, Parkinson’s disease, hypertension, severe cognitive impairment, and required maximum ADL assistance, had a representative report missing money and said the DON promised answers within a week, but no follow-up was received. Resident #62, who had adult failure to thrive, chronic respiratory failure, cerebral infarction, moderate cognitive impairment, and required substantial to maximal assistance with all ADLs, had grievances for a missing blanket, microphone, clothes, and checks; the record showed the concerns were reported, but the outcome of the investigations was not completed, and the social services assistant was not aware of completed follow-up for the missing checks.
Infection Control Failures During Housekeeping, Medication Administration, and Sink Maintenance
Penalty
Summary
The facility failed to follow infection control measures during housekeeping activities and medication administration. During observation, housekeeper #1 cleaned resident rooms without performing hand hygiene between tasks, entered and exited rooms without cleaning his hands, handled trash from a resident bathroom without hand hygiene, and later blew his nose with gloved hands before touching a door handle and leaving the room. He also cleaned toilets in resident rooms by spraying and immediately wiping the surfaces with a sponge and rag, without allowing the disinfectant to remain on the toilet surface, and he cleaned the toilet from a dirtier area to a cleaner area rather than in the sequence described in the facility policy. During medication administration, RN #1 dropped a medication tablet onto the floor, picked it up with bare hands, placed it in medication destruction solution, and then continued dispensing another medication tablet without performing hand hygiene. The DON stated that hand hygiene should have been performed after picking up the tablet from the floor and before continuing with medication administration. The facility also had heavily soiled sink drains and buildup in multiple sinks and drains throughout the building, including common area sinks, a staff bathroom sink, a food preparation area sink, a rehabilitation therapy room sink, a nurses cart area sink, and resident room sinks. Observations described black sludge, brown debris, tarry buildup, green chalky buildup, slow drainage, and food waste in and around drains. The facility’s water management plan was provided as a plan to reduce Legionella and other opportunistic pathogens, but it did not document steps to prevent the development of other opportunistic pathogens in the water system. Staff interviews indicated that sinks in resident rooms and common areas were supposed to be cleaned daily, but the maintenance director said he did not have a clear explanation of how and who cleaned several of the sinks and drains observed to be soiled.
Failure to Prevent Resident-to-Resident Physical Abuse on Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident from physical abuse by another resident. On the date of the incident, an RN heard a commotion in the hallway outside the alleged assailant’s room and observed that resident strike another resident, causing the victim’s lip to bleed. The RN had seen both residents near the medication cart a few minutes earlier without concern and attempted to intervene when she saw the victim standing outside the assailant’s room, but was unable to reach them before the strike occurred. The two residents were then separated, and frequent checks were initiated. The victim was a younger-than-65 resident with vascular dementia (severe, with agitation), Alzheimer’s disease, Lewy body disease, bipolar disorder, and chronic pain. Her MDS showed short- and long-term memory problems, hallucinations, delusions, and physical and verbal behaviors toward others, with moderately impaired cognition and impaired decision-making. She was independent with mobility and had a care plan for wandering and dementia that identified her as pleasantly confused and easily redirected, with interventions to identify wandering patterns, offer diversions, and assess for pain or toileting needs when agitated. Documentation on the day of the incident noted her involvement in a resident-to-resident altercation, a small laceration to the middle of her upper lip, and a small bruise below her lower lip. The assailant was an older resident with severe vascular dementia with agitation, memory deficit after intracranial hemorrhage, and recurrent depressive disorder. Her MDS documented short- and long-term memory problems, fluctuating disorganized thinking, and verbal behaviors directed toward others that could significantly intrude on others’ privacy or disrupt the environment. Her behavior/dementia care plan identified verbal aggression (yelling/screaming), physical aggression (hitting), refusal of care, withdrawal, tearfulness, and negative statements, and noted that she was protective of her room and became upset if others entered or tried to enter. The care plan included use of a velcro stop sign across her doorway or keeping her door closed, but also documented that she often declined having the door closed, requiring staff to redirect other residents away from her room. Staff statements indicated that at the time of the incident there was one CNA and one nurse on the memory care unit, that one CNA had called in and was not replaced, and that it was hard when there were not two CNAs on the unit. The facility’s investigation substantiated the incident as abuse and identified that both residents may have been experiencing increased pain leading up to the altercation, with pain, constipation, and urinary retention noted as contributing factors for the victim and hand contracture pain and refusal of interventions noted for the assailant.
Failure to Provide Written Notice of Room and Roommate Changes
Penalty
Summary
The facility failed to provide written notification of room changes and roommate changes for one resident reviewed for notifications. The resident had diagnoses including adult failure to thrive, chronic respiratory failure, and cerebral infarction, and a prior MDS assessment showed moderate cognitive impairment with a BIMS score of 8 out of 15. The resident required substantial maximal assistance from staff for all ADLs. The resident stated she had moved rooms three or four times and was upset because she had missing items after the room changes. She said she was not given anything in writing or any verbal notice before the room changes. The EMR contained alert notes showing the resident was on alert charting for a room change and had adjusted well, but also noted possible difficulty with the room change when a roommate complained the resident was yelling and belligerent. The record included Room and/or Roommate Change Authorization Notification forms for room moves related to maintenance concerns, with verbal consent documented from the resident's representatives and signatures from the SSD. However, there was no documentation in the EMR showing the resident or her representative received a copy of the room change forms. The SSD and NHA stated residents and representatives were informed and provided copies, but they had no documentation to show the resident was informed of the moves.
Failure to Follow Ordered Air Mattress Settings
Penalty
Summary
The facility failed to ensure nursing staff followed a physician’s order for Resident #61’s alternating pressure mattress. The resident, who was over age 65, had diagnoses including paraplegia, West Nile infection, muscle weakness, acute respiratory failure, and chronic pain syndrome. The 2/5/26 MDS showed the resident was cognitively intact with a BIMS score of 15 and dependent on staff for all care. The physician’s order directed that the alternating pressure mattress be set at 150 pounds of pressure and checked every shift for proper setting and function. During observations, the resident’s air mattress was found set at 350 pounds of pressure on 4/27/26, 4/28/26, and 4/29/26, despite the order for 150 pounds of pressure. The resident stated the mattress was intended to prevent pressure sores and reported discomfort when the head of the bed was elevated. She also reported that the mattress had recently failed and deflated, leaving her on the metal frame until maintenance repaired and reinflated it. On 4/30/26, the mattress was observed set at 150 pounds of pressure, and the pump was labeled with the ordered setting and directions not to change it. The TAR showed nurses signed off each shift that the mattress was on the proper setting and functioning properly from 4/1/26 through 4/29/26, but survey observations showed the setting was incorrect. RN #3 said she was not sure of the correct setting and relied on maintenance. The MTD said an outside DME vendor installed and set up the mattresses, and he was unsure how staff could tell what the air flow should be set to. RN #4 said the mattress setting was based on the resident’s weight and was unsure whether there were physician’s orders. The MTD later stated the pump was not working properly and had been replaced, and the DON said the facility was educating staff to monitor mattress settings and report failures.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. On the date of the incident, a maintenance assistant witnessed one resident lightly hitting another on the cheek after an exchange involving incomprehensible speech and agitation. The maintenance assistant intervened by separating the residents and notifying nursing staff. No injuries were observed on the resident who was struck, and there was no notable change in her baseline mood or cognition following the event. Prior to the incident, both residents involved had documented histories of cognitive impairment and behavioral issues. The resident who initiated the physical contact had diagnoses including Alzheimer's disease, dementia, and agitation, and was known to become irritated when others entered her personal space or when exposed to noise. She also had a history of pain and agitation related to ingrown toenails, which was not addressed prior to the incident due to her inability to consistently verbalize discomfort. The other resident had severe dementia with mood disturbance, exhibited wandering and intrusive behaviors, and was known to disrupt other residents' privacy or activities. Staff interviews revealed that both residents were known to have interactions that could lead to agitation, with one being intrusive and the other sensitive to personal space. Staff attempted to monitor and redirect both residents but did not provide extra supervision or specific interventions to prevent such altercations. At the time of the incident, staff were not present to witness the event, and there was a lack of clear documentation or awareness of the residents' whereabouts immediately prior to the altercation. The care plans for both residents did not fully address the specific triggers or risks associated with their behaviors, contributing to the failure to prevent the abusive incident.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse, resulting in several substantiated incidents involving resident-to-resident altercations. Four residents were directly affected, with repeated episodes of physical aggression primarily involving one resident with a history of severe cognitive impairment, aggressive behaviors, and complex psychiatric diagnoses. This resident exhibited unpredictable and escalating behaviors, including yelling, hitting, pushing, and slapping other residents, as well as self-injurious actions such as hitting herself and pulling her own hair. The care plans for this resident identified a history of trauma, severe dementia, and behavioral disturbances, with interventions in place for both pharmacological and non-pharmacological management. Despite these interventions, the resident continued to engage in aggressive acts toward others, including dumping water, slapping, pushing, and grabbing, which resulted in physical harm to other residents, such as bruises and a skin tear. Other residents involved in these incidents also had significant cognitive impairments and behavioral symptoms, with care plans outlining interventions for managing aggression and agitation. In several cases, altercations occurred in common areas under staff supervision, but staff were unable to prevent or effectively de-escalate the situations before physical contact occurred. The facility's own investigations substantiated the allegations of abuse, documenting that the aggressive resident was the primary assailant in multiple incidents. Environmental factors, such as overstimulation in the memory care unit and busy periods after meals, were identified as contributing to the escalation of aggressive behaviors. Staff interviews confirmed the unpredictability of the aggressive resident's actions and the challenges in redirecting her, even with individualized interventions and education provided to staff. The facility's abuse policy emphasized the importance of providing a safe environment and preventing abuse by anyone, including other residents. However, the repeated incidents of physical abuse, the inability to prevent resident-to-resident altercations, and the failure to consistently implement effective interventions led to multiple residents being subjected to physical harm. The documentation and interviews revealed that staff were aware of the risks and had attempted various strategies, but these were not sufficient to prevent the substantiated episodes of abuse.
Improper Use of Physical Restraints
Penalty
Summary
A deficiency was identified regarding the use of physical restraints on residents. The report notes that residents were not consistently free from the use of physical restraints, except when required for medical treatment. This indicates that physical restraints were used in situations where they were not medically necessary, contrary to regulatory requirements.
Failure to Prevent Resident-to-Resident Physical Abuse
Penalty
Summary
The facility failed to protect multiple residents from physical abuse by other residents, resulting in several resident-to-resident altercations involving four out of six sampled residents. Incidents included one resident being pushed and slapped by another, a resident being pushed to the floor after a dispute over a shoe, and repeated altercations between two residents who both exhibited cognitive impairments and behavioral disturbances. In each case, the residents involved were either unable to recall the incidents due to cognitive deficits or were non-verbal, and staff or other residents witnessed the altercations. The care plans for the residents involved did not consistently identify them as being at risk for abuse or as having been victims of physical abuse, even after multiple incidents had occurred. Updates to care plans and the implementation of new interventions were delayed, with some changes not made until after several additional altercations had taken place. For example, one resident's care plan was not updated to reflect her risk for abuse or to include new interventions until after she had been involved in three more altercations following the initial incident. Despite the facility's policy stating a commitment to preventing abuse and providing a safe environment, the measures in place, such as 15-minute checks and staff education, did not prevent further incidents. The documentation also revealed that some injuries, such as bruising, were not clearly accounted for in the medical record, and the interventions implemented did not effectively reduce the frequency of resident-to-resident abuse. The facility's failure to promptly and adequately address the risk factors and behavioral triggers for these residents contributed to ongoing physical altercations and a lack of protection from abuse.
Failure to Investigate Injuries of Unknown Origin
Penalty
Summary
The facility failed to investigate an allegation of abuse and neglect for one resident out of a sample of six, specifically not completing thorough and timely investigations when the resident sustained injuries of unknown origin. According to the facility's abuse policy, any suspicion of abuse, neglect, or injury of unknown source must be reported immediately and investigated, including interviews with relevant staff, residents, or family members. However, documentation showed that bruising and discoloration on the resident's forearms were noted in nursing records, but there was no evidence that these injuries were investigated or that their origin was determined. The resident involved was over 65 years old, diagnosed with Alzheimer's disease with late onset, severe dementia with agitation, lack of coordination, and anxiety disorder. The resident required staff assistance with most activities of daily living and had care plans in place for dementia, ADL support, and skin care, which directed staff to observe and report any skin changes such as bruises or cuts. Despite these directives, nursing documentation on two separate occasions identified bruising and discoloration on the resident's arms, but there was no follow-up to determine the cause or to rule out abuse, as required by facility policy. Interviews with the NHA and DON revealed that they were unaware of the documented bruising and that no investigation had been initiated at the time the injuries were first observed. The NHA acknowledged that bruises and injuries of unknown origin should have been investigated and that she should have been notified to start an investigation. The lack of documentation and investigation into the origin of the bruising constituted a failure to respond appropriately to alleged violations, as required by the facility's own policies.
Resident Hospitalized Due to Medication Error
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors, resulting in the administration of another resident's medications. This incident involved a resident who was cognitively intact and required partial assistance with self-care. The resident was mistakenly given 200 mg of pregabalin and 25 mg of metoprolol, which were not prescribed to her. As a result of this error, the resident experienced nausea and was sent to the hospital for monitoring. The hospital records indicated that the resident suffered from cardiac dysrhythmia, hypotension, and bradycardia following the medication error. The nursing home administrator confirmed that the nurse responsible for the error resigned after the incident. The report highlights that the facility did not adhere to the professional standards of medication administration, which include verifying the right patient and medication, among other checks, to prevent such errors.
Food Storage and Temperature Control Deficiencies
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen and two kitchenettes. Specifically, dented canned foods were found stored in the pantry, and food items were not labeled with use-by dates. Large plastic containers were observed with dates that were not specified as being an opening date or a use-by date, and some containers were not labeled as to what the item was inside. Additionally, a prepared container of food in the walk-in cooler was not labeled or dated. The dietary manager was unaware of these issues and acknowledged the need to address the labeling system to ensure clarity and compliance with regulations. The facility also failed to appropriately clean thermometers before obtaining temperatures from ready-to-eat foods. A dietary aide was observed using alcohol wipes incorrectly to clean the thermometer probe, by poking the thermometer through the middle of the wipe without fully opening it. This improper cleaning method was repeated multiple times during lunch service. The dietary manager demonstrated the correct method of cleaning the thermometer but was unaware that the dietary aide was not following the proper procedure. Furthermore, the facility did not maintain appropriate temperatures in kitchen refrigerators and freezers. Several thermometers were missing or broken, and the digital thermometer in the walk-in cooler was not displaying the temperature. Additionally, cold foods were not held at 41 degrees Fahrenheit or below before serving residents. Individual bowls of fresh mixed fruit were observed sitting on the counter without being on ice, and the temperature of the fruit was found to be 63.6 degrees Fahrenheit after lunch service. The dietary manager admitted that maintaining the correct temperature of meals had been a continuous issue and did not check the temperature of the fruit during or after lunch service.
Failure to Address Resident Grievances on Call Light Response Times
Penalty
Summary
The facility failed to address and act promptly upon grievances and recommendations raised during resident council meetings, specifically regarding call light response times. Residents reported waiting up to 45 minutes for assistance, leading to accidents and significant delays in receiving care. Despite these concerns being raised consistently from December 2023 through March 2024, the facility did not document or implement effective interventions to resolve the issue. The resident council minutes repeatedly noted the unresolved nature of the grievances, and there was no evidence of a completed grievance form for these concerns. Interviews with staff revealed that the grievance process was not being followed correctly. The Social Services Director (SSD) acknowledged that grievances were not being followed up on or resolved by the responsible departments. The Nursing Home Administrator (NHA) admitted to not reviewing resident council minutes regularly and identified a lack of accountability and understanding among new management team members regarding the importance of addressing grievances timely and accurately. The NHA also noted that the grievance system needed to be revamped to ensure proper follow-up and resolution. The facility's policy required grievances to be investigated and resolved within specific timeframes, but this was not adhered to. The SSD and NHA recognized the deficiencies in the grievance process and the need for improved oversight. Despite a staff in-service on call light times, residents continued to report unresolved issues, indicating that the interventions were ineffective. The facility's failure to address these grievances promptly and adequately resulted in ongoing dissatisfaction and unmet care needs among residents.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to ensure that three residents were free from abuse, specifically physical resident-to-resident altercations involving Resident #42. On one occasion, Resident #42 slapped Resident #23 in the face after attempting to take her hat while she was sleeping on a couch in the common area. This incident was witnessed by a CNA who intervened but not before the altercation occurred. Resident #42 had refused her medications throughout the day and was agitated at the time of the incident. Both residents were assessed and found to have no injuries, and neither recalled the incident afterward. Resident #42 had a history of behavioral disturbances, including physical and verbal aggression, and was on a care plan that included frequent checks and pain management interventions, which were not effectively implemented to prevent the altercation. In another incident, Resident #42 smacked Resident #36 on the back of the head with an open palm while she was participating in a group activity. This incident was also witnessed by staff, and no injuries were reported. Resident #42 was agitated and pacing before the incident, and attempts to redirect her were ineffective. The resident was later administered her medication, which helped to calm her down. Resident #42 had a history of severe cognitive impairment, behavioral disturbances, and chronic pain, which were identified as potential contributing factors to her aggressive behavior. The care plan for Resident #42 included monitoring for pain and constipation, as well as providing one-on-one support and redirecting her to less stimulating environments, but these measures were not sufficient to prevent the altercation. The facility's failure to effectively implement and monitor the care plans for Resident #42, including ensuring she received her medications and addressing her pain and behavioral needs, led to the physical altercations with Residents #23 and #36. The staff's inability to anticipate and manage Resident #42's needs and behaviors resulted in a failure to protect the residents from abuse, as required by the facility's abuse policy. The incidents highlight deficiencies in the facility's ability to provide a safe environment for its residents, particularly those with severe cognitive impairments and behavioral disturbances.
Failure to Implement Effective Fall Interventions
Penalty
Summary
The facility failed to provide an environment free from accident hazards and ensure residents received adequate supervision and assistance to prevent accidents for two residents. Resident #52, who was assessed to be at high risk for falls upon admission, did not have a baseline fall care plan implemented in a timely manner. Following a fall from his recliner, the facility did not implement appropriate fall interventions to prevent future falls from the recliner. Despite being identified as a high fall risk, the facility failed to include specific interventions related to the recliner in Resident #52's care plan. Resident #50, who had a history of falls and severe cognitive impairment, experienced multiple falls due to inadequate fall interventions. The resident's wheelchair did not have anti-tip brakes, which contributed to her falls. Observations revealed that the resident frequently attempted to stand from her wheelchair, and staff did not consistently implement interventions to prevent falls. The facility's care plan for Resident #50 did not include timely and effective fall interventions, and staff were not consistently implementing the interventions that were in place. Interviews with facility staff, including the DON, ADON, and clinical consultant, revealed gaps in the implementation and updating of fall care plans. The ADON was unable to provide a baseline care plan for Resident #52, and the DON acknowledged that interventions to prevent falls from the recliner were not included in the care plan. For Resident #50, the lack of anti-tip brakes on her wheelchair and the failure to update the care plan with effective interventions were identified as contributing factors to her repeated falls. Staff interviews indicated a need for better education and adherence to fall management policies to ensure resident safety.
Emergency Response Equipment Deficiency
Penalty
Summary
The facility failed to maintain the emergency response equipment in safe operating condition for one of two emergency response carts. Specifically, the oxygen cylinder on the south emergency response cart was not secured properly and was observed hanging loosely by the oxygen regulator. The registered nurse (RN) responsible for the cart was not familiar with the cylinder, had not been trained on its use, and was unable to verify the oxygen level. The daily checklist for the emergency cart did not include the requirement to inspect and check the oxygen cylinder, and the RN indicated that in an emergency, she would rely on oxygen supplies from resident rooms or assistance from city emergency response teams. Additionally, the facility failed to remove expired medical supplies from the emergency response cart. During an inspection, a plastic pencil box labeled for emergency use was found to contain a glucometer with test strips that had expired in 2021. The RN acknowledged that using expired test strips could result in incorrect blood sugar readings and immediately removed the expired items. The night shift nurse was identified as responsible for checking the supplies and should have removed the expired test strips. The Director of Nursing (DON) confirmed that the oxygen cylinder was not secured safely and that the facility would replace it with a larger cylinder. The DON also noted that the glucometer should not have been stored in the emergency response cart and observed several medical supplies that were not included on the inventory list. The facility did not have a policy for the emergency response cart, and the provided checklist did not include checks for the glucometer or the oxygen cylinder.
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Illustrative
What surveyors actually found near you
We read the 26 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Olathe
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Willow Tree Care Center | 8.7 mi | ★★★★★ | 14 | 0 |
| Hope Springs Care Center | 11.3 mi | ★★★★★ | 0 | 0 |
| Valley Manor Care Center | 11.8 mi | ★★★★★ | 11 | 0 |
| Horizons Care Center | 14.5 mi | ★★★★★ | 1 | 0 |
| Paonia Care And Rehabilitation Center | 27.8 mi | ★★★★★ | 0 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.