Creekside Village Rehabilitation And Nursing Llc
Inspection history, citations, penalties and survey trends for this long-term care facility in Fort Collins, Colorado.
- Location
- 1000 E Stuart St, Fort Collins, Colorado 80525
- CMS Provider Number
- 065221
- Inspections on file
- 30
- Latest survey
- February 9, 2026
- Citations (last 12 mo.)
- 11 (3 serious)
Citation history
Health deficiencies cited at Creekside Village Rehabilitation And Nursing Llc during CMS and state inspections, most recent first.
A resident with Lewy body dementia, severe cognitive impairment, orthostatic hypotension, and a history of falls repeatedly exhibited wandering, pacing, agitation, paranoia, and exit-seeking behaviors, yet the facility did not develop or implement a resident-centered elopement care plan with clear, nonpharmacologic interventions or defined supervision needs. Despite multiple documented episodes of wandering and two separate elopements in which the resident left the building and had to be brought back by staff, the facility relied largely on PRN psychotropic medications and intermittent 15-minute checks that were not consistently documented or care-planned. Elopement risk assessments eventually identified the resident as high risk, but staff reported the resident often sat near an unlocked front door in a sparsely monitored lobby, demonstrating ongoing inadequate supervision to prevent further elopement.
A resident with epilepsy and renal failure on hemodialysis had a complex antiepileptic regimen including phenobarbital, lacosamide, clobazam, Depakote, later Tegretol, and PRN post-dialysis seizure medications. The facility repeatedly failed to administer multiple scheduled doses of these medications, including entire mornings when all seizure meds were omitted, and never gave the ordered PRN post-dialysis doses despite ongoing seizures. Staff followed an informal practice of holding medications when the resident was at dialysis without clarifying orders with the PCP or neurologist, and nurses missed additional Tegretol doses because they were unaware the drug was available in a separate storage area. The EMR lacked documentation that the neurologist or PCP were notified of these missed doses, while hospital records documented breakthrough seizures and subtherapeutic antiepileptic levels. An additional observation showed a nurse unable to locate an ordered inhaler for another resident and not notifying the physician or documenting the omission, illustrating broader medication administration failures.
The facility failed to provide physician‑ordered modified diet textures to several residents with dysphagia, resulting in one resident with severe cognitive impairment and a Level 5 minced and moist order being served a regular‑texture soft taco on a whole tortilla and subsequently choking, requiring repeated Heimlich attempts and supplemental O2. During later meal observations, two residents with Level 6 soft and bite‑sized orders were served regular‑texture items including a hamburger bun, whole lettuce leaf, and whole cookies. Staff interviews showed inconsistent understanding of IDDSI diet levels and reliance on meal tickets that did not always reflect appropriate textures, while the dietary manager reported being new, unaware of dietary extensions before the incident, and unsure of prior staff education. The report states that these failures to follow ordered diet textures placed residents at risk for serious harm or death if not corrected immediately.
The facility’s QAPI program failed to identify and address multiple serious quality of care and safety problems, including a choking incident when a resident on a minced and moist diet was served a regular meal, additional residents receiving incorrect diet textures, repeated elopements by a resident with wandering behaviors without effective new interventions, and a resident experiencing increased seizures and hospitalizations when seizure meds were not administered as ordered, including on dialysis days. The facility also had repeat citations for abuse on a secure unit and for significant med errors, and interviews with the MD and NHA showed that, despite awareness of some incidents, there was uncertainty about whether performance improvement plans were initiated and a lack of awareness of ongoing diet errors, demonstrating that QAPI activities did not effectively capture or correct these recurring issues.
A cognitively intact resident with a fracture and type 2 DM, who required partial to moderate assistance for hygiene, did not receive showers according to his expressed preferences and documented schedule. He reported going weeks without showers and being repeatedly told by staff on different shifts that the shower would be done later, despite his verbal complaints to nurses, CNAs, and managers. Although his EMR contained specific shower days and time preferences, his care plan lacked this information, and shower records showed only three showers in a 30-day period. Staff interviews revealed confusion about which shift was responsible, poor communication of updated shower schedules to CNAs, and uncertainty among nursing staff about the resident’s current shower schedule.
A resident with dementia and behavioral issues physically struck two other residents on a secure unit on separate occasions, causing at least one documented skin tear, while only one CNA was present on the unit at times and the assigned nurse was covering another unit. The aggressive resident had severe cognitive impairment and primarily spoke Spanish, yet staff reported difficulty communicating with him when agitated and there was no clear use of an interpreter during key interviews. Care plans for the involved residents identified behavioral risks and the need for close supervision and redirection but lacked resident‑specific redirection strategies and clearly defined alternative communication tools, and the facility’s abuse investigation did not reconcile staff reports of contact and injury with its inconclusive findings.
A resident with Lewy body dementia, parkinsonism, and anxiety received PRN lorazepam and Seroquel without the facility enforcing the 14‑day limit for PRN psychotropic orders or obtaining documented physician reevaluation and rationale for continuation beyond that period. Pharmacy reviews had recommended 14‑day stop dates and behavior tracking for psychotropics, but these were not timely implemented, and the EMR lacked consistent behavior and side‑effect monitoring orders or documentation for the resident’s lorazepam and Seroquel. Nursing and leadership staff reported that they typically monitor behaviors and side effects for psychotropic use and understood that PRN psychotropics should not exceed 14 days, yet the DON confirmed that behavior and side‑effect monitoring orders were missing for this resident and that new medication orders were not being reviewed daily.
A resident experienced a significant medication error due to a failure in the medication administration process.
The facility did not submit final reports of two separate physical abuse investigations to the State Agency within the required timeframe. In both cases, initial reports were timely, but the final investigative findings were submitted late, despite the investigations being completed. The administrator acknowledged the delay and confirmed it was not in accordance with facility policy or state requirements.
Multiple environmental deficiencies were identified, including detached and soiled ceiling tiles, improperly secured light fixtures, sagging drywall, and unsanitary swamp coolers. These issues were observed throughout the facility, with incomplete repairs and lack of maintenance documentation contributing to an unsafe and unsanitary environment for residents, staff, and the public.
Two residents with cognitive impairment were not protected from abuse by another resident, resulting in one incident of physical abuse and another of verbal abuse. In both cases, the aggressor became upset when other residents entered or approached his room, leading to physical contact and yelling that caused distress and minor injury. Staff were aware of the aggressor's behavioral triggers but were unable to prevent the incidents, and one staff member was not immediately aware of the verbal abuse event.
A resident with a history of C. difficile and multiple diagnoses did not receive a prescribed course of Fidaxomicin because the medication was not available at the facility. Staff and the DON reported the antibiotic was not in stock and attempts to obtain an alternative or clarification from the infectious disease physician were unsuccessful or undocumented. The medication was not administered as ordered, and there was no documentation of discontinuation, substitution, or anticipated delivery in the medical record.
A resident with severe cognitive impairments was kissed without consent by another resident with a history of unwanted advances. The facility failed to implement new interventions to prevent reoccurrence, contributing to the deficiency.
Two residents in the facility did not receive their scheduled showers, despite being dependent on staff for bathing. Resident #3, with moderate cognitive impairments, received only 10 out of 18 scheduled showers, with no documentation for missed showers. Resident #8, who preferred showers, received fewer than scheduled, and the care plan inaccurately reflected a preference for bed baths. Staff shortages and lack of documentation contributed to these deficiencies.
The facility failed to notify residents of a change in attending physicians and did not provide them with a choice, as required. Interviews and record reviews revealed that residents were not informed about the switch to a new provider group, and there was no documentation of notification or choice. The DON acknowledged the lack of written notice, and the RDQA confirmed the facility's responsibility to inform residents.
The facility experienced issues with serving food that was palatable, attractive, and at a safe and appetizing temperature. Residents reported dissatisfaction with the taste, temperature, and quality of meals, including complaints about cold, overcooked, and unappetizing food. Observations during a test tray evaluation confirmed that food temperatures were not within acceptable ranges. Despite a policy emphasizing the importance of conserving nutritive value, flavor, and appearance, and opportunities for resident feedback, inconsistencies in food preparation and service persisted.
The facility experienced deficiencies in maintaining sanitary conditions during food storage, preparation, distribution, and service. Observations indicated lapses in hand hygiene, glove usage, and proper handling of glassware. Food items were not consistently labeled, dated, or covered during transport, increasing the risk of contamination. Staff interviews revealed inconsistent adherence to established protocols for food safety, highlighting gaps in training and compliance.
The facility failed to provide scheduled showers for three residents, resulting in missed hygiene care. One resident with a history of trauma related to showers did not receive any showers or sponge baths for two months. Another resident, observed with disheveled and greasy hair, only received two out of 16 scheduled showers. A third resident, dependent on staff for bathing, received only one out of six scheduled bed baths. Staff were unaware of the residents' preferences and schedules, and documentation did not reflect any interventions for missed showers.
The facility failed to maintain the dignity of two residents by not providing timely meals and allowing staff to enter rooms without knocking or identifying themselves. One resident missed meals and had to request food, while another experienced frequent unannounced entries by staff.
A resident did not receive prescribed doses of Bisacodyl, Baclofen, Linaclotide, and Zonisamide due to medication unavailability. The facility failed to notify the provider and document the unavailability, despite in-service education on the issue.
The facility failed to provide routine dental care to a resident who had not been to a dental appointment in two years. Despite a physician order for dentist appointments as needed, there was no documentation in the resident's EMR indicating that dental care had been offered or provided. Interviews with staff revealed that the resident had not signed a consent form for dental services and that the facility did not document refusals of dental services.
The facility failed to maintain a safe, functional, and sanitary environment in the laundry area, with issues such as a non-functional exhaust fan, unfinished sheet rock, chipped paint, hanging light cover, holes in the ceiling and walls, and lint accumulation. The Environmental Services Director and Maintenance Supervisor were unaware of these issues, contributing to the deficiency.
Failure to Implement Resident-Centered Elopement Protections for High-Risk Resident
Penalty
Summary
The deficiency involves the facility’s failure to ensure adequate supervision and accident prevention for a cognitively impaired resident at high risk for elopement. The resident had Lewy body dementia, parkinsonism, orthostatic hypotension, repeated falls, and severe cognitive impairment with a BIMS score of 4/15. He required supervision to substantial assistance for most ADLs and needed supervision to touching assistance to walk ten feet. Despite these needs, an initial elopement assessment after admission concluded he was not at risk for wandering, documenting no memory or decision-making impairments and no verbalization of wanting to leave, even though he was cognitively impaired and ambulatory. Beginning in late September and throughout October and November, progress notes documented frequent wandering, pacing, agitation, paranoia, and exit-seeking behaviors. The resident was found wandering near an elevator, stated he was trying to find his way out, and had a fall associated with poor safety awareness and cognitive decline. He repeatedly required PRN lorazepam and later Seroquel for anxiety, agitation, pacing, packing and unpacking belongings, rummaging, hyper-fixation on leaving, and beliefs that he was in a hotel and needed to check out or that he needed to rescue his sister. Hospice and physician notes addressed medication management but did not address his wandering, packing, pacing, or elopement behaviors with nonpharmacologic interventions. Despite this pattern, the facility did not develop or implement a resident-centered elopement care plan that specified effective nonpharmacologic interventions or the level of supervision he consistently required. On one occasion, the resident left the building and walked with his walker toward a nearby school, stopping in the middle of a street crosswalk and asking passersby to call the police before staff redirected him back inside. An elopement risk evaluation completed that day scored him as high risk, noting dementia, memory and decision-making impairments, verbalization of wanting to leave, wandering with and without his walker, ineffective verbal redirection, and inability to find his room without hands-on assistance. The IDT reviewed this elopement and attributed it to confusion and paranoia, adding 15-minute checks, but did not document the duration of these checks or add consistent, nonpharmacologic elopement interventions to the care plan. Later, the resident again left the facility at night without his walker and was found outside at a locked back door attempting to reenter; 15-minute checks and line-of-sight observation were used temporarily, but his 15-minute check sheet for part of that time was left blank. Progress and hospice notes continued to document wandering, restlessness, and exit-seeking, and a subsequent elopement risk evaluation showed an even higher risk score, yet the facility still did not initiate a resident-centered elopement care plan or clearly define required supervision. Staff interviews further revealed that the resident often sat in the front lobby near an unlocked front door that was infrequently monitored by staff, underscoring the lack of consistent supervision in an area of easy egress.
Removal Plan
- Place Resident #13 on one-to-one supervision indefinitely.
- Review and update Resident #13's care plan to reflect current wandering and elopement risk and person-centered interventions, including implementation of a one-to-one supervisor and providing redirection as needed when wandering behaviors occur.
- Complete an audit to evaluate each resident in the facility and identify residents who are at high risk for elopement.
- Review residents identified as high risk to ensure appropriate and effective elopement prevention measures are in place and documented in their care plans.
- Educate all staff members in all departments on resident-centered interventions for residents at high risk of elopement, the facility policy on reducing wandering and elopement risk, and reporting of any increased exit-seeking behaviors prior to working their next scheduled shift.
- Provide this education to new staff members during orientation.
- Educate the interdisciplinary team (IDT) on conducting root cause analyses of significant events to ensure appropriate actions are taken to prevent reoccurrence.
- Review the Elopement and Wandering Residents policy.
- Ensure progress notes for the prior 24 hours are reviewed each day for all residents during the clinical stand-up meeting to address any changes in behavior including wandering, exit seeking, or expressions of wanting to leave the facility.
- Address identified concerns through the IDT, including non-pharmacological interventions and a care plan review.
- Reevaluate residents by the IDT quarterly and any time increased exit-seeking symptoms are noted to ensure appropriate elopement prevention measures are in place and effective.
- Inform staff of any changes through in-servicing, care plan updates, and updates to the resident's Kardex.
- Audit new admissions for elopement risk and ensure appropriate interventions are in place.
- Conduct the new-admission elopement-risk audit daily for four weeks, then five times per week for four weeks, then three times per week for four weeks, and document it on an audit form.
Failure to Administer Ordered Antiepileptic Medications and Notify Providers of Missed Doses
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident with epilepsy and acute kidney failure requiring hemodialysis received prescribed anti-seizure medications as ordered, resulting in significant medication errors. The resident was cognitively intact but dependent on staff for all activities of daily living and had a care plan intervention to receive seizure medications as ordered and be monitored for effectiveness. The resident’s complex seizure regimen included scheduled phenobarbital, lacosamide, clobazam, and Depakote, with later addition of Tegretol, as well as PRN phenobarbital and lacosamide to be given after dialysis for breakthrough seizures. Despite these orders, the MAR and record review showed multiple missed doses of scheduled seizure medications and no administration of PRN seizure medications after dialysis, even though the resident continued to have seizures after dialysis. Record review showed that on multiple days the resident did not receive ordered doses of lacosamide, Depakote, clobazam, and phenobarbital, including entire mornings when all four scheduled seizure medications were not administered, and additional missed evening and noon doses on other days. The MAR also showed that the PRN phenobarbital and PRN lacosamide ordered to be given after dialysis for seizures were never administered, despite ongoing post-dialysis seizure activity. After a hospitalization for seizures where subtherapeutic phenobarbital and valproic acid levels were documented, the resident returned with an order to start Tegretol three times daily; however, four Tegretol doses were not given because nurses were unaware the medication was available and stored in a separate area. Subsequent MAR review after this hospitalization showed further missed Tegretol doses on multiple days. The facility’s practice contributed directly to these omissions. The DON stated it was facility practice to hold medications when a resident was at dialysis, and seizure medications and other medications scheduled on dialysis days were marked as not administered in the EMR without clarifying these orders with the PCP or neurologist. The DON also acknowledged awareness that four Tegretol doses were not administered but did not complete a full audit of the resident’s seizure medications and was not aware of additional missed doses beyond dialysis days. The DON and PCP both believed the PRN post-dialysis seizure medications were to be administered by the dialysis clinic, but the dialysis triage nurse and nephrologist reported the clinic did not administer medications from the facility’s orders and expected such medications to be given at the facility before or after dialysis. Throughout these events, the resident’s EMR did not contain documentation that the neurologist or PCP were notified of the multiple missed doses of anti-seizure medications. The resident experienced repeated seizures and multiple hospitalizations, with hospital records repeatedly referencing breakthrough seizures, subtherapeutic antiepileptic levels, and seizure activity despite reported adherence, while facility records showed that ordered antiepileptic medications were not consistently administered. In addition to the issues with this resident, an observation of another medication pass showed a nurse unable to locate a prescribed inhaler for another resident and not administering it, without notifying the physician or documenting the missed dose. This further demonstrated that medications were not consistently administered as ordered and that missed doses were not reliably communicated to providers or documented in progress notes, contributing to the identified deficiency of significant medication errors.
Removal Plan
- The DON and ADON completed an audit to ensure all residents are getting medications as ordered, including a review of each resident's medication administration record and an audit of the medication carts to ensure the medications were available.
- The DON and regional clinical resource #1 audited all residents currently on dialysis to ensure administration of medications per physician order on dialysis days.
- The Medication Administration policies were reviewed by the NHA, the DON, and regional clinical resource #1.
- The DON educated all licensed nursing staff on the Medication Administration policy, properly following physician's orders, and the process of notifying of medication errors, including notifying providers when medications conflict with scheduled dialysis days; education to be provided to all nursing staff prior to their next scheduled shift.
- The DON or designee will educate all new hire licensed nurses on medication administration and physician notification guidelines during orientation.
- The DON or designee will review MAR reports for all residents to ensure medications are administered as ordered, or the physician was notified appropriately if a medication was held.
- All licensed nurses will be observed by the DON or designee administering medications to ensure competency across shifts and with various staff members.
Failure to Provide Ordered Dysphagia Diet Textures Resulting in Choking Event and Ongoing Meal Service Errors
Penalty
Summary
The deficiency involves the facility’s failure to provide physician‑ordered modified diet textures to multiple residents with dysphagia. One resident with diagnoses including oropharyngeal dysphagia, cerebral infarction, cognitive communication deficit, and unspecified dementia had a physician’s order for a Level 5 minced and moist diet and required supervision and hands‑on assistance for meals. Despite this, the resident was served a regular‑texture soft taco on a whole tortilla instead of the ordered minced and moist texture. During this meal, the resident began choking on a piece of tortilla that became stuck in the throat. A nurse attempted the Heimlich maneuver several times without dislodging the tortilla; the resident was moving air and eventually coughed up the tortilla and then required supplemental oxygen by mask. Two additional residents with dysphagia and cognitive deficits were also not provided with the correct modified diet textures. One resident, with oropharyngeal dysphagia, hemiplegia and hemiparesis following cerebrovascular disease, and cognitive communication deficit, had a physician’s order for a Level 6 soft and bite‑sized diet. Observation of a dinner meal service showed this resident received a regular‑texture hamburger on a bun with a whole lettuce leaf and a whole cookie, despite the soft and bite‑sized order. Another resident, with diagnoses including GERD, oral‑phase dysphagia, and cognitive communication deficit, had a physician’s order for a Level 6 soft and bite‑sized diet, with documentation that this resident could have regular sandwiches and hamburgers. However, this resident was observed receiving a whole cookie, which was not consistent with the ordered soft and bite‑sized texture. Staff interviews and documentation revealed gaps in understanding and implementation of diet textures and meal ticket verification. Nursing staff and CNAs reported receiving some training on diet textures, but one CNA believed that residents on soft and bite‑sized diets could have bread and possibly cookies depending on softness, which conflicted with IDDSI guidance cited in the report. The dietary manager stated he was new to the position, had been unaware of dietary extensions prior to the choking incident, and was unsure whether dietary staff had been educated on diet textures and extensions. The registered dietitian confirmed that diet tickets were generated from the EMR and included diet orders, extensions, and specific foods, and acknowledged that the residents on soft and bite‑sized diets should not have received hamburger buns, lettuce, or cookies. The administrator later attributed one instance of incorrect items (whole cookies) on tickets to a computer program glitch, while the DON acknowledged that only limited meal audits had been occurring and that the number of residents included in those audits was insufficient. The report states that the facility’s failure to ensure residents received the physician‑ordered diet textures placed residents at risk for serious harm or death if not corrected immediately. The report also notes that, at the time of the choking incident, the nurse assigned to the secured unit where the choking resident resided was not on the unit, and another RN responded to perform the Heimlich maneuver. The event note for the choking incident identified risk factors and root causes including the resident’s dysphagia, cognitive decline, poor safety awareness, and the fact that the resident was served a regular‑texture meal including a whole tortilla despite an order for minced and moist texture. The note documented that the resident lacked insight into safety regarding food intake and that the preventative measure in place prior to the incident was simply confirming the minced and moist order. Subsequent observations during survey showed that, even after this choking event, residents with ordered soft and bite‑sized diets continued to receive regular‑texture items such as whole cookies, hamburger buns, and lettuce leaves, demonstrating ongoing failure to consistently match plated meals to physician‑ordered diet textures.
Removal Plan
- Re-educate all staff involved in meal preparation or service (IDT, nursing, dietary, activities) on diet modifications and following physician orders using IDDSI standards prior to their next scheduled shift, including a post-test to demonstrate understanding; provide this education to all new IDT/nursing/dietary/activities staff during orientation; education provided by the DON or designee.
- Re-educate all dietary staff on food preparation utilizing diet extensions and recipes to adhere to each resident's diet order prior to their next scheduled shift; provide this education to all new dietary staff during orientation.
- Have the registered dietitian (RD) conduct an audit to ensure all dietary orders, recommendations, and documentation are accurate in the medical record and match the dietary department's tray ticket information for each resident.
- Review and revise the facility's pertinent menu and therapeutic diet policies.
- Educate the IDT on conducting root cause analysis of serious events, including choking incidents, and ensuring appropriate actions are taken to prevent recurrence.
- Implement daily audits of new admissions by the dietary manager (DM) and the DON or designee to ensure dietary orders/recommendations/documentation are accurate in the medical record and match the dietary department's meal ticket information for that resident, documenting findings on an audit form.
- Have the DON or designee review all new orders to monitor for changes to diet orders; communicate any changed orders to the dietary department through a diet change communication form.
- Monitor food service at all three meals for all residents by the DON or designee, comparing the meal being served to the physician order/documentation for that resident's dietary needs; document findings on an audit form.
Failure of QAPI Program to Identify and Address Serious Quality of Care and Safety Issues
Penalty
Summary
The facility failed to maintain an effective, comprehensive, data‑driven QAPI program capable of identifying and addressing quality of care, quality of life, and resident safety concerns. Surveyors cross‑referenced multiple serious deficiencies that were not effectively captured or addressed through QAPI. These included a choking incident in which a resident on a minced and moist diet was served a regular meal, resulting in an actual choking episode that required multiple Heimlich attempts, as well as other residents being served incorrect diet textures during the survey. Additional cross‑referenced deficiencies involved two elopement incidents for a resident with wandering behaviors, where no new interventions were implemented after the first elopement and the resident later left the building without staff knowledge and was found locked outside. Another cross‑referenced deficiency involved a resident whose seizure medications were not administered as ordered on multiple occasions, including not being given at all on dialysis days, leading to increased seizures and multiple hospitalizations. The facility’s regulatory history showed repeat deficiencies that the QAPI program failed to prevent, including multiple citations for abuse prevention on the secure unit and repeated citations for significant medication errors, which escalated from potential for more than minimal harm to actual harm. The facility’s own QAPI policy required an effective, comprehensive, data‑driven program, but interviews revealed gaps in implementation. The MD reported being notified of the seizure medication error and expressed concern that seizure medications must be administered as ordered and that the neurologist should have been contacted for clarification. The NHA stated that abuse allegations were reviewed in QAPI and that he was aware of the significant seizure medication error but was unsure whether any performance improvement plans had been initiated. He also reported being aware of the choking incident but not aware that the kitchen was serving inappropriate diets, and he described the resident who eloped twice as someone for whom the facility was seeking a secured unit placement. These findings collectively demonstrated that the QAPI committee did not effectively identify, track, or address these serious and recurring quality of care and safety issues.
Failure to Honor Resident Bathing Preferences and Schedule
Penalty
Summary
The deficiency involves the facility’s failure to honor a cognitively intact resident’s stated bathing preferences and to provide showers according to his chosen schedule. The resident, over age 65 with diagnoses including a left tibia fracture and type 2 diabetes, required partial to moderate assistance for personal hygiene and showers. He reported that from admission he went several weeks without showers, and that staff on different shifts repeatedly told him his shower would be done by the next shift, which did not occur. He stated he verbally complained to nurses, CNAs, and managers, but his shower schedule was never corrected. A manager later placed a sign in his room listing specific shower days, but the resident reported that showers still were not completed as scheduled. Record review showed the resident’s shower preferences were documented in the EMR, initially as twice weekly on specific evenings, and later updated to three times weekly on specific days before 8:00 p.m. but after lunch. However, his comprehensive care plan did not include his shower preferences or specific days. Shower records for the 30-day review period showed he received only three showers. Staff interviews revealed a CNA did not know when the resident was to receive showers and described confusion due to shower schedule updates not being communicated to CNAs. An RN acknowledged the resident’s specific time preferences and stated it was sometimes difficult to accommodate due to CNA workload and that his schedule had been changed multiple times, leaving her unsure of the current schedule. The DON stated she was unaware the resident was not receiving showers and that staff were confused about which shift was responsible for providing them.
Failure to Prevent Resident-to-Resident Physical Abuse on Secure Unit
Penalty
Summary
The deficiency involves the facility’s failure to protect two residents from physical abuse by another resident on a secure memory unit. Facility policy defined abuse and neglect and required identification, assessment, care planning, and monitoring of residents with behaviors that might lead to conflict, as well as deployment of sufficient, trained staff and appropriate supervision. Despite this, the facility did not prevent resident‑to‑resident altercations involving a resident with dementia and behavioral issues who physically struck two other residents. The facility’s abuse investigations, care plans, and documentation show gaps in behavioral assessment, communication support, and supervision that contributed to these incidents. In the first incident, a CNA observed a resident with severe cognitive impairment and dementia enter another resident’s room. As the CNA approached to redirect him, she heard the cognitively intact resident in the bathroom tell the intruding resident to get out, followed by a sound like a punch. When the CNA entered, she redirected the intruding resident out of the room and noted a scratch on the other resident’s neck. The victim reported that the other resident punched him three or four times and that something sharp from the assailant’s knuckles scratched him. A physician note documented that the victim had an altercation with another resident who scratched his neck, resulting in a small skin tear approximated with steri‑strips. Staff on the unit reported that contact had been made and that the injury was most likely from the assailant’s nail. The facility’s investigation concluded the allegation could not be substantiated or unsubstantiated and did not explore alternative causes for the neck injury, despite the victim’s statements and staff reports of hearing a punch and observing contact. In the second incident, a CNA was the only staff member present on the secure unit while the nurse was on another unit. She heard two male residents’ voices escalating in the hallway and, after quickly finishing care in a room, found two residents in a verbal dispute. As she positioned herself between them to deescalate, the same resident with dementia approached and swung with a closed fist, making contact with one disputing resident’s cheek. A nursing progress note documented that the resident walked by and punched the other resident in the face. The victim, who had severe cognitive impairment and dementia, denied being hit, and no apparent injuries were found on assessment. The assailant denied involvement, and there was no indication that an interpreter was used during his interview, even though his primary language was documented as Spanish and staff reported difficulty communicating with him when he was agitated. Care plans for the assailant and the victim referenced behavioral risks and the need for close supervision, frequent checks, and redirection, but did not specify effective, resident‑specific redirection techniques or clearly defined alternative communication tools for the Spanish‑speaking resident. Staffing on the secure unit routinely consisted of one nurse (also assigned to another unit) and one CNA, resulting in periods when only one staff member was present to both assist residents and monitor behaviors.
Failure to Monitor PRN Psychotropics and Enforce 14-Day Limits
Penalty
Summary
The deficiency involves the facility’s failure to adequately monitor and manage the use of psychotropic medications, specifically PRN lorazepam and Seroquel, for one resident with severe cognitive impairment and multiple neuropsychiatric diagnoses. The resident had Lewy body neurocognitive disorder, parkinsonism, and anxiety, and the MDS documented severe cognitive impairment with no recorded physical or verbal behaviors toward others during the assessment period, although the resident was receiving antipsychotic and antianxiety medications. The facility’s psychotropic care plan for this resident, initiated in November, included interventions such as administering medications as ordered and monitoring for side effects and efficacy each shift, as well as consulting with the pharmacist and physician for possible dose reductions at least quarterly. Record review showed multiple PRN lorazepam and Seroquel orders that exceeded the 14‑day limit for PRN psychotropic medications without documented physician reevaluation or rationale for continuation beyond that limit. One PRN lorazepam order in October was continued for 25 days, 11 days beyond the 14‑day limit, and a PRN Seroquel order was continued for 22 days, 8 days beyond the limit. In January, another PRN lorazepam order was continued for 23 days, 9 days beyond the 14‑day limit. The MAR documented frequent administration of PRN lorazepam over several months, including doses given during periods when the PRN orders had been continued past 14 days without documentation of reevaluation. The resident also received a PRN dose of Seroquel after the 14‑day limit had passed. There was no documentation in progress notes or hospice notes that the physician had reevaluated the PRN lorazepam to justify its use beyond 14 days. The facility also failed to ensure behavior and side‑effect monitoring for the resident’s lorazepam and Seroquel. The EMR did not show any standing orders for behavior monitoring until an order was entered during the survey, and there was no evidence of consistent behavior monitoring by nursing staff prior to that time. There were no physician orders for side‑effect monitoring for either lorazepam or Seroquel, and no documentation of consistent side‑effect monitoring. Pharmacy medication regimen reviews had previously recommended that behavior tracking be in place for all antipsychotic and anxiolytic medications, that all PRN psychotropics have a 14‑day stop date, and that PRN antipsychotics not be continued beyond 14 days without a new order and justification. These recommendations were not implemented until months later, during the survey period. Staff interviews indicated that nurses and the DON understood that psychotropic medications required behavior and side‑effect monitoring and that PRN psychotropic orders should not exceed 14 days, but the DON acknowledged that behavior and side‑effect monitoring orders were not in place for this resident’s psychotropic medications and that new medication orders were not being reviewed daily.
Significant Medication Error Occurred
Penalty
Summary
Residents were not ensured to be free from significant medication errors. The report identifies that there was at least one instance where a resident received a significant medication error, indicating a failure in the medication administration process. Specific details about the actions or inactions leading to the error, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Timely Submit Final Abuse Investigation Reports
Penalty
Summary
The facility failed to submit final reports of its investigations into two separate physical abuse allegations to the State Survey and Certification Agency within the required five working day timeframe, as mandated by both state law and the facility's own Abuse, Neglect and Exploitation policy. In the first incident, involving two residents, the final report was submitted two days late. In the second incident, also involving two residents, the final report was submitted twelve days after the deadline. In both cases, the initial reports were submitted on time, but the final investigative findings were not reported within the required period. The nursing home administrator confirmed during an interview that the investigations and interviews for both incidents had been completed, but acknowledged that the final reports were not submitted in a timely manner. The administrator stated that he was aware of the facility's policy and the state reporting timelines, and that the delay was due to his failure to submit the reports on time. The facility's policy requires reporting all alleged violations and the results of investigations to the appropriate authorities within specified timeframes, which was not followed in these instances.
Environmental Safety and Maintenance Deficiencies
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Observations revealed multiple environmental deficiencies, including detached and soiled hallway ceiling tiles with visible discoloration, frayed edges, and signs of repeated water damage. The drywall in common areas and nurses' stations showed irregular staining and discoloration, indicating potential moisture exposure and improper attachment to supporting framing, resulting in sagging and warping. Light fixtures in the foyer were partially detached from the ceiling, exposing wiring and support components in a high-traffic area. Additionally, swamp coolers in one hallway were found to be discolored and soiled with various substances. Interviews with the maintenance director and the nursing home administrator confirmed that repairs had been started but were left incomplete due to issues with external contractors and lack of staff familiarity with certain equipment, such as the swamp coolers. The maintenance director was unable to provide documentation of maintenance records, and the facility's policy for maintaining a safe and sanitary environment was not provided upon request. These actions and inactions resulted in the facility not meeting the required standards for environmental safety and cleanliness.
Failure to Prevent Resident-to-Resident Abuse
Penalty
Summary
The facility failed to protect two residents from abuse by another resident, resulting in both physical and verbal abuse incidents. In the first incident, a resident with severe cognitive impairment and a history of wandering entered another resident's room. The resident whose room was entered became upset, waved his fists, and contact occurred that caused the wandering resident to fall and sustain a bruise and abrasion. Both residents involved had cognitive impairments, and the incident was substantiated as physical abuse by the facility. Prior to the incident, the care plan for the wandering resident noted the risk of physical aggression and included interventions such as encouraging direct line-of-sight supervision to prevent wandering into other residents' rooms. In the second incident, another resident with severe cognitive impairment and agitation was verbally abused by the same resident who had previously engaged in physical aggression. As the resident in a wheelchair approached the aggressor's room and touched a stop sign on the door, the aggressor became visibly angry and yelled loudly, causing the other resident to appear scared and confused, with observable physical signs of distress. Staff immediately intervened to separate and redirect the residents. The care plan for the verbally abused resident included interventions for wandering and agitation, but the incident still occurred. Staff interviews revealed that the resident who committed the abuse was known to display verbal aggression, particularly in the afternoon, and that staff were aware of his behavioral triggers. On the day of the verbal abuse, staff were occupied with other residents and unable to prevent the incident. The social services director was not aware of the verbal abuse incident until informed during the survey, indicating a lack of immediate awareness and response to the event. The facility's failure to prevent these incidents resulted in residents not being kept free from abuse as required by policy.
Failure to Administer Prescribed Antibiotic Due to Unavailability
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors by not administering a prescribed antibiotic, Fidaxomicin, as ordered by the physician. The resident, an 83-year-old with diagnoses including diverticulitis with perforation and abscess, lower abdominal pain, bipolar disorder, and a history of C. difficile infection, was admitted with a physician's order for Fidaxomicin 200 mg twice daily for 10 days. Review of the medication administration record and progress notes confirmed that the antibiotic was not administered from admission through the review period, with documentation indicating the medication was not available. Nursing staff and the DON reported that the medication was not in stock, was expensive, and not included in the emergency kit, and that attempts were made to contact the infectious disease doctor for alternatives, but no alternative was provided or documented. The resident and her representative both confirmed that the prescribed antibiotic was not given since admission. The DON stated that the pharmacy indicated a delay in obtaining the medication and that she attempted to contact the infectious disease doctor and the hospital for clarification, but did not document all communication attempts. The physician assistant confirmed that there was no approved alternative for the resident's condition and was not aware the medication was never administered. There was no documentation in the medical record regarding the reason for holding the antibiotic or the anticipated delivery date, and no evidence of discontinuation or substitution by the medical team.
Failure to Protect Resident from Abuse
Penalty
Summary
The facility failed to protect a resident from physical abuse by another resident. The incident involved a resident with severe cognitive impairments who was kissed on the mouth without consent by another resident with a history of making unwanted sexual advances. The facility's investigation determined that no abuse occurred due to both residents having cognitive impairments and no apparent adverse effects, but the report identifies the incident as sexual abuse. The resident who committed the act had a history of behavioral issues related to dementia, including making unwanted sexual advances when agitated. Despite this history, the resident's care plan did not include new person-centered interventions to prevent reoccurrence after the incident. The resident was known to become agitated with changes in routine and staff, which was the case on the day of the incident. The staff, including a registered nurse, responded by separating the residents and monitoring them for behavioral changes. However, the report highlights that the facility did not have specific interventions in place to manage changes in routine and staff, which contributed to the resident's agitation and subsequent behavior. The facility's failure to implement adequate preventive measures and interventions led to the deficiency.
Failure to Provide Scheduled Showers to Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, two residents, who were dependent on staff for bathing, did not receive their scheduled showers. The facility's policy required that shower schedules be determined based on resident preference and documented accordingly, but this was not adhered to. Resident #3, who had moderate cognitive impairments and required assistance with daily activities, reported receiving only two showers and one bed bath since admission. The resident's care plan indicated a need for moderate assistance with showering, and the shower schedule showed she was to receive showers twice a week. However, records revealed she received only 10 out of 18 scheduled showers, with no documentation explaining the missed showers or interventions attempted. Staff interviews confirmed that the elimination of a bath aide and insufficient staffing contributed to the failure to provide scheduled showers. Resident #8, who was cognitively intact but had functional limitations, also did not receive the scheduled showers. Despite expressing a preference for showers over bed baths, the resident's care plan inaccurately reflected a preference for bed baths. The resident received or refused a bath only five out of eight opportunities in August and three out of seven in September. Staff interviews highlighted a lack of documentation for refusals and interventions, and the assistant director of nursing acknowledged the need for accurate charting and adherence to resident preferences.
Failure to Provide Residents with Choice of Attending Physician
Penalty
Summary
The facility failed to honor residents' rights to choose their attending physician, as evidenced by the switch to a new provider group without notifying all residents or providing them with options. The Director of Nursing (DON) was unable to provide the facility's policy on resident choice of attending physician when requested. Interviews with residents revealed that they were not informed about the change in providers and were not given a choice. One resident expressed dissatisfaction with the new provider, citing issues with medication management and lack of communication. Record reviews showed no documentation of resident notification or choice regarding the change in providers. The DON confirmed that the provider group switch affected almost all residents and acknowledged the lack of written notice to residents. The Regional Director of Quality Assurance also confirmed that it was the facility's responsibility to inform residents and provide them with a choice, but no documentation of such notification was available.
Inconsistent Food Quality and Temperature in Meal Service
Penalty
Summary
The facility failed to consistently serve food that was palatable, attractive, and at a safe and appetizing temperature. Residents reported various issues with the food, including taste, temperature, and quality. Interviews with multiple residents revealed complaints about cold, overcooked, and unappetizing food. Residents expressed dissatisfaction with the menu choices, taste, and temperature of the meals served. Observations during a test tray evaluation showed that the food temperatures were not within acceptable palatable ranges, with items like the tilapia fillet and peas being below the required temperature. The facility's policy on Meal Preparation for Nutritive Value and Palatability emphasized the importance of conserving nutritive value, flavor, and appearance of food. However, residents consistently reported receiving food that did not meet these standards. Despite the opportunity for residents to provide feedback and request substitutes, issues with food quality persisted. The dietary manager mentioned conducting test trays to ensure food quality, but the observations during the evaluation revealed discrepancies in temperature and taste, indicating a lack of consistency in food preparation and service.
Deficiencies in Food Handling and Hygiene Practices
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in a sanitary manner in various areas, including the main kitchen, main dining room, nourishment rooms, and resident units. Observations revealed multiple instances where staff did not perform proper hand hygiene, handle glassware appropriately, wash hands, change gloves, label and date food items, and cover food during transport. Staff members were observed not washing hands or changing gloves between tasks, handling glassware improperly, and failing to label and date food items in nourishment rooms. Additionally, food items on meal trays were not adequately covered during transport in the hallway to resident rooms, potentially exposing the food to contamination. During observations in the main dining room, staff members were seen handling glassware and serving residents without proper hand hygiene, potentially leading to contamination of food-contact surfaces. In the main kitchen, staff did not wash hands or change gloves appropriately while plating and serving resident meals, increasing the risk of cross-contamination. Furthermore, in one of the nourishment rooms, food items were not labeled, dated, or disposed of timely, potentially compromising food safety and quality. The deficiency in food handling practices was also evident during meal delivery to resident rooms, where food items on meal trays were not adequately covered, risking contamination during transport. Staff interviews revealed that while some staff members were aware of proper food handling practices, there were instances where staff lacked understanding or compliance with established protocols. The facility's policies and procedures regarding hand hygiene, glove usage, labeling and dating of food items, and food transport were not consistently followed by staff members, leading to the identified deficiency in food safety practices. The lack of adherence to established guidelines and protocols in various areas of food handling and service contributed to the deficiency reported by surveyors, highlighting the need for improved staff training and oversight in ensuring compliance with food safety standards.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to provide assistance with activities of daily living (ADL) for three residents, specifically failing to ensure they received showers as scheduled. Resident #15, who had a history of respiratory failure, kidney disease, diabetes, and anemia, was cognitively intact and required moderate assistance for oral hygiene and was dependent for tub and shower transferring, showering, and dressing. Despite her preference for a bath over a shower due to a traumatic experience at a previous facility, she did not receive any showers or sponge baths between February and March 2024. The facility's documentation did not reflect her preferences or any interventions attempted when she missed her scheduled showers. Resident #37, diagnosed with kidney disease, low blood pressure, diabetes, and epilepsy, was also cognitively intact and required substantial assistance with showering. He was observed with disheveled and greasy hair, indicating a lack of proper hygiene. The records showed that out of 16 scheduled opportunities for showers from February to March 2024, he only received two showers. Staff interviews revealed a lack of awareness about his shower schedule and indicated that the night shift staff were not providing showers for many residents. Resident #60, who had severe cognitive impairment and was dependent on staff for showers, was supposed to receive bed baths three times a week. However, the records indicated that out of six opportunities for bathing from January to February 2024, the resident only received one bath. The documentation did not show any refusals or progress notes explaining the missed baths. The DON confirmed that the resident should have received six baths during the reviewed period but did not, and there were no notes indicating any refusals.
Failure to Maintain Resident Dignity
Penalty
Summary
The facility failed to promote and maintain the residents' dignity for two residents. Resident #45, who has multiple diagnoses including multiple sclerosis and COPD, did not receive his breakfast and lunch meals in a timely manner. On one occasion, he had to go to the kitchen himself to order his meal, and on another occasion, he was only provided with peanut butter and jelly sandwiches after his call light was activated. Interviews with staff revealed that there was no verification process to ensure meal orders were taken and delivered, and food was discarded after meal service, leaving residents without proper meals if they missed the initial service time. Resident #57, who has diagnoses including sepsis and neuropathy, reported that staff frequently entered her room without knocking or identifying themselves. This was observed during the survey when a physical therapist entered her room without knocking and without wearing a name badge. Interviews with staff confirmed that they were aware of the policy requiring them to knock and identify themselves before entering a resident's room, but this practice was not consistently followed. The deficiencies highlight a lack of adherence to policies designed to ensure residents' dignity and respect. The facility's failure to provide timely meals and to ensure staff knock and identify themselves before entering rooms directly impacted the residents' quality of life and sense of dignity.
Failure to Administer Medications as Prescribed
Penalty
Summary
The facility failed to ensure that Resident #1 received all prescribed medications per the physician's orders, resulting in significant medication errors. Specifically, the resident did not receive doses of Bisacodyl, Baclofen, Linaclotide, and Zonisamide on various dates in March 2024. The medication administration records (MAR) and progress notes indicated that these medications were unavailable, and there was no documentation that a provider was notified about the unavailability of these medications. Resident #1, who has diagnoses including paraplegia, sciatica, low blood pressure, epilepsy, major depressive disorder, anxiety disorder, and morbid obesity, reported that the facility had run out of his seizure medication for two days. Despite the facility's policy requiring that medications be administered accurately and timely, and that providers be notified if medications are unavailable, this protocol was not followed. The resident's computerized physician orders (CPO) and MAR revealed multiple instances where medications were not administered as prescribed, and there was a lack of documentation indicating that the provider was informed. Interviews with facility staff, including an LPN, a CNA, and the DON, confirmed that there were issues with medication reordering and communication with the pharmacy. The staff acknowledged delays in receiving medications and the need to notify providers when medications were unavailable. Despite in-service education provided to the staff on medication availability and the need to notify providers, the deficiency persisted, as evidenced by the continued failure to administer Resident #1's medications and the lack of proper documentation and provider notification.
Failure to Provide Routine Dental Care
Penalty
Summary
The facility failed to provide routine dental care to Resident #13, who was one of three residents reviewed for ancillary services. Despite a physician order for dentist appointments as needed, there was no documentation in the resident's electronic medical record (EMR) indicating that the resident had been offered or provided access to dental care. The resident, who was cognitively intact and required assistance with various activities of daily living, reported not having been to a dental appointment in two years and stated that facility staff did not ask residents about appointments but only informed them if an appointment was set up. Interviews with facility staff revealed further deficiencies. Certified nurse aide (CNA) #4 stated that Resident #13 did not request to see a dentist, while the social services director (SSD) confirmed that there was no documentation of the resident refusing dental services. The SSD also noted that Resident #13 had not signed a consent form for dental services and had not been seen by a dentist. The facility did not document resident refusals of dental services, contributing to the failure to provide necessary dental care to Resident #13.
Environmental Deficiencies in Laundry Area
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, specifically in the laundry area. Observations revealed multiple environmental concerns, including a non-functional exhaust fan with exposed wires in the soiled linen room, unfinished sheet rock and a hole in the ceiling in the sorting room, chipped paint on the ceiling above a dryer, and a fluorescent light cover hanging down with lint inside. Additionally, there were five holes in the ceiling, two holes in the walls, and lint accumulation behind dryers and on the walls in the laundry room. The Environmental Services Director (ESD) was unaware of these issues and stated she would notify the Maintenance Supervisor (MS). The MS confirmed there were no open work orders for the laundry area and acknowledged the need for repairs, noting that the lint and holes posed a fire safety hazard. The facility's policy on submitting maintenance requests was provided, but no specific protocol for addressing environmental issues was available by the end of the survey. The MS admitted he had never been in the soiled linen area before and had not noticed the wall and ceiling issues in the laundry room. He confirmed that the exhaust fan needed replacement and that all observed environmental concerns required repair. The lack of awareness and action from both the ESD and MS contributed to the failure in maintaining a safe and sanitary environment in the laundry area.
Latest citations in Colorado
Two severely cognitively impaired residents in a memory care unit, both with dementia and significant behavioral risk factors, became agitated with each other and engaged in a physical altercation that resulted in a facial scratch to one resident. Facility policy required immediate intervention, separation, and monitoring to prevent abuse, and both residents’ care plans identified risks for aggression, anxiety, and resident-to-resident altercations. Staff reported that only one staff member was assigned to seven residents, that residents often invaded each other’s space, and that fights did occur, including a fist fight between these two residents during the incident in question. The facility’s investigation substantiated the event as physical abuse, demonstrating a failure to protect residents from abuse and to implement effective monitoring and behavioral interventions.
A resident with bipolar disorder, PTSD, traumatic brain injury, and moderate cognitive impairment alleged that an LPN and CNA were rough and sexually abusive during incontinence care, stating the LPN aggressively rolled him, caused his head to hit the wall, and repeatedly inserted a finger into his anus despite his protests. The facility’s investigation relied on staff statements and lack of observed rectal trauma, did not interview the roommate, and did not explore why staff continued care after the resident’s abuse allegation. The resident also reported ongoing rough transfers, inadequate repositioning in a wheelchair causing pain and bruising, and lack of assistance with proper positioning for meals, which was corroborated by observation of poor positioning, a bruise on his arm, and food spilled on his shirt. Although the care plan noted a history of false allegations and required care in pairs and investigation of voiced concerns, it lacked a specific focus on the resident’s PTSD and did not address his repeated reports that staff’s incontinence care and handling were rough and abusive.
A resident with a history of falls, fractures, and significant mobility impairment experienced an unwitnessed fall from bed, which had been left in a high position despite care-plan interventions requiring it to be kept low with a fall mat. An RN found the resident on the floor, initiated neuro checks, and documented elevated BP readings and pain but did not complete or document a thorough head-to-toe assessment before moving the resident back to bed, and did not promptly notify the MD, hospice, or the resident’s representative. Hospice was contacted several hours later due to rising BP and severe pain; a hospice RN then assessed the resident, notified the on-call MD, and obtained an order to transfer the resident to the hospital, where imaging revealed multiple fractures and a scalp contusion. Staff interviews and facility policy confirmed that standard practice required immediate RN assessment prior to moving a fallen resident, timely MD and family notification, and adherence to fall-prevention interventions, all of which were not followed in this case.
The deficiency centers on failures in transportation safety and fall management that led to serious resident injuries. A resident with dementia and bilateral lower extremity impairments was transported in a wheelchair without foot pedals, seated on a blanket and Hoyer sling, and improperly restrained when the driver misapplied the lap and shoulder belt to avoid disturbing an ostomy bag. During the trip the resident slid forward, struck both legs on a step in the vehicle, and was later found to have bilateral tibial fractures with significant bruising, swelling, and pain. The driver’s training had been informal, passed down from another staff member without documented competencies, van‑specific procedures, or clear emergency protocols, and leadership acknowledged they had not investigated the admitted misuse of the seat belt. Separately, two residents at high risk for falls experienced multiple falls, including one with a facial laceration and maxillary sinus fracture, while care‑planned fall interventions such as scheduled toileting, prompted voiding, monitoring, and assisted transfers were not consistently implemented, and IDT reviews and implementation of recommended interventions were not always timely.
A resident with severe cognitive impairment, multiple comorbidities, and a known history of alcohol use left the facility and was later found outside yelling for help and lying on the ground. Police identified the individual, determined the resident was intoxicated, and returned him to the facility, where he required wheelchair transport to his room despite normally walking without assistive devices. Officers helped the resident into bed, but nursing staff did not complete a change of condition assessment, obtain vitals, perform a head-to-toe or post-fall evaluation, or document his condition or monitoring afterward. The physician and legal guardian were not notified of the intoxication or change in condition, and there was no care plan addressing alcohol use or intoxication despite existing orders to monitor for substance use and notify the provider. A few hours later, a CNA found the resident face down on the floor, unresponsive, and he was pronounced dead, with the death certificate citing respiratory failure, aspiration event, and alcoholism; the incident was not promptly reported or thoroughly investigated at the time.
A resident with cognitive impairment and documented visual deficits requested very hot tea, which a PTA dispensed from a hot beverage machine and then further heated in a microwave, contrary to facility policy prohibiting reheating of facility-provided drinks. The PTA secured a lid on the cup and placed it at the bedside. Due to visual impairment, the resident could not locate the drinking opening, attempted to remove the lid independently, and spilled the hot liquid onto an arm and thigh, sustaining second-degree partial thickness burns over approximately 6% TBSA. Nursing and NP assessments documented bright red, blanchable burns with blistering and subsequent healing, and staff interviews confirmed that the beverage had been overheated and that the resident’s visual impairment and lack of appropriate supervision and adaptive equipment contributed to the accident.
A resident with CHF and multiple comorbidities was readmitted from the hospital with an order for metolazone 2.5 mg PRN, to be given only when weight increased by 5 lbs over baseline and 30 minutes before Lasix. Due to incorrect transcription of the hospital discharge orders into the EMR by the ADON, and the absence of a required second-nurse verification, metolazone was entered and administered as a scheduled daily medication instead of PRN. Nursing staff gave the drug daily for eight days without confirming the weight-based parameter, including on days when no weight was obtained and when the resident’s weight was stable or decreasing. During this period, the resident experienced a 12–14 lb weight loss, marked weakness, fatigue, excessive somnolence, and was later found to have hypokalemia, while continuing on other diuretics (Lasix and spironolactone). Interviews with the resident, her representative, nursing staff, the DON, PCP, and pharmacist linked these changes to the medication error, which did not follow the prescriber’s PRN order or the facility’s medication error policy.
The facility failed to maintain a full-time RN DON when the existing DON was reassigned as a temporary emergency NHA, leaving no separate RN designated to the DON role. Records showed the acting NHA held a temporary administrator permit while the staffing list indicated no full-time DON in place, despite a job description assigning the DON responsibility for 24-hour nursing oversight, staffing, and key clinical systems. Staff interviews revealed that nurses were unaware of the DON’s reassignment and continued to view this person as their direct supervisor, while the acting NHA reported performing both administrative and DON functions, including abuse coordination and state occurrence reporting, without any formal announcement or signage to inform staff, residents, or families of these role changes.
The facility’s QAPI program failed to identify and address critical quality of care issues related to resident change in condition, despite a written policy requiring comprehensive, data‑driven performance monitoring and corrective action. The facility had repeat F684 citations for quality of care and, in the current survey, was found to have not adequately assessed, monitored, documented, or communicated a resident’s change in condition, which was associated with the resident’s death and resulted in an immediate jeopardy finding. The MD reported he reviewed only those cases and policies presented to him and was unaware that the DON was also serving as the temporary emergency NHA amid leadership changes. The DON/acting NHA stated that QAPI meetings focused on standard topics and that change of condition evaluations were limited mainly to skin alterations and falls, acknowledging that staff were new to other types of change of condition assessments requiring thorough evaluation and provider/family notification.
A resident with CVA-related left-sided hemiplegia, who used a wheelchair and was cognitively intact, was moved to a different room after reporting strong chemical odors and refusing to return to the original room. Facility policy stated that staff would assist with packing and unpacking belongings for room changes, and staff reported that environmental services, nursing, or maintenance typically helped move items. In this case, however, staff repeatedly told the resident they could not move her belongings and would only escort her while she attempted to move them herself, despite her physical limitations. The NHA communicated by email that, due to prior disputes about handling of personal property, the resident was responsible for arranging family or third-party movers at her own expense, while staff would only provide access and oversight. As a result, most of the resident’s personal items remained in the original room for an extended period after she agreed to the permanent room change.
Failure to Prevent Resident-to-Resident Physical Abuse in Memory Care Unit
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from abuse, specifically resident-to-resident physical abuse between two cognitively impaired residents in the memory care unit. Facility policy required that residents be free from all forms of abuse and that staff immediately intervene, ensure resident safety, and keep residents separated and monitored when an assailant is identified. Despite this policy, the facility’s own investigation of an incident on 11/26/25 documented that two residents in the memory care unit became frustrated and agitated with each other, with elevated voices and defensive body language, and moved their arms as if they were going to hit each other. One resident sustained a superficial scratch above his left eyebrow, and the investigation concluded that the other resident likely made contact, resulting in the injury, and the incident was substantiated as physical abuse. One resident involved had Alzheimer’s disease and schizophrenia, was severely cognitively impaired with a BIMS score of 1, and required maximum assistance with ADLs. His care plan identified him as being at risk for resident-to-resident altercations related to individuals invading his space and at risk for re‑traumatization, with anxiety triggered by male caregivers or those perceived to be male. Interventions in his care plan included providing opportunities for positive interaction and attention, such as stopping and talking with him while passing by. On the date of the incident, a skin assessment documented a scratch above his left eyebrow, consistent with the facility’s determination that he was the victim of physical abuse by another resident. The other resident involved had Lewy body dementia, hypertension, and depression, was also severely cognitively impaired with a BIMS score of 0, and required maximum assistance with ADLs. His behavior care plan identified a risk for verbally abusive behaviors and potential psychosocial issues due to a prior incident in which he had received unprovoked agitation with physical abuse from another resident, with interventions including monitoring for signs of aggression, fear, or psychosocial trauma and documenting behaviors and interventions. An antipsychotic medication care plan further identified him as being at risk for aggressive behaviors, including non‑redirectable agitation, with instructions to intervene immediately if agitation was observed. Staff interviews indicated that only one staff member was assigned to seven residents on the unit, that residents sometimes got into each other’s space and fights occurred, and that the two residents had been seen in a fist fight on the date of the incident, demonstrating that the facility did not effectively prevent or intervene to stop resident‑to‑resident physical abuse in accordance with its abuse prevention policy and the residents’ care plans.
Failure to Thoroughly Investigate and Address Allegations of Sexual and Rough, Abusive Care
Penalty
Summary
The deficiency involves the facility’s failure to thoroughly investigate and document allegations of sexual abuse and rough, abusive care toward a resident. The facility’s abuse policy required that all reports of resident abuse be thoroughly investigated and documented. An investigation dated 2/24/26 addressed an allegation that a resident was sexually abused during incontinence care, but the investigation did not include interviewing the resident’s roommate about what he might have seen or heard during the alleged incident. The investigation concluded the allegation was unsubstantiated based on lack of physical trauma and staff statements, and it attributed the resident’s report to cognitive decline and terminal agitation, despite the resident’s clear and consistent account during the survey interview. The resident involved was under age 65 with diagnoses including bipolar disorder, anxiety, depression, PTSD, and traumatic brain injury. A recent MDS showed moderate cognitive impairment (BIMS 12/15), aggressive behavior, and delusions, and the resident was dependent on staff for toileting, transfers, and bed mobility, using a manual wheelchair. During the facility’s investigation, the resident reported that while yelling for help after a bowel movement, a CNA entered and began care, and then an LPN took over. The resident stated he did not want the LPN to provide care, tried to swat him away, and that the LPN grabbed his hands, rolled him aggressively causing his head to hit the wall, and inserted a finger into his anus four times while wiping, despite the resident yelling for him to stop. Staff statements conflicted with the resident’s account regarding who provided care and what occurred, and the facility did not investigate why staff did not stop care and have another staff member take over when the resident alleged abuse during the episode. The resident continued to report that staff were rough and that their approach to care felt abusive, including prior rough transfers by the same LPN and improper positioning and repositioning by other staff that caused pain and bruising. On the survey date, the resident described ongoing rough care, lack of staff responsiveness to his requests, and feeling that no one listened to or believed him. He reported that staff did not assist him to sit up properly for breakfast, resulting in difficulty eating and spilled food on his shirt. Observation during the interview showed the resident slouched and slumped to the left in his wheelchair, with his left arm hanging over the side, a bruise on his upper arm where the armrest was pressing, and dried oatmeal on his shirt from the morning meal. The resident’s care plan documented a history of false allegations and required care in pairs, investigation of all concerns voiced, and a calm, slow approach, but there was no specific care plan focus addressing his PTSD or his allegations of rough or abusive incontinence care, and the facility did not pursue his ongoing reports of rough and abusive treatment during personal care.
Failure to Assess, Notify, and Respond Appropriately After Unwitnessed Fall With Major Injury
Penalty
Summary
The deficiency involves the facility’s failure to provide treatment and care in accordance with professional standards following an unwitnessed fall. A cognitively intact resident with a history of falls, prior fractures (including a right humerus fracture), osteoarthritis, muscle weakness, and difficulty walking was admitted with orders and care plan interventions that included keeping the bed in the lowest position, use of a high-impact fall mat, and a lipped mattress. The resident required maximal assistance with transfers and used a wheelchair. On the night of the incident, the resident was found on the floor on her left side in a somewhat fetal position, partially on and partially off the fall mat, with the bed raised in a high position. RN #1, who heard a loud sound and discovered the resident on the floor, documented an initial assessment that included vital signs showing elevated blood pressure and initiation of neurological monitoring. However, there was no documentation that RN #1 completed a thorough head-to-toe assessment before the resident was moved back to bed, despite facility policy requiring a nurse evaluation to determine presence of injury prior to moving a resident who has fallen. The record lacked evidence of a full assessment of injuries at the time of the fall, even though the resident later was found to have multiple fractures and a scalp contusion. Staff interviews, including from the DON and other nurses, confirmed that standard practice and policy required a complete RN assessment before moving a resident after a fall. Following the fall, RN #1 did not notify the physician, the resident’s representative, or hospice at the time of the incident, despite facility policy and staff statements that the physician and responsible party should be notified immediately after the assessment. The resident’s blood pressure continued to rise over several hours, and she complained of pain, yet the first notification was to hospice at 6:00 a.m., approximately three hours after the fall. The hospice RN arrived around 6:30 a.m., found the resident arousable to verbal stimuli with tense features, facial grimacing, and reporting severe pain, and then notified the on-call physician, who ordered transfer to the hospital. Hospital imaging revealed a left parietotemporal scalp contusion, an acute nondisplaced C7 vertebral fracture, multiple displaced fractures of at least the first six left ribs, a left scapula fracture, and a left clavicle fracture. The facility also failed to ensure the resident’s bed was maintained at a safe, low height as care-planned, and the transfer to the hospital did not occur until after hospice assessment and physician notification several hours post-fall. The resident’s representative reported that the resident lay in bed for three hours in severe pain without medical attention and that the family and physician were not notified by facility staff, but rather by hospice. Documentation showed that the facility did not contact the resident’s representative until later that afternoon, after the hospital had already identified multiple fractures and the resident was being admitted to intensive or trauma care. Staff interviews, including from CNAs, an LPN, an RN, and the DON, consistently described that facility practice required immediate RN assessment before moving a resident, prompt vital signs and neurological checks, and immediate notification of the physician and responsible party after a fall, particularly if there was pain or potential major injury. In this case, the facility failed to accurately and timely assess the resident after the fall, failed to promptly notify the physician and responsible party, did not ensure the bed was at the lowest and safest height, and did not ensure timely transfer to the hospital after an unwitnessed fall that resulted in major injury and pain. The facility’s own fall care plan and incident policy emphasized prevention of avoidable accidents, completion of a nurse evaluation prior to moving a resident who has fallen, and documentation of injury status and notifications. Despite these requirements, the EMR lacked a full head-to-toe assessment at the time of the fall, and the DON acknowledged that RN #1, an agency nurse, failed to document the fall appropriately, complete an accurate assessment, and notify the physician and the resident’s representative. The hospice RN confirmed that RN #1 did not notify the physician or the resident’s representative and that hospice was contacted due to the resident’s increased pain and rising blood pressure. These actions and omissions collectively led to the cited deficiency for failure to provide treatment and care in accordance with professional standards and the resident’s care plan following the fall.
Transportation Safety and Fall Management Failures Leading to Resident Injuries
Penalty
Summary
The deficiency involves the facility’s failure to ensure an environment free from accident hazards and to provide adequate supervision to prevent accidents, particularly in relation to transportation safety and fall prevention. One resident with vascular dementia, bilateral lower extremity impairments, and dependence on staff for transfers was transported to an outside appointment in a facility vehicle while seated in a wheelchair without foot pedals. During the trip, the resident began sliding forward in the wheelchair. The transportation driver reported he could not immediately pull over while exiting the highway, and by the time he stopped, the resident had slid further forward so that her knees and legs were resting on a step behind the driver’s seat. The resident subsequently exhibited multiple bruises, abrasions, swelling of both legs, and severe pain. Facility records and later hospital documentation identified bilateral tibial fractures associated with this transport incident. The report details that the wheelchair was secured with a four‑point tie‑down, but the resident’s body was not properly restrained. The driver later demonstrated that he had routed the shoulder portion of the seat belt around the back of the van seat instead of across the resident’s shoulders, and placed the lap portion across the resident’s chest instead of her lap. He acknowledged this was not the proper use of the seat belt and attributed his actions in part to concern about disturbing the resident’s ostomy bag. He also stated that the resident was sitting on a blanket and a Hoyer sling, which he believed contributed to sliding, and that the absence of foot pedals left nothing to stop the resident’s forward movement. The facility’s own transportation policy required that drivers and passengers wear seatbelts and shoulder harnesses any time the vehicle was in motion and that wheelchairs be made secure with straps, but there was no evidence that the seat belt system was applied as intended in this case. The report further identifies systemic issues in transportation training and oversight that contributed to the deficiency. The van driver had been in the role for a little over a month and was trained informally by the central supply coordinator, who herself had been trained years earlier by a prior driver without documented competencies, checklists, or reference to an operations manual. The central supply coordinator reported no additional training or competencies since that initial instruction and was unaware of any policy or procedure for driving emergencies or clear guidance on whom the driver should contact for clinical or mechanical emergencies during transport. The maintenance director, responsible for monthly checks of the van, used a generic medical transport checklist, had no van‑specific training or competencies, and was unsure whether an operations manual was available. The administrator acknowledged that she was not sure what competencies the trainer had when she trained the current driver, that the DON and ADON were not trained on transportation, and that no investigation was completed into the driver’s admitted misuse of the seat belt. Collectively, these actions and inactions led to the transportation‑related accident and constituted a failure to maintain an accident‑free environment and adequate supervision. In addition, the deficiency includes failures related to fall management for two other residents at high risk for falls. One resident with vascular dementia, muscle wasting, difficulty walking, and severe cognitive impairment experienced 16 falls over a defined period, including an unwitnessed fall that resulted in a facial laceration and a maxillary sinus fracture requiring emergency department evaluation. The facility had a fall management policy requiring IDT review of falls and individualized care plan interventions, and the resident’s care plan contained multiple fall interventions such as scheduled toileting, prompted voiding, use of a non‑recording video monitor, and assistance with transfers. However, the report notes that care‑planned fall interventions were not consistently implemented in a timely manner, and surveyor observations during the survey period showed that staff were not consistently following the resident’s fall interventions. The report also notes that the IDT did not consistently review falls in a timely manner or ensure that recommended interventions were implemented. For the high‑risk resident with multiple falls, IDT notes documented repeated unwitnessed and witnessed falls associated with poor safety awareness, failure to use the call light, weakness, and attempts to ambulate or transfer without assistance. New interventions such as occupational therapy evaluations, room relocation closer to staff, and pharmacy review were recommended, but one occupational therapy evaluation was recommended after a fall even though it had already been recommended after a prior fall, indicating delays or gaps in implementation. Another resident with multiple falls had no timely identification and documentation of fall interventions after several falls. These patterns demonstrate that the facility did not ensure timely IDT review of falls or consistent implementation of care‑planned fall interventions, contributing to repeated falls and at least one major injury. Overall, the cited deficiency encompasses the facility’s failure to safely transport a dependent, cognitively impaired resident in accordance with its own transportation safety policy, resulting in bilateral tibial fractures, and its failure to consistently implement and timely review fall prevention interventions for residents at high risk for falls, including residents who sustained multiple falls and a serious injury.
Removal Plan
- Temporarily suspend all facility resident transportation services and transfer transportation to an outside company pending completion of training and validation.
- Immediately remove all staff members assigned transportation responsibilities from transportation duties pending completion of retraining and competency validation.
- Transport residents requiring appointments using medical transportation services through external transportation companies.
- Implement a resident transportation risk assessment tool to identify residents who require special transportation precautions; assess all residents who utilize facility transportation using this tool.
- Implement a comprehensive transportation safety program including: updated Transportation Safety Policy; Transportation Driver Job Description with defined safety duties; Transportation Staff Competency Validation process; Pre-Transport Safety Checklist (reviewed by administrator or designee); Transportation Special Circumstances Protocol; Transportation Incident Investigation Template; Transportation Safety Training Program; and Transportation Safety QAPI Monitoring Process.
- Require wheelchairs to be secured using a four-point tie-down system.
- Require residents to be secured with lap and shoulder seatbelts.
- Verify wheelchair brakes and foot pedals prior to transport by the administrator or designee.
- Confirm resident stability before departure by the administrator or designee.
- Evaluate residents’ medical devices/special medical circumstances individually (e.g., ostomies, indwelling urinary catheters, suprapubic catheters, oxygen equipment, other devices) and implement appropriate precautions prior to transportation as necessary.
- Provide mandatory transportation safety training for all transportation staff (wheelchair securement, restraint placement, medical device accommodations, emergency response); document attendance and validate competency using a checklist, with validation by the maintenance director and clinical liaison/designee as approved by the administrator.
- Complete a Pre-Transport Safety Checklist prior to each transport verifying wheelchair brakes engaged, foot pedals attached, four-point tie-down secured, lap and shoulder restraints applied, medical devices protected, and resident stability confirmed (completed by Maintenance Director and Clinical Liaison/Designee).
- Use a transportation incident ad hoc QAPI tool to ensure structured review of any transportation-related incident (incident description, equipment review, root cause analysis, corrective action planning).
Failure to Assess and Respond to Resident Intoxication and Change in Condition Resulting in Death
Penalty
Summary
The deficiency involves the facility’s failure to ensure that a resident with multiple complex medical conditions received treatment and care in accordance with professional standards of practice following a clear change in condition related to alcohol intoxication. The resident had diagnoses including alcoholic polyneuropathy, history of traumatic brain injury, CHF, type 2 diabetes mellitus, alcoholic cirrhosis of the liver, hypertension, long-term anticoagulant use, and alcohol use with an unspecified alcohol-induced disorder. His MDS showed severe cognitive impairment and functional dependence for many ADLs, though he typically ambulated without a mobility device. Physician orders included monitoring for potential substance use each shift and documenting and notifying the physician if any substance use indicators were noted, but the January TAR documented no substance use behaviors for that month. On the day of the incident, the resident signed out of the facility in the morning and was later found outside the facility grounds by bystanders, yelling for help and lying on the ground near a hotel with a shopping cart. Police dispatch records show multiple calls reporting the resident on the ground and yelling for help, and the police ultimately identified him and returned him to the facility. The police reported to staff that the resident was intoxicated and had been wandering. Upon return, he required wheelchair transport from the front door to his room, despite normally walking without assistive devices. According to an IDT note, officers assisted him in removing his shoes and coat and helped him into bed, after which he was observed resting in his room, but no time or assessment details were documented. Record review revealed no documentation that nursing staff completed a change of condition assessment, a post-fall or post-ground-level event assessment, or any RN assessment when the resident was returned by police in an intoxicated state. There was no documentation of vital signs, head-to-toe assessment, skin evaluation, or monitoring between the time of his return and the time he was later found unresponsive. The physician and the resident’s legal guardian were not notified of his intoxication or change in condition, and there was no progress note describing his condition upon return or how he was transferred to bed. The resident’s comprehensive care plan contained no care plan addressing alcohol use, intoxication, or potential substance use, and there were no interventions related to his known history of alcohol abuse and drinking while away from the facility. Staff interviews, including with the DON/acting NHA, ADON, and RNs, confirmed that no change of condition assessment, vital signs, or physician/guardian notifications were completed despite their own descriptions of what should occur when a resident returns intoxicated. The resident was later found face down on the floor in his room, unresponsive, and was pronounced dead; his death certificate listed respiratory failure, aspiration event, and alcoholism as the causes of death. The facility also failed to promptly recognize and investigate the incident as an unexpected death associated with a significant change in condition. A frequent visitor reported that the DON/acting NHA initially did not believe an occurrence report was required for the resident’s intoxicated return and unexpected death, and the occurrence report to the state was not submitted until eight days after the death. There was no evidence of an immediate, thorough internal investigation or root cause analysis at the time of the event to determine why nurses did not complete a change in condition assessment or follow the existing physician order to monitor for substance use and notify the physician. Surveyors determined that the facility did not thoroughly assess and monitor the resident’s alcohol use and change in condition, did not document changes, and did not seek medical treatment or notify the physician and guardian when required, and that these failures contributed to serious harm and death for the resident.
Removal Plan
- NHA notified the facility medical director of the incident.
- Nursing supervisors/designees completed physical assessments/interviews on all residents to identify any changes in condition and notified the physician of any noted changes.
- Initiated a look-back audit of current and discharged residents to ensure change-of-condition policy was followed.
- Identified one current resident without a required 72-hour alert monitoring order; educated the assigned nurse regarding timely initiation of the 72-hour alert monitoring order after completing the eINTERACT change-in-condition evaluation.
- Initiated the missing 72-hour change-in-condition alert monitoring order for the identified resident, including nursing assessments and documentation on the TAR and in progress notes each shift for three days per physician-indicated frequency.
- Reviewed resident change-in-condition and notification policies/procedures for clinical accuracy.
- Educated all nursing staff on addressing changes of condition (assessment, monitoring, physician/family notification, orders, and facility policies/procedures); staff were not permitted to work a shift until education was completed.
- Educated new hires (licensed nurses and nurse aides) during orientation on change-of-condition and physician/family notification requirements and facility policies/procedures.
- DON/designee to conduct audits five times per week for three months of the 24-hour report and progress note report to ensure change-of-condition policies/procedures are followed.
- DON/designee to conduct daily nursing staff huddles Monday through Friday to monitor for changes in resident condition.
- Regional director of clinical services and regional vice president to provide clinical/administrative oversight to ensure education and audits are completed and accurate.
- DON educated by the CNO on appropriately addressing changes of condition (assessment, monitoring, physician orders, and facility policies/procedures).
- DON/designee to complete chart audits to verify detailed assessments/documentation and physician/family notification related to changes of condition.
- Regional Director of Clinical Services to visit the facility to provide general oversight and monitoring of the plan.
Burn Injury from Improperly Heated Hot Beverage and Inadequate Supervision
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from accident hazards and received adequate supervision when provided a hot beverage. A resident with diagnoses including a displaced intertrochanteric fracture of the left femur with routine healing, unspecified cataract, unspecified macular degeneration, disorientation, and restlessness and agitation requested very hot tea. The resident had moderate cognitive impairment with a BIMS score of 11 and was care planned as needing set-up assistance with eating and drinking. Although an MDS assessment indicated adequate vision without corrective lenses, subsequent care planning documented vision impairment related to cataracts, macular degeneration, and diplopia, and that the resident wore an eye patch and glasses. On the day of the incident, the resident asked a physical therapy assistant (PTA) to make her tea “very hot.” The PTA dispensed hot water for tea from the kitchenette coffee machine and then heated the beverage in a microwave for an additional 30 seconds at the resident’s request. The PTA then secured a lid on the cup and placed it on the resident’s bedside table. The facility’s Hot Beverage policy, in effect at the time, stated that hot beverages were to be served at a safe, palatable temperature, that hot beverage machines were to be set and maintained at manufacturer-recommended temperatures, and that microwaves were not to be used to reheat hot beverages if the temperature was not considered palatable; instead, a fresh cup was to be poured. The policy also directed staff to report safety or decline in managing hot beverages to the IDT or therapy for review and possible care plan updates. After the PTA placed the lidded cup at the bedside, the visually impaired resident attempted to drink the tea but could not locate the opening in the lid due to her macular degeneration. The resident then attempted to remove the lid independently, during which the hot tea spilled onto her right forearm and right posterior thigh. Nursing assessment documented bright red, blanchable burns with a broken blister on the arm, and measurements of 8 cm by 5 cm on the arm and 12 cm by 22 cm on the thigh. The NP assessed the injuries as second-degree partial thickness burns involving approximately 6% total body surface area, with the resident reporting pain of 3 out of 10 and denying numbness, tingling, fevers, or chills. Subsequent documentation showed the wounds progressing with scabbing and epithelial tissue formation prior to the resident’s discharge home. Staff interviews confirmed that, following the incident, it was recognized that the tea had been heated beyond the temperature at which it was dispensed from the coffee machine and that the resident’s impaired vision contributed to her difficulty using the standard lidded cup. The DON and RN stated that the PTA had reheated the tea in the microwave without checking the temperature and then served it to the resident, contrary to the facility’s policy prohibiting reheating of facility-provided drinks in microwaves. The dietary manager and nursing staff also indicated that the facility’s practice was to avoid reheating hot beverages and to rely on the coffee machine settings, which were kept at or below 160°F, rather than using microwaves for additional heating. These actions and inactions led to the resident being provided an excessively hot beverage in a manner that did not account for her visual impairment, resulting in the burn injury. The facility’s failure centered on not adhering to its own Hot Beverage policy and not adequately supervising or accommodating the resident’s known visual impairment when providing a very hot beverage. The PTA’s use of the microwave to further heat the tea, the absence of a temperature check before serving, and the placement of a standard lid that the visually impaired resident could not safely manage independently all contributed to the incident. The care plan at the time identified the resident as needing set-up assistance and, after the incident, was updated to include interventions such as encouraging the resident to leave lids on hot beverages and to use the call light for assistance with lids, indicating that these precautions were not in place or not implemented at the time of the burn event.
Failure to Follow PRN Diuretic Order Leads to Significant Weight Loss and Hypokalemia
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors when a diuretic, metolazone, was entered and administered as a scheduled daily medication instead of as a PRN medication with specific weight-based parameters. After an acute hospitalization for conditions including acute on chronic CHF, acute respiratory failure with hypoxia, COPD, atrial fibrillation, hypertension, morbid obesity, COVID-19, and MDRO history, the resident was readmitted to the facility. The hospital discharge order specified metolazone 2.5 mg to be taken once daily as needed for pulmonary edema due to chronic heart failure, only when the resident had a weight gain of 5 lbs over baseline, and to be given 30 minutes prior to Lasix. However, when the orders were transcribed into the facility’s EMR on readmission, metolazone was entered as a scheduled daily medication without PRN parameters, and this incorrect order did not match the hospital discharge instructions. The assistant DON, who entered the readmission orders from the hard-copy discharge packet because the phone lines were down and the usual electronic admission process was not used, input metolazone as a daily scheduled medication. The normal process of having two nurses verify and enter orders was not completed; the ADON entered the orders alone, and the second nurse verification did not occur. As a result, nursing staff administered metolazone 2.5 mg daily for eight days, in addition to the resident’s other diuretics (Lasix and spironolactone), without confirming that the resident had experienced the required 5 lb weight gain from baseline. The MAR documented daily administration of metolazone over this period, including on days when no weight was obtained, and on days when the resident’s weight was stable or decreasing rather than increasing. During this time, the resident experienced significant weight loss and symptoms consistent with a change in condition. Weight records showed a decline from approximately 190 lbs prior to hospitalization to 176.6 lbs when the error was identified, reflecting a loss of about 12–14 lbs over a short period. The resident and her representative reported that she became severely weak, excessively tired, and felt she could not regain her strength, with the representative describing the resident as very tired, exhausted, and feeling as though she could not “hang on any longer.” Clinical documentation noted significant weakness, excessive sleepiness during therapy, and that the resident was triggering for significant weight loss. Laboratory testing later showed hypokalemia, with a potassium level of 3.2 mEq/L. Interviews with nursing staff, the DON, the ADON, the PCP, the pharmacist, the resident, and the resident’s representative consistently attributed the resident’s weight loss, weakness, and low potassium at least in part to the erroneous daily administration of metolazone instead of PRN dosing based on weight gain. The facility’s own medication error policy defined a medication error as preparation or administration of medications not in accordance with the prescriber’s order, manufacturer’s specifications, or accepted professional standards, and defined a significant medication error as one that causes resident discomfort or jeopardizes health and safety. In this case, the metolazone order in the EMR did not reflect the prescriber’s PRN order with weight-based parameters, and the medication was administered without verifying the required 5 lb weight gain. The resident’s care plan for diuretic therapy called for administering diuretics as ordered, monitoring for side effects such as fatigue and increased fall risk, and reporting pertinent lab results, including potassium. Staff interviews acknowledged that the error persisted for about eight days, that medication reconciliation was not completed upon readmission, and that the lack of a second nurse verification contributed to the error. The pharmacist and PCP described the effects of metolazone, especially in combination with Lasix, as including electrolyte abnormalities, weight loss, and weakness, and characterized the error as moderate, with the potential to increase electrolyte depletion and require close monitoring.
Failure to Maintain a Full-Time RN Director of Nursing During Temporary NHA Appointment
Penalty
Summary
The deficiency involves the facility’s failure to designate a registered nurse (RN) to serve as the full-time director of nursing (DON) while the existing DON was reassigned to act as the temporary emergency licensed nursing home administrator (NHA). Record review showed that the acting NHA held an active temporary permit for emergency situations beginning on 12/30/25 and expiring on 3/30/26. A staffing list review revealed there was no full-time DON in the building during this period. The DON job description, signed by the DON, specified that the DON’s primary purpose was to plan, organize, develop, and direct nursing operations, ensure quality resident care on a 24-hour basis, oversee recruitment and hiring of licensed personnel, manage nursing schedules, monitor staffing levels, and oversee implementation of nursing service objectives, policies, and procedures, including key clinical systems such as infection prevention and control, psychotropic and controlled substance management, skin and weight systems, risk management, and hospice liaison. Staff interviews confirmed that the individual serving as the full-time temporary NHA was also functioning as the full-time DON, with no other person appointed to the DON role. The chief nursing officer stated that the temporary NHA was also acting as the full-time DON and reported not knowing there was a regulation preventing this. Nursing staff, including an LPN and an RN, reported they were unaware that the DON had been appointed as the temporary NHA and continued to view the DON as their supervisor. The acting NHA described performing both administrative and clinical leadership duties, including occurrence reporting to the state, serving as abuse coordinator and investigator, and leading stand-up meetings, while relying on two unit managers, an LPN assistant DON, and an infection preventionist to assist with clinical duties and audits. There had been no announcement to staff, residents, or families about the acting NHA appointment or her role as abuse coordinator, and there was no signage indicating this responsibility.
Failure of QAPI Program to Address Change in Condition Leading to Immediate Jeopardy
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective, comprehensive, data‑driven QAPI program that identified and addressed quality of care concerns, particularly related to changes in resident condition. The facility’s QAPI policy required ongoing tracking and measuring of performance, identification and prioritization of quality deficiencies, systematic analysis of underlying causes, and development and monitoring of corrective actions, with a focus on resident safety, health outcomes, and high‑risk or problem‑prone areas. Despite this written policy, the facility did not operate its QA program in a manner that prevented repeat deficiencies, as evidenced by prior citations at F684 (quality of care) in consecutive annual recertification surveys. Surveyors found that the QAPI committee failed to identify and address concerns related to quality of care by not ensuring that resident changes in condition were assessed, monitored, documented, and communicated when indicated. This failure rose to the level of immediate jeopardy and was associated with a serious adverse outcome resulting in a resident’s death. The cross‑referenced F684 citation states that the facility failed to provide quality care by not assessing, monitoring, documenting, and communicating a resident’s change in condition when indicated. The facility’s regulatory history showed that F684 had been cited twice previously at a D scope and severity, indicating a potential for more than minimal harm, isolated, without effective QA‑driven prevention of recurrence. Interviews further demonstrated gaps in the QAPI program’s functioning and oversight. The medical director reported he visited at least twice a month, reviewed cases and policies presented to him, and made changes based on what was brought forward in QAPI, but he was not informed that the DON was also serving as the full‑time temporary emergency licensed NHA for several months, and he described multiple leadership changes. The DON/acting NHA stated that QAPI meetings were held monthly and covered standard topics such as admissions, discharges, falls, staffing, abuse, infection control, and grievances, with use of audit tools and tracking spreadsheets. However, she acknowledged that while change of condition evaluations were being done for skin alterations and falls, staff were “new to the other types of change of condition assessments” that required thorough assessment and notification of the physician and family/guardian, and that change of condition evaluations beyond those limited areas had not been a focus of QAPI until after the incident that led to the immediate jeopardy finding.
Failure to Provide Timely Assistance With Resident Room-Change Belongings
Penalty
Summary
The deficiency involves the facility’s failure to reasonably accommodate a resident’s needs and preferences during a room change, specifically by not providing timely assistance with moving the resident’s personal belongings. The facility’s Room Change policy, revised April 2025, states that environmental services staff or a designee will assist residents to pack their belongings prior to a room change, and nursing staff will assist residents to unpack belongings and get settled into the new room. The policy does not specify who will physically move the belongings between rooms, but staff interviews indicated an expectation that environmental services, nursing, or maintenance staff would typically assist with moving items or furniture. The resident involved was under age 65 and had multiple diagnoses, including CVA with left-sided hemiparesis and spastic hemiplegia, coronary artery disease, hyperlipidemia, depression, ADHD, lower back pain, and muscle weakness. The resident was cognitively intact with a BIMS score of 15, used a wheelchair for mobility, and was independent with hygiene, toileting, bathing, and dressing, but required setup and cleanup assistance with eating. The resident had documented verbal behavioral symptoms such as yelling and cursing, and a behavior care plan that included communicating via email and following up on concerns in a timely manner. The resident reported irritation of the nose and eyes and refused to return to her original room after complaining of a strong smell of ammonia and bleach, and staff assisted her into another room that night so she could sleep. Following this move, the resident requested assistance from staff to bring toiletries, a plant, and other personal items from the original room to the new room. Progress notes documented that staff told the resident they were not allowed to move her belongings and could only accompany her while she moved them herself, despite her left-sided hemiplegia and inability to move the items independently. The resident stated she was told she needed to move the items herself or arrange for someone else to move them and that she felt she should not have to pay to move her own items because the facility had offered the room change. Email communications show that the NHA characterized the room change as an accommodation requested by the resident and informed her that, due to prior concerns about staff handling her property, her belongings should be moved by family, an authorized representative, or a third-party mover at her own expense, with staff only providing access and oversight. The resident agreed to permanently move to the new room, but most of her belongings remained in the previous room, and staff continued to only escort her to retrieve items herself. Staff interviews confirmed that, in typical room changes, families or staff would assist with moving belongings, and that in this case the facility did not expect the resident to move her own items but also did not provide direct assistance or documented resources for moving services. The permanent move of the resident’s belongings did not occur until 39 days after she agreed to the room transfer, during which time the majority of her personal items remained in the original room.
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