Eagle Ridge Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Grand Junction, Colorado.
- Location
- 2425 Teller Ave, Grand Junction, Colorado 81501
- CMS Provider Number
- 065286
- Inspections on file
- 24
- Latest survey
- February 4, 2026
- Citations (last 12 mo.)
- 8 (1 serious)
Citation history
Health deficiencies cited at Eagle Ridge Post Acute during CMS and state inspections, most recent first.
A resident with type 1 DM and a history of low BG had orders for Lantus 29 units HS and Humalog per sliding scale before meals. An RN mistakenly administered 29 units of Humalog instead of the ordered Lantus at bedtime, then administered the Lantus as well without first consulting a provider. The RN instructed the resident to self-monitor BG every 20–30 minutes and encouraged intake of sugary foods, but did not perform or document serial BG checks, vital signs, or a full assessment. Despite notifying the DON and the on-call service, the RN did not immediately send the resident to the ED as directed, instead delaying EMS transport for several hours while the resident’s BG dropped to severely hypoglycemic levels, ultimately requiring EMS-administered oral glucose and hospital monitoring for recurrent hypoglycemia.
The facility failed to ensure required training was completed and documented for most staff, including annual abuse identification/prevention/reporting, dementia management, resident rights, QAPI, effective communication for all direct care staff, infection control, compliance and ethics, and behavioral health. Record review showed large numbers of staff without evidence of completion, missing sign-in sheets for in-services, and training modules without documentation of use. In interviews, the NHA reported that most training, including abuse and dementia, had been completed and described onboarding and lunch-and-learn processes, but could not locate records to verify staff participation. The regional nurse consultant acknowledged that the existing training plan was not effective in ensuring staff received all required education.
The facility did not provide required annual training on abuse, neglect, exploitation, misappropriation of resident property, and dementia care to most staff. Policy required facility-wide training on abuse prevention, identification, reporting, stress management, and managing verbally or physically aggressive resident behavior. When surveyors reviewed training records, they found that 75 of 83 staff had not received annual abuse training since 2024, and the available materials did not show comprehensive education on all types of abuse, prevention strategies, timely reporting requirements, or evidence-gathering methods. In interviews, the NHA and ADON reported that training was primarily done at onboarding and stated that all staff had received abuse and dementia care training, but this conflicted with the documented records showing the last extensive abuse-prevention training occurred in 2024.
A resident with a known fish allergy was served a meal containing tilapia after staff failed to check the diet ticket for allergies, resulting in the resident experiencing anaphylactic shock and requiring ICU hospitalization.
The facility failed to promptly notify representatives for two residents about significant changes, including a new anticoagulant prescription after a cardiology appointment and a transfer to the hospital for hip pain and mobility issues. In both cases, the representatives learned of the events from sources other than facility staff, and there was no documentation in the EMR of timely notification.
A resident with severe cognitive impairment and a history of wandering was not protected from verbal and physical abuse by another resident with dementia and behavioral symptoms. Despite multiple altercations, care plans did not address the risk of abuse, documentation was incomplete, and staff were not consistently informed or educated about necessary interventions to prevent further incidents.
A resident with complex medical and behavioral needs was transferred to the hospital after exhibiting aggressive behaviors. The facility refused to readmit the resident after stabilization, did not obtain physician documentation for discharge, failed to provide required ombudsman contact information, and did not reassess the resident for return. The discharge process lacked regulatory compliance and proper communication with the resident's representative.
A resident with a history of depression, developmental delay, and behavioral disturbances did not receive required psychiatric consultation or individual therapy, despite escalating behaviors and a care plan specifying these services. Facility staff confirmed that mental health counseling was not provided due to a lapse in contracted services, and documentation showed ongoing behavioral incidents without appropriate specialized interventions.
The facility failed to promptly address resident grievances regarding long wait times for call light responses, particularly during night shifts and weekends. Multiple residents reported excessive delays, with some waiting over 45 minutes for assistance. Despite the facility's grievance policy, there was inadequate follow-up and resolution of these complaints, as confirmed by call light logs and resident council minutes. Staff interviews revealed a lack of awareness and communication regarding the grievances, contributing to the deficiency in care.
A resident with paraplegia and quadriplegia in an LTC facility was not assisted in turning in bed as requested, despite being dependent on staff for all care. The facility's policy emphasized the resident's right to self-determination, but staff cited constraints and did not accommodate his requests, leading to the resident's frustration. Interviews revealed that the resident's care preferences were not consistently honored, contributing to the deficiency.
A resident did not receive a full course of prescribed antibiotics following surgery due to the facility running out of the medication. Despite having a backup system, the facility failed to administer all doses, and there was no documentation of notifying the physician or pharmacy. Staff interviews revealed a lack of communication and understanding of the medication refill process.
A resident experienced severe weight loss due to inadequate nutritional care in an LTC facility. Despite significant weight loss over several months, the facility failed to assess the resident or implement new nutrition interventions. The resident expressed dissatisfaction with meals, leading to skipped meals and hunger. Staff interviews revealed a lack of communication and follow-up on the resident's weight loss, with no consistent weight monitoring or updated care plans.
The facility failed to maintain an effective infection control program, with housekeeping staff not adhering to proper cleaning protocols and staff not using PPE for residents on enhanced barrier precautions. Additionally, residents were not offered hand hygiene before meals, and soiled linens were not changed after wound care. The facility also lacked an effective water management plan, indicating significant gaps in infection control practices.
The facility's QAPI program failed to effectively identify and address compliance concerns, leading to multiple deficiencies in resident care, staff training, and infection control. Interviews revealed that the QAPI committee did not conduct thorough reviews, and several areas of concern were overlooked, resulting in failures across various operational aspects, including resident grievances, medical equipment provision, and emergency preparedness.
The facility did not have a designated infection preventionist (IP) with adequate time to manage the infection prevention and control program, affecting all 74 residents. The DON was serving as the IP but could not effectively fulfill both roles. The ROM recognized the issue and was working to hire another staff member for the IP role.
The facility failed to provide food that was palatable, attractive, and at the correct temperature. Residents reported issues with food being under-seasoned, cold, and bland. Surveyors observed that meals were not served at appropriate temperatures, with specific issues like mushy lima beans and overcooked garlic toast. Staff interviews confirmed improper food storage practices, contributing to these deficiencies.
The facility failed to address grievances related to call light response times, as residents reported long waits for assistance. Despite some staff education and attempts to resolve the issue, the problem persisted, with call light logs confirming prolonged wait times. Staffing issues, particularly during night shifts, contributed to the delays, leading to the deficiency.
The facility failed to coordinate PASRR Level II evaluations for five residents with documented mental health needs, resulting in a deficiency. These residents, with diagnoses such as anxiety, bipolar disorder, and major depressive disorder, were identified as needing Level II evaluations, which were not completed. The Social Services Director cited unfamiliarity with the PASRR system as a reason for the oversight.
The facility did not complete annual performance reviews or provide in-service education based on these reviews for several CNAs. The DON was unaware of the requirement to link training to performance reviews, and the NHA acknowledged the need for a better tracking system. One CNA reported never having completed a performance evaluation.
The facility failed to maintain sanitary conditions in the kitchen and unit refrigerators. The dietary director did not follow proper hand hygiene protocols, using the same gloves for multiple tasks without washing hands. Additionally, food items in the kitchen and unit refrigerators were found unlabeled and undated, indicating improper food storage practices. The dietary director acknowledged these issues and expressed uncertainty about the shelf life of certain items.
The facility failed to maintain safe operating conditions for patient care equipment by using non-medical grade blood pressure cuffs. An LPN and an RN were observed using blood pressure cuffs not rated for medical use on residents. The nursing home administrator confirmed the lack of documentation supporting the safety or accuracy of these devices for medical use.
The facility failed to provide annual training on abuse prevention and dementia management to certain staff members, including the activities assistant, cook, and housekeeper. Training records and staff interviews revealed that these staff members had not participated in the required training over the past year, despite facility policies mandating such education. The nursing home administrator and director of nursing were unable to provide evidence of completed training and acknowledged the oversight.
The facility failed to ensure CNAs received the required 12 hours of annual in-service training, including dementia management and abuse prevention. A review of training records showed that four CNAs did not meet these requirements. Interviews revealed a lack of awareness and documentation regarding training needs, with the DON unaware of the need to document training lengths and the NHA acknowledging training as a work in progress.
A resident experienced an unwitnessed fall while transferring from bed to scooter, but the facility failed to notify the resident's representative, who was also the power of attorney and emergency contact. The facility's policy requires such notifications, but documentation showed only the resident was informed. The DON confirmed the family should have been contacted.
A resident at moderate risk for falls experienced two falls during her stay at an LTC facility. The facility failed to assess and report the falls, particularly after the resident sustained facial injuries. The resident was also allowed to smoke unsupervised, contrary to the facility's policy, leading to a second fall. The care plans did not include necessary interventions for fall prevention or safe smoking practices, indicating a lapse in ensuring resident safety.
A facility failed to manage a resident's personal funds account properly by not obtaining signed authorization for withdrawals. The resident had three unauthorized withdrawals, and the business office manager admitted to not requiring receipts or signed authorization from the resident's legal representative. The BOM was unaware of the need for resident authorization and planned to audit accounts to update consent forms.
A facility failed to provide a resident with a Notice of Medicare Provider Non-Coverage (NOMNC) at least two days before the termination of Medicare Part A services, as required. The resident received the notice on the last day of coverage, preventing an opportunity to appeal. The admission/discharge coordinator was unaware of the notification requirement and lacked a system to confirm or track the delivery of NOMNCs.
A resident reported feeling threatened by a staff member during a billing discussion, but the facility failed to investigate the allegation as required by their abuse prevention policy. The resident, who was cognitively intact and had a history of paraplegia and depressive episodes, expressed fear of retaliation. The NHA did not consider the incident as abuse initially, despite the facility's policy stating that threats are considered abuse. An investigation was only initiated during a survey, highlighting a delay in addressing the resident's concerns.
A resident discharged to another LTC facility had an incomplete discharge summary, missing key information such as functional status, continence, vision, behavior, cognitive status, and lab results. The interdisciplinary team was responsible for completing the summary, but several sections were left unfinished, as confirmed by staff interviews.
A resident over 65 with chronic conditions did not receive new eyeglasses despite having a prescription from an eye doctor. The facility failed to assist the resident in obtaining the glasses, resulting in the resident experiencing blurry vision. The oversight was confirmed through interviews and record reviews, revealing a lack of documentation for the replacement of the eyeglasses.
A facility failed to discontinue a resident's PRN lorazepam order after 14 days, as required. The resident, with diagnoses including COPD and major depressive disorder, had a 90-day PRN order without documented rationale. Staff interviews revealed a lack of awareness about the 14-day limit for PRN psychotropic medications, and the pharmacist had not reviewed the order due to being behind schedule.
The facility failed to properly secure medication storage and maintain consistent temperature logs for medication refrigerators. A medication cart was found unlocked, and there were gaps in temperature documentation despite a performance improvement plan. Staff interviews confirmed the need for better adherence to procedures.
Two residents with dysphagia were not provided with the correct mechanically altered diets as per their physician orders. One resident received a regular sandwich and soup, while another was served regular spaghetti and meatballs. The dietary director admitted to not offering the prescribed diet to reduce food waste and was unaware of serving incorrect textures. Staff interviews highlighted the importance of following diet orders to prevent aspiration or choking.
A facility failed to ensure hospice agency notes were accessible to staff, affecting care coordination for a resident with COPD and prostate cancer. The resident was unaware of receiving hospice services, and there was no physician's order in the EMR. Staff interviews revealed a lack of awareness and documentation, with hospice notes initially sent to the wrong contact. The issue was resolved after updating contact information.
A resident with limited range of motion did not receive restorative therapy services, despite recommendations from a physical therapy discharge summary. The resident, who had conditions such as COPD and muscle weakness, expressed concerns about becoming weaker and more dependent. Staff interviews revealed a lack of awareness and implementation of restorative therapy services, attributed to communication issues and staff turnover.
The facility did not post nurse staffing information daily as required. Observations showed no postings on two days, and records revealed a lack of maintained staffing data for 18 months. The DON, unaware of the requirement, stated that the facility had not used the necessary form for over four years.
Significant Insulin Medication Error and Delayed Response to Hypoglycemia
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident was free from significant medication errors related to insulin administration. The resident, who had type 1 diabetes mellitus and a history of low blood glucose levels, had physician’s orders for Lantus (insulin glargine) 29 units subcutaneously at bedtime and Humalog (lispro) insulin per sliding scale at 6:00 a.m., 11:00 a.m., and 4:00 p.m. On the evening in question, the RN responsible for medication administration drew up and administered 29 units of Humalog, a rapid-acting insulin, instead of the ordered 29 units of Lantus, a long-acting insulin, at the resident’s bedtime medication pass. After discovering that the wrong insulin had been given, the RN informed the resident of the error and then administered the Lantus insulin that had originally been ordered, without first consulting the resident’s physician. The RN documented that the resident was instructed to check her own blood glucose every 20–30 minutes and report the results, and she was encouraged to eat sugar-rich foods. The RN did not perform or document a full nursing assessment, including serial blood glucose checks performed by staff, vital signs, or evaluation of the resident’s cognitive or physical status, despite the known medication error and the resident’s history of low blood sugars. The RN notified the DON and called the on-call physician service but did not immediately send the resident to the emergency room as directed by the DON and as required by facility protocol for a significant insulin error and hypoglycemia. Instead, the RN waited approximately four and a half hours before arranging EMS transport, during which time the resident’s blood glucose fluctuated and dropped to 54 mg/dL, with no documented staff monitoring of vital signs or continuous assessment. EMS ultimately found the resident in a hypoglycemic state with a blood glucose of 42 mg/dL and provided oral glucose before transporting her to the hospital, where she was monitored and treated for recurrent hypoglycemia related to the excessive and incorrect insulin administration. Facility investigation and staff interviews confirmed that the RN failed to follow medication administration standards, physician orders, and the facility’s Management of Hypoglycemia policy. The investigation documented that there was no record of ongoing blood glucose monitoring by staff, no documentation of vital signs such as heart rate and blood pressure, and no timely implementation of emergency measures following the insulin overdose. The medical director later stated she was not notified at the time of the error and that, given the excessive amount of incorrect insulin, the resident could be at cardiac and neurologic risk, underscoring the seriousness of the medication error and the lack of appropriate clinical response by facility staff at the time of the incident.
Widespread Failure to Complete and Document Required Staff Training
Penalty
Summary
The facility failed to provide, implement, and maintain an effective training program for new and existing staff as required by its own In-Service Training policy. The policy, revised in April 2021, required all staff to participate in initial orientation and annual in-service training on topics including effective communication, resident rights, abuse prevention and reporting, QAPI, infection prevention, behavioral health, and compliance and ethics. Record review showed that 75 of 83 staff did not receive the required annual abuse identification, prevention, and reporting training; 39 of 83 staff did not complete dementia management training; 31 of 83 staff did not complete resident rights training; 30 of 83 staff did not complete QAPI training; 49 of 49 direct care staff did not complete effective communication training; 20 of 83 staff did not complete infection control training; 16 of 83 staff did not complete compliance and ethics training; and 13 of 49 direct care staff did not complete behavioral health training. Further review of training records revealed missing or incomplete documentation for several required topics. For dementia training, 39 staff lacked documentation of completion and no alternative in-service records were provided. For resident rights, the facility produced an in-service training document but no sign-in sheet to verify attendance. For QAPI, an in-service document and sign-in sheet were provided, but 30 staff still lacked evidence of completion. No direct care staff had documented completion of effective communication training, and although a copy of the training content existed, there was no proof it had been used. Infection prevention records showed some staff completed online and in-service training, but 20 staff still lacked required training. Compliance and ethics training records listed all staff on an online roster, but many had no completion dates and no documentation of use was provided. Behavioral health training records showed 13 staff without required online training and no in-service documentation. In interviews, the NHA reported that most training was done during onboarding, stated that about 91% of trainings were completed, and claimed all abuse and dementia trainings were finished, but she could not produce records to support these statements, and acknowledged that some training sessions such as lunch-and-learns were not documented. The regional nurse consultant stated the current training plan was not effective to ensure all staff were sufficiently trained as required.
Failure to Provide Required Annual Abuse and Dementia Training to Staff
Penalty
Summary
The facility failed to provide required annual staff training on abuse, neglect, exploitation, misappropriation of resident property, and dementia care, as required by its own Abuse policy and regulatory standards. The written policy, revised in April 2021, stated that the facility’s abuse, neglect, and exploitation prevention program included staff orientation and training on abuse prevention, identification and reporting of abuse, stress management, and handling verbally or physically aggressive resident behavior. Surveyors requested current training records for annual abuse and dementia training, and the records provided did not demonstrate that staff received thorough abuse training covering identification of all types of abuse, steps and measures to prevent abuse and neglect, techniques to prevent resident-to-resident altercations, requirements for timely reporting of abuse, and methods of gathering evidence for a complete investigation. Record review showed that 75 of 83 total staff members had not been provided annual abuse training since 2024. During interviews, the NHA and ADON stated that most training was done during onboarding and that all staff had been provided abuse and dementia care trainings, indicating they believed the trainings were completed. However, this statement was inconsistent with the documented training records, which showed that the last extensive training on abuse prevention occurred in 2024 and that the majority of staff lacked the required annual abuse training thereafter.
Failure to Prevent Allergen Exposure Resulting in Resident Hospitalization
Penalty
Summary
A deficiency occurred when a resident with a documented allergy to fish was served a meal containing tilapia. The resident, who had a history of anaphylaxis and other medical conditions including cognitive communication deficit and muscle weakness, consumed the fish during lunch. The resident was not aware the meal contained fish until after eating it, which led to the onset of itching and difficulty breathing. Staff interviews and facility investigation revealed that both the cook and the certified nurse aide involved in preparing and serving the meal did not check the diet ticket for allergies prior to sending and serving the tray. The cook had previously received a written warning and corrective education for a similar incident involving another resident and a known allergen. The failure to check the diet ticket and confirm the resident's allergies directly resulted in the resident being exposed to a known allergen. Following the meal, the resident developed symptoms consistent with anaphylactic shock, including altered consciousness, facial swelling, difficulty breathing, and low oxygen saturation. Emergency medical services were contacted, and the resident required hospitalization in the intensive care unit for treatment of anaphylaxis. The incident was confirmed through record review, staff interviews, and medical documentation.
Failure to Notify Representatives of Significant Changes and Events
Penalty
Summary
The facility failed to ensure timely notification of residents' representatives regarding significant changes in condition, medical appointments, and medication changes for two residents. In one case, a resident with multiple diagnoses, including diabetes, dementia, and atrial fibrillation, was sent to a cardiology appointment and subsequently started on an anticoagulant medication. There was no documentation in the electronic medical record (EMR) that the resident's representative was notified of either the appointment or the new medication order. Both the resident and the former representative confirmed that the representative only learned of these events after being informed by the resident, not by the facility. In another instance, a resident with a history of falls and muscle weakness reported hip pain and difficulty bearing weight. Although the facility documented the resident's symptoms and planned for further assessment and notification, there was no evidence in the EMR that the representative was informed of the change in condition or the subsequent transfer to the hospital for X-rays. The representative stated he was not notified by the facility about the resident's change in mobility or hospital transfer until several hours after the event, learning of the situation first from the outpatient physician's office. Facility policy requires prompt notification of residents, their attending physicians, and representatives regarding changes in condition or status. However, interviews with facility leadership revealed there was no standardized process for such notifications or for documenting them in the EMR. The lack of timely and documented communication with residents' representatives regarding significant changes and events led to the identified deficiencies.
Failure to Protect Resident from Abuse by Another Resident
Penalty
Summary
The facility failed to protect a resident with severe cognitive impairment and a history of wandering from verbal and physical abuse by another resident. The resident, who had diagnoses including dementia and Alzheimer's disease, was involved in multiple altercations with another resident who also had severe cognitive impairment, hallucinations, and delusions. Despite documented incidents of verbal threats and physical aggression, the care plans for both residents did not adequately address the risk of abuse or specify interventions to prevent further altercations. The facility's investigations confirmed that one resident verbally threatened and later physically assaulted the other, including an incident where staff witnessed the aggressor grabbing and choking the victim. Documentation in the electronic medical records was incomplete, with key incidents not fully recorded or followed up in progress notes. The care plans lacked updates to reflect the ongoing risk, and interventions such as the use of a stop sign barrier were delayed and not consistently implemented. Staff interviews revealed a lack of clear communication and documentation regarding the need for increased supervision and specific interventions to keep the residents apart. Some staff were unaware of the residents' history of altercations or the need for purposeful rounding and redirection. The director of nursing acknowledged that the residents should have been care planned for their risk of abuse, and the nursing home administrator noted deficiencies in timely staff education and documentation following the incidents.
Failure to Ensure Safe and Compliant Discharge Process
Penalty
Summary
The facility failed to ensure a safe and regulatory-compliant discharge process for a resident who was transferred to the hospital following behavioral incidents. The resident, who had a history of depression, developmental delay, suicide attempt, skin graft failure, muscle contractures, and a permanent tracheostomy, exhibited escalating behaviors including yelling, cursing, threatening staff, and attempting to tamper with his tracheostomy device. Following these events, the resident was transferred to the hospital by EMS after expressing threats to harm staff. Despite the hospital determining the resident was stable and did not require inpatient admission, the facility refused to allow the resident to return, citing inability to meet his needs and concerns for the safety of others. The facility did not provide documentation from a physician agreeing to the discharge, nor did it include a physician's order for discharge or a physician's signature on the discharge form. The discharge notice was issued 11 days after the resident's transfer, and the section of the form for ombudsman contact information was left blank. Additionally, the facility listed a receiving facility for discharge, but that facility denied the resident's admission. There was no evidence in the medical record that the facility reassessed the resident for readmission after he was stabilized at the hospital and ready to return. Interviews with the resident's representative, hospital staff, and facility staff confirmed that the facility did not follow its own discharge policy or regulatory requirements. The resident's representative was not informed of the right to appeal the discharge, and the admissions assistant expressed discomfort with the discharge process due to lack of proper notice and documentation. The NHA acknowledged that not all regulations were followed in the discharge process, and efforts to place the resident in another facility were unsuccessful. The resident remained at the hospital at the time of the interviews.
Failure to Provide Required Mental Health Services
Penalty
Summary
The facility failed to provide appropriate mental health treatment and services to a resident with a diagnosed mental disorder and psychosocial adjustment difficulties. The resident, under the age of 65, had a history of depression, developmental delay, suicide attempt, and required a permanent tracheostomy. The resident exhibited significant behavioral symptoms, including yelling, threatening, cursing, throwing items, striking out, grabbing others, and inappropriate sexual behavior. The care plan included interventions such as antipsychotic medications, behavior monitoring, and psychiatric consultation as indicated. The PASRR Level II determination specifically required specialized services, including psychiatric case consultation, individual therapy, and a neuropsychological assessment. Despite these documented needs and the resident's escalating behaviors, the facility did not arrange for psychiatric case consultation or individual therapy. Progress notes over several months documented repeated behavioral incidents, including aggression toward staff and other residents, and attempts to tamper with the resident's tracheostomy. Staff interviews confirmed that the resident did not receive individual therapy services during his stay, as the facility lacked a contract with a mental health provider for an extended period. The social services director and nursing home administrator both acknowledged the absence of these services, noting that a new contract for mental health services was only recently established, and that the previous provider had stopped coming to the facility some time ago. The lack of mental health services persisted even as the resident's behaviors increased, and there was no evidence in the medical record that the required specialized services were provided. Staff attempted to manage the resident's behaviors with medication adjustments and non-pharmacological interventions such as music, but these did not substitute for the required psychiatric and therapeutic interventions. The deficiency was identified through record review and staff interviews, which confirmed the facility's failure to provide the necessary mental health counseling and therapy services as required by the resident's care plan and regulatory requirements.
Facility Fails to Address Resident Grievances on Call Light Delays
Penalty
Summary
The facility failed to ensure prompt action was taken upon the filing of grievances by residents, specifically regarding the timeliness of call light responses. Multiple residents reported excessive wait times for assistance, with some waiting up to 45 minutes or more for staff to respond to their call lights. Resident interviews revealed that these delays were a common issue, particularly during night shifts and weekends, and that grievances submitted by residents were not adequately addressed or resolved by the facility. The facility's grievance policy required that grievances be reviewed and investigated within seven working days, with findings reported to the administrator. However, the facility did not adhere to this policy, as evidenced by the lack of timely follow-up on grievances submitted by residents. Resident council minutes also documented concerns about long wait times for staff assistance, but there was no evidence of action or response from the facility to address these concerns. Additionally, the facility's call light logs confirmed prolonged response times, further substantiating the residents' complaints. Interviews with facility staff, including the NHA, SSD, and DON, revealed a lack of awareness and communication regarding the grievances and the ongoing issue of delayed care. The NHA admitted to not thoroughly reviewing resident council minutes and not having an action plan to address the concerns raised. The SSD and DON were also unaware of specific grievances related to delayed care, indicating a breakdown in the grievance handling process. This failure to address and resolve grievances in a timely manner contributed to the deficiency in providing adequate care to residents.
Failure to Honor Resident's Dignity and Care Preferences
Penalty
Summary
The facility failed to ensure the dignity and respect of a resident who was dependent on staff for all care. The resident, who was cognitively intact and had diagnoses including complete paraplegia and incomplete quadriplegia, requested assistance to be turned in bed. However, the nursing staff informed the resident that his next scheduled turn was at a later time, which led to the resident expressing anger and frustration. The facility's policy emphasized the resident's right to self-determination and participation in care planning, but this was not upheld in the resident's case. The resident's care plans included interventions for frequent turning and repositioning to prevent pressure ulcers, as well as providing choices about his care. Despite these plans, the staff did not accommodate the resident's requests for repositioning, citing constraints such as the need for two staff members and a hoyer lift. Progress notes documented multiple instances where the resident's requests were not met, leading to his aggravation and dissatisfaction with the care provided. Interviews with staff members revealed that the resident was known to refuse care at times, but it was acknowledged that his requests should be accommodated. The Director of Nursing confirmed that the resident had the right to request repositioning and that it was crucial for his skin health. The DON also stated that it was unacceptable for staff to deny such requests and that care should be reoffered if initially refused. The inconsistency in honoring the resident's preferences and the failure to accurately document his care refusals contributed to the deficiency.
Failure to Administer Full Course of Antibiotics
Penalty
Summary
The facility failed to ensure that a resident received a full three-week course of antibiotics as recommended by the hospital following a surgical procedure. The resident, who was cognitively intact, had been admitted with a wound on her left big toe, which led to an amputation due to osteomyelitis. Post-surgery, the hospital prescribed a three-week antibiotic regimen, which included both intravenous and oral antibiotics. However, the facility did not administer all the required doses of the oral antibiotic, Augmentin, as prescribed. The medication administration record indicated that the resident received only 26 out of the 32 prescribed doses of Augmentin. The facility ran out of the medication on multiple occasions, and there was no documentation in the resident's electronic medical record indicating that the physician or pharmacy was notified about the missed doses. Despite having a backup medication system in place, the facility failed to utilize it to ensure the resident received the necessary medication. Interviews with staff revealed a lack of communication and understanding of the medication refill process. The medical director was unaware of the missed doses, and the licensed practical nurses were not informed about the medication shortage. The director of nursing stated that the staff should have contacted the pharmacy and informed her about the situation, but this did not occur. The failure to administer the full course of antibiotics was identified as a significant medication error.
Failure to Address Severe Weight Loss in Resident
Penalty
Summary
The facility failed to ensure that a resident received the necessary care and services to meet their nutritional needs, resulting in severe weight loss. The resident, who was admitted with chronic obstructive pulmonary disease (COPD), diabetes, and generalized muscle weakness, experienced a significant weight loss of 26 pounds (17.4%) over three months and 12.2 pounds (9%) in one month. Despite this severe weight loss, the facility did not assess the resident or implement any new nutrition interventions after the weight loss was documented on February 5, 2024. The resident expressed dissatisfaction with the meals provided, specifically mentioning the blandness of scrambled eggs served frequently for breakfast, which led to skipped meals and feelings of hunger. Observations confirmed that the resident often left the scrambled eggs untouched. The facility's records showed that the resident's weight was not monitored consistently, with no weights recorded for over four months after the significant weight loss was identified. The care plan did not reflect any new interventions to address the resident's nutritional needs following the weight loss. Interviews with staff revealed a lack of communication and follow-up regarding the resident's weight loss. The Registered Dietitian (RD) had verbally requested additional weights but did not document these requests, and the Director of Nursing (DON) acknowledged that the facility failed to identify and address the significant weight loss. The DON also noted that the facility had issues with obtaining and documenting weights, which had been identified by the Quality Assurance and Performance Improvement (QAPI) committee but not yet addressed with a correction plan.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by several deficiencies observed during the survey. Housekeeping staff did not consistently change gloves or perform hand hygiene when appropriate during room cleaning. They also failed to use disinfectant chemicals according to the manufacturer's instructions, not allowing the required dwell time for effective disinfection. Additionally, there was a communication barrier due to language differences, which hindered proper training and adherence to cleaning protocols. The facility also failed to ensure that staff donned appropriate personal protective equipment (PPE) when providing direct care to residents on enhanced barrier precautions (EBP). Observations revealed that staff assisted residents without wearing PPE, and there was a lack of clear signage and communication regarding which residents required EBP. Interviews with staff indicated a lack of understanding and training on EBP protocols, leading to non-compliance with infection control measures. Furthermore, the facility did not offer hand hygiene to residents before meals, and there was a failure to change soiled linens after wound dressing changes. Observations showed that residents were not provided with hand hygiene opportunities before eating, and soiled bedding was not replaced after wound care, potentially leading to contamination. Additionally, the facility lacked an effective water management plan, with inadequate documentation and assessment of potential risks for waterborne pathogens, such as Legionella, indicating a significant gap in infection control practices.
Ineffective QAPI Program and Multiple Deficiencies
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program, which is crucial for identifying and addressing compliance concerns to improve the quality of care, quality of life, and resident safety. The QAPI committee did not effectively identify and address issues related to residents' quality of care, quality of life, staff training, and infection prevention and control. The facility's policy outlined a comprehensive approach to problem-solving, including defining problems, analyzing root causes, setting measurable goals, implementing interventions, and monitoring performance. However, these steps were not effectively executed. The report highlights several specific deficiencies across various areas of the facility's operations. These include failures in responding to resident council grievances, obtaining proper consent for personal fund spending, notifying representatives of changes in resident conditions, and providing necessary medical equipment and services. Additionally, the facility did not adequately investigate potential abuse allegations, complete required assessments and documentation, or provide necessary training and evaluations for staff. There were also significant lapses in infection control practices, food service, and emergency preparedness. Interviews with the Nursing Home Administrator (NHA), Regional Operations Manager (ROM), and Director of Nursing (DON) revealed that while the QAPI committee met monthly and included an interdisciplinary team, the process was not thorough. The ROM admitted that the QAPI plan failed, as not all concerns discussed in morning meetings were brought to the committee for a full review. The DON acknowledged that some areas of concern were overlooked and emphasized the need for the committee to hold each other accountable and address all potential issues with fresh perspectives.
Inadequate Infection Preventionist Staffing
Penalty
Summary
The facility failed to ensure a qualified infection preventionist (IP) was designated to manage the infection prevention and control program (IPCP), potentially affecting all 74 residents. The facility's policy, revised in October 2018, required adherence to current infection prevention and control standards. However, observations during the survey period revealed multiple infection control failures. Interviews with the Director of Nursing (DON) and the Regional Operations Manager (ROM) highlighted that the DON was also serving as the IP, but lacked sufficient time to fulfill the IP responsibilities effectively. The ROM acknowledged the issue and mentioned efforts to hire another staff member to assume the IP role.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that residents consistently received food that was palatable, attractive, and served at the appropriate temperature. Multiple residents reported dissatisfaction with the food, describing it as under-seasoned, cold, bland, and sometimes over-seasoned or undercooked. Specific complaints included meals being delivered cold to rooms, food being processed and bland, and some residents skipping meals due to poor taste. These resident interviews highlighted a consistent issue with the quality and temperature of the food served. Observations by surveyors confirmed these complaints. A test tray evaluation revealed that the spaghetti and meatballs were served at 130 degrees Fahrenheit, below the desired temperature of 135 degrees Fahrenheit. The lima beans were mushy, bland, and appeared gray, while the garlic toast was overcooked, hard, and partially burnt. The chocolate pudding was not cold enough, measured at 54.5 degrees Fahrenheit, which is above the required temperature for cold foods. Staff interviews revealed that the pudding was not stored properly during meal service, contributing to the temperature issue. The dietary director acknowledged these temperature discrepancies and the need for proper food storage and serving practices.
Facility Fails to Address Call Light Response Time Grievances
Penalty
Summary
The facility failed to promptly address grievances related to call light response times, as reported by residents during council meetings. Residents expressed frustration over long wait times for assistance, with some waiting between five minutes to two hours. The facility's policy required grievances to be investigated and resolved, but the residents felt their concerns were not adequately addressed, as evidenced by unresolved issues documented in resident council minutes from December 2023 to June 2024. Interviews with residents revealed consistent complaints about call light response times, with several residents reporting waits of over an hour. The facility's grievance forms and resident council minutes indicated that the issue was ongoing, with no effective interventions implemented. Despite some staff education and attempts to address the problem, the residents continued to experience delays, and the facility's response was deemed insufficient. The facility's call light logs and audits further confirmed the residents' concerns, showing numerous instances of prolonged wait times. Staff interviews highlighted issues with staffing levels, particularly during night shifts, contributing to the delays. The facility's failure to implement a systematic approach to resolving the grievances and ensuring timely call light responses led to the deficiency.
Failure to Coordinate PASRR Level II Evaluations
Penalty
Summary
The facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program for five residents, resulting in a deficiency. These residents, identified as #26, #36, #4, #18, and #22, were all documented as needing a PASRR Level II evaluation, which was not completed. The PASRR Level I identification screens for these residents indicated the necessity for a Level II evaluation due to their mental health diagnoses, including generalized anxiety disorder, bipolar disorder, major depressive disorder, and intellectual disabilities. Resident #26, aged 71, was cognitively intact but experienced feelings of depression. Despite a PASRR Level I screen indicating the need for a Level II evaluation, no documentation of such an evaluation was found in the resident's electronic medical record (EMR). Similarly, Resident #36, aged 84, with severe cognitive impairment and depression, also lacked documentation of a completed Level II PASRR. Resident #4, aged 86, with moderate cognitive impairments and depression, had a provisional PASRR but no completed Level II evaluation. Resident #18, over 65 years old, was cognitively intact but also lacked a Level II PASRR despite the need being documented. Lastly, Resident #22, who passed away, had a PASRR Level I screen indicating a Level II was needed, but no evaluation was completed before their death. Interviews with the Social Services Director (SSD) revealed a lack of follow-up on PASRR evaluations, attributed to the SSD's unfamiliarity with the system due to being from another state. The SSD acknowledged the importance of completing PASRR evaluations to ensure residents receive appropriate mental health care. The deficiency was identified during a survey, highlighting the facility's failure to ensure necessary PASRR Level II evaluations were conducted for residents with documented mental health needs.
Deficiency in CNA Performance Reviews and Training
Penalty
Summary
The facility failed to conduct annual performance reviews and provide regular in-service education based on these reviews for four out of five certified nurse aides (CNAs) reviewed. Specifically, CNAs hired on various dates did not have completed performance reviews or in-service education plans tailored to the outcomes of such reviews. During interviews, the Director of Nursing (DON), who was also acting as the staff development coordinator, admitted to being unaware of the requirement to base in-service training on performance reviews. The Nursing Home Administrator (NHA) acknowledged the need for improvement in staff training and mentioned the absence of a reliable tracking system for performance evaluations. Additionally, one CNA reported never having completed a performance evaluation at the facility.
Sanitation and Food Storage Deficiencies
Penalty
Summary
The facility failed to maintain sanitary conditions in the main kitchen and unit refrigerators, as observed during a survey. The dietary director (DD) did not adhere to proper hand hygiene protocols while preparing food. Specifically, the DD was observed putting on gloves without washing hands, using the same gloves for multiple tasks, and handling food items without changing gloves or washing hands in between tasks. This lack of proper hand hygiene was acknowledged by the DD during an interview, where he admitted to not realizing the extent of his glove usage and the need for hand hygiene. In addition to hand hygiene issues, the facility did not properly label and store food items in the main kitchen refrigerator, freezer, and unit refrigerators. Observations revealed several food items, including a large bowl of meat and sauce, condiment containers, chopped lettuce, a chocolate pie, and cartons of egg whites, were either unlabeled or undated. Similar issues were found in the walk-in freezer, where items like puff pastry, raw beef hamburger patties, frozen potatoes, and egg rolls were uncovered and undated. Furthermore, thawed Mighty Shakes in unit refrigerators were not dated, indicating a lack of adherence to proper food storage and date marking protocols. Interviews with the DD revealed that dietary staff were required to label all food not in its original packaging, but this was not consistently done. The DD also admitted to being unsure about the shelf life of thawed health shakes and relied on the manufacturer's use-by date. The DD expressed an intention to personally oversee food delivery orders to ensure proper labeling and dating, highlighting a gap in the current food storage and handling practices at the facility.
Use of Non-Medical Grade Blood Pressure Cuffs
Penalty
Summary
The facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, specifically regarding the use of blood pressure cuffs. Observations revealed that a Licensed Practical Nurse (LPN) and a Registered Nurse (RN) used blood pressure cuffs not rated for medical use to take residents' blood pressure readings. The LPN used an Equate model VA-4000WM blood pressure cuff, while the RN used an Ever Ready First Aid wrist blood pressure cuff. Both devices were not rated for medical use, as confirmed by the nursing home administrator. Interviews with the staff further confirmed the use of non-medical grade blood pressure cuffs. The LPN and RN admitted to using these devices for obtaining blood pressure readings on residents. The nursing home administrator acknowledged that there was no documentation to support the safety or accuracy of these devices for medical use in the facility. This lack of proper equipment and documentation led to the deficiency in maintaining safe operating conditions for patient care equipment.
Deficiency in Staff Training on Abuse and Dementia Management
Penalty
Summary
The facility failed to provide necessary training to its staff on critical areas such as abuse, neglect, exploitation, and dementia management. Specifically, the activities assistant, cook, and housekeeper did not receive annual training on abuse prevention and reporting, while the cook, dietary aide, and maintenance assistant did not receive training on dementia management. This deficiency was identified through a review of training records and staff interviews, which revealed that these staff members had not participated in the required training over the past 12 months. The facility's policies, including the Abuse, Neglect, Exploitation and Misappropriation Prevention Program and the Dementia Clinical Protocol, mandate annual training for staff on these topics. However, the nursing home administrator and director of nursing were unable to provide evidence of completed training for the involved staff members. The director of nursing, who was also the staff development coordinator, acknowledged the lack of training and mentioned that the facility offered a four-hour dementia class and used an electronic system for abuse training. The nursing home administrator admitted to being unaware of the requirement for non-clinical staff to receive such training and was in the process of developing a new tracking system for training.
Deficiency in CNA Training Compliance
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNAs) received the required 12 hours of annual in-service training, including specific training in dementia management and resident abuse prevention. This deficiency was identified through a review of training records for five randomly selected CNAs, where it was found that four CNAs did not meet the training requirements. CNA #2, hired on May 16, 2023, completed only six hours and 45 minutes of training. CNA #5, hired on August 18, 2021, attended a four-hour dementia class, but the facility could not provide a complete training record for abuse, neglect, or exploitation. CNA #4, hired on April 6, 2017, completed four hours and 30 minutes of training and had no record of abuse, neglect, or exploitation training. CNA #1, hired on April 6, 2023, completed six hours and 30 minutes of training. Interviews with staff revealed a lack of awareness and documentation regarding the training requirements. The Director of Nursing (DON), who was also acting as the staff development coordinator, admitted to being unaware of the need to document the length of the training provided to CNAs. The Nursing Home Administrator (NHA) acknowledged that staff training was an area needing improvement and was a work in progress. CNA #5 mentioned that training was assigned on the computer, and she completed a four-hour dementia training session. These findings indicate a systemic issue in the facility's training program, leading to non-compliance with regulatory requirements for CNA training.
Failure to Notify Resident Representative of Fall
Penalty
Summary
The facility failed to inform the designated resident representative of a change in condition for one of the residents reviewed. Specifically, the facility did not notify the responsible party of a resident after an unwitnessed fall occurred. The facility's policy on managing falls, revised in March 2018, requires that a fall is defined as unintentionally coming to rest on the ground, floor, or lower level, and that notification should be made to the resident's representative. However, in this case, the resident's representative was not informed of the fall, which was concerning given the resident's post-surgery care needs following a neck injury. The resident, who was cognitively intact and required assistance for transferring, experienced an unwitnessed fall while attempting to transfer from her bed to her scooter. The incident was documented in the nurse's notes, indicating no injuries occurred, and the resident did not hit her head. Despite this documentation, the resident's representative, who was also the power of attorney and emergency contact, was not notified of the fall. Interviews with the director of nursing confirmed that the notification should have been made to the resident's family, as per the facility's policy.
Failure to Prevent Falls and Ensure Safe Smoking Practices
Penalty
Summary
The facility failed to provide adequate supervision and assistance to prevent falls for Resident #173, who was identified as being at moderate risk for falls. The resident, who had a history of spinal fusion, an acquired absence of the left leg below the knee, and dependence on a wheelchair, experienced two falls during her stay. The first fall occurred when she attempted to transfer from her bed to her scooter, and the second fall happened outside while she was smoking alone at night. Despite these incidents, the facility did not assess the resident after the potential falls, nor did they report the falls or monitor the resident for injuries, particularly after facial injuries were identified. The facility's policies on fall risk management and smoking were not adequately followed. The resident's care plan did not include interventions to address her moderate risk for falls, and the smoking care plan failed to outline safe smoking practices. The resident was allowed to smoke unsupervised, contrary to the facility's policy that required direct supervision for residents with smoking privileges. This lack of supervision contributed to the resident's second fall, where she slipped off her scooter while reaching for a cigarette. Interviews with the resident and her representative revealed that the resident had facial bruising and swelling after the second fall, which was not documented or reported by the staff. The Director of Nursing (DON) confirmed that the incident was not reported, and the resident was not assessed for injuries following the fall. The DON acknowledged that the nurse should have reported the incident and assessed the resident, highlighting a breakdown in communication and adherence to facility policies. The failure to document and address the resident's falls and injuries indicates a significant lapse in the facility's duty to ensure resident safety and prevent accidents.
Failure to Obtain Authorization for Resident's Personal Fund Withdrawals
Penalty
Summary
The facility failed to ensure that a resident's personal funds account was managed adequately, specifically by not obtaining signed authorization for withdrawals. Resident #19 had three unauthorized withdrawals from their personal needs account, with amounts of $94.00, $105.00, and $110.00, respectively, on different dates. The facility did not provide receipts or signed authorization from the resident for these transactions. During an interview, the business office manager (BOM) stated that the resident's legal representative requested funds each month to pay the resident's bills but did not provide receipts. The BOM admitted to not asking for receipts and was unaware that the resident needed to sign a personal funds withdrawal for their legal representative to use the funds. The BOM mentioned auditing all resident accounts to update consent forms and ensure proper authorization for personal fund usage.
Failure to Provide Timely Medicare Coverage Notice
Penalty
Summary
The facility failed to inform a resident of changes in their Medicare Part A coverage in a timely manner, specifically by not providing a Notice of Medicare Provider Non-Coverage (NOMNC) at least two days prior to the termination of services. The resident, identified as #216, was discharged from Medicare Part A funded therapy services and received the NOMNC on the same day her benefits ended, which did not comply with the required notification timeframe. This failure prevented the resident from having the opportunity to appeal the decision regarding the termination of services. Interviews with the admission/discharge coordinator (ADC) revealed a lack of awareness regarding the requirement to provide the NOMNC at least two days before benefits expired. The ADC stated that she typically sent the NOMNC 72 hours before benefits ended but did not have a system to confirm the delivery or track the forms. Additionally, the NOMNC was sent to the resident's medical durable power of attorney (MDPOA), who was out of state and unable to sign it, leading to the resident signing the notice on the last day of coverage. This oversight highlights a gap in the facility's process for ensuring timely notification of coverage changes.
Failure to Investigate Allegation of Abuse
Penalty
Summary
The facility failed to investigate an allegation of abuse involving a resident who reported feeling threatened by a staff member. The resident, who was cognitively intact and had a history of paraplegia and depressive episodes, reported that a staff member raised her voice and threatened him during a discussion about a billing issue. The resident expressed fear of retaliation and filed a grievance with the nursing home administrator (NHA), who informed him that the staff member would no longer be assigned to his care. Despite the resident's grievance and the facility's policy requiring all allegations of abuse to be investigated, the NHA did not initiate an investigation into the incident. The NHA believed the situation did not constitute abuse and noted that the resident had changed his story and requested to drop the matter. However, the facility's policy clearly states that threats are considered abuse and should be investigated. The failure to investigate the allegation was acknowledged by the NHA during an interview, where she admitted that threats should have been treated as abuse. The staff member involved was only suspended and an investigation initiated during the survey, indicating a delay in addressing the resident's concerns and a breach of the facility's abuse prevention and investigation protocols.
Incomplete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure a complete discharge summary for a resident who was discharged to another long-term care facility. The resident, an 83-year-old individual, was admitted with diagnoses including hyperkalemia, benign prostatic hyperplasia, and major depressive disorder. At the time of discharge, the resident was cognitively intact with a BIMS score of 13 out of 15 and required supervision with activities of daily living. However, the discharge summary was incomplete, missing critical information such as the resident's physical and mental functional status, continence status, vision status, behavior, cognitive status, and pertinent lab results. Interviews with facility staff revealed that the interdisciplinary team (IDT) was responsible for completing the discharge summary, with each member tasked with filling out their respective sections. The social service director confirmed that the discharge summary was not fully completed, and the corporate clinical manager acknowledged the oversight after reviewing the document. The deficiency was identified during a review of the resident's records and staff interviews, highlighting a lapse in the facility's discharge procedures.
Failure to Provide New Eyeglasses for Resident
Penalty
Summary
The facility failed to ensure that a resident received necessary vision services, specifically the provision of new eyeglasses. The resident, who is over 65 years old and has diagnoses including chronic obstructive pulmonary disease and malignant neoplasm of the prostate, was admitted to the facility with adequate vision when using eyeglasses. However, during an interview, the resident reported that his current glasses were outdated and his vision was blurry. Despite having seen an eye doctor and receiving a new prescription for eyeglasses on February 8, 2023, the facility did not assist the resident in obtaining the new glasses. A review of the resident's electronic medical record did not show any documentation indicating that the eyeglasses had been replaced. Interviews with the social service director and the regional operations manager confirmed that the facility missed obtaining the new eyeglasses for the resident. The oversight was identified during the survey, and it was acknowledged that the resident had not received the necessary assistive device to maintain his vision abilities.
Failure to Discontinue PRN Psychotropic Medication After 14 Days
Penalty
Summary
The facility failed to ensure that a resident was free from unnecessary psychotropic medications, specifically regarding the use of PRN lorazepam. The resident, who was over 65 years old and had diagnoses including COPD, major depressive disorder, and chronic systolic heart failure, was cognitively intact with a BIMS score of 15 out of 15. Despite this, the resident's PRN order for lorazepam was set for 90 days without a documented rationale, contrary to the requirement that PRN psychotropic medications should be limited to 14 days unless a specific reason is documented by the physician. Interviews with facility staff revealed a lack of awareness and oversight regarding the appropriate duration for PRN psychotropic medications. The DON was unsure of the correct duration and relied on the corporate consultant for clarification, who confirmed the 14-day requirement. The facility had recently switched pharmacies, and the NHA was unaware if the pharmacist had reviewed the PRN orders for compliance. The pharmacist admitted to being behind on medication reviews and had not yet addressed the 90-day order for the resident's lorazepam.
Deficiency in Medication Storage and Temperature Logging
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored properly according to professional standards. Specifically, the central hall medication cart was observed in an unlocked position, which was later locked by a registered nurse. This indicates a lapse in maintaining the security of medication storage, as both registered nurses and licensed practical nurses acknowledged that medication carts should always be locked when not in use. Additionally, the facility did not maintain a consistent medication refrigerator temperature log for one of the medication refrigerators. Out of 102 days, temperatures were documented on only 88 days, with a notable gap of nine days where temperatures were not recorded. Despite a performance improvement plan initiated to address this issue, the facility still failed to document temperatures for eight days after the plan was put in place. Interviews with staff, including the director of nursing and the nursing home administrator, confirmed the responsibility of night shift nurses to log temperatures and highlighted the need for further education on proper procedures.
Failure to Provide Correct Mechanically Altered Diets
Penalty
Summary
The facility failed to provide two residents with the correct mechanically altered diet texture as per their physician orders. Resident #62, who has a history of dysphagia and moderate cognitive impairments, was observed during a lunch meal receiving a regular sandwich and soup instead of the prescribed mechanical soft diet. The dietary director admitted to not offering the mechanically altered food to Resident #62, as the resident had previously refused it, and the director wanted to reduce food waste. This decision was made despite the resident's care plan indicating a risk for aspiration and choking. Similarly, Resident #4, who also has a history of dysphagia following a cerebral infarction, was observed being served regular texture spaghetti with whole meatballs and garlic toast, contrary to the mechanical soft diet prescribed. The cook initially plated the incorrect meal, and it was only corrected after prompting. The dietary director acknowledged the mistake, stating he was unaware of serving the incorrect texture to Resident #4. Interviews with facility staff, including the nursing home administrator, director of nursing, and registered dietitian, revealed a lack of adherence to physician orders for mechanically altered diets. The staff emphasized the importance of following these orders to prevent aspiration or choking. The dietary director recognized the need for additional training for the dietary department to ensure compliance with diet orders and tracking of any resident refusals in the electronic medical record.
Failure to Coordinate Hospice Care Documentation
Penalty
Summary
The facility failed to ensure that hospice agency notes regarding a resident's care were easily accessible to the facility staff, which hindered effective coordination of care with the hospice agency. The resident, over 65 years old, was admitted with diagnoses including chronic obstructive pulmonary disease with exacerbation and malignant neoplasm of the prostate. Despite being documented as receiving hospice services, the resident was unaware of this, and there was no physician's order for hospice care services in the electronic medical record (EMR). The care plan identified the resident as having an end-of-life care plan and receiving hospice services, but it did not specify the involvement of the hospice care team. Interviews with facility staff revealed a lack of awareness and documentation regarding the resident's hospice services. A licensed practical nurse confirmed the absence of a physician's order for hospice services and was unaware of the resident's hospice status due to missing notes. The director of nursing acknowledged the resident was receiving hospice services but noted the absence of a physician's order in the EMR. The social service director confirmed the resident was on hospice services, and the corporate consultant discovered that hospice progress notes were being sent to the facility's previous medical records director. The new medical records director later received the hospice notes after updating contact information with the hospice services provider.
Failure to Provide Restorative Therapy Services
Penalty
Summary
The facility failed to provide restorative therapy services to a resident with limited range of motion, leading to a deficiency in care. The resident, who was over 65 years old and had diagnoses including COPD, diabetes, and generalized muscle weakness, was not receiving the necessary restorative therapy services to prevent physical decline. Despite recommendations from a physical therapy discharge summary for a restorative therapy program, the resident did not have an order for such services, and staff interviews revealed a lack of awareness and implementation of restorative therapy services. The resident expressed concerns about becoming weaker and more dependent on staff since her readmission, indicating a desire to work towards greater independence. Interviews with staff, including a CNA, LPN, PT, and the DOR, highlighted a lack of communication and understanding regarding the provision of restorative therapy services. The PT department had previously communicated and educated nursing staff on the resident's needs, but due to significant turnover in the physical therapy department, these recommendations were not effectively implemented. The DON acknowledged the absence of restorative therapy services for the resident and attributed it to communication issues stemming from staff turnover. The facility's leadership, including the NHA, ROM, and DON, recognized the deficiency and identified restorative therapy services as an area needing improvement within the facility's quality assurance and performance improvement committee.
Failure to Post Nurse Staffing Information
Penalty
Summary
The facility failed to comply with the requirement to post nurse staffing information daily. Observations on two consecutive days revealed the absence of nurse staffing postings. A review of records indicated that the facility had not maintained staffing data for the required 18 months. During an interview, the Director of Nursing (DON) admitted that the facility had not utilized staff posting in over four years. The DON, who was temporarily covering as the staff development coordinator, was unaware that staffing data needed to be posted in a visible area for residents and families. She mentioned that a form used for staffing data posting had not been used in over four years.
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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