Average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Good Samaritan Society -- Loveland Village during CMS and state inspections, most recent first.
A resident with dementia, dysphagia, and anxiety, who required significant assistance with ADLs and mobility, experienced increasing leg and hip pain, functional decline, and remained in bed after a suspected fall. Nursing and hospice notes documented escalating pain, new PRN morphine orders, non-verbal pain behaviors, and staff pre-medicating with morphine before care. CNAs and an LPN reported the resident’s increased pain, weakness, and reduced mobility to nursing staff. Although facility policy required communication with family or a healthcare proxy during a change in condition, and the DON stated that the hospice nurse spoke with the resident’s representative, the EMR lacked documentation that the representative was notified of the resident’s increased pain or that treatment decisions related to this change in condition were discussed with the resident or her representative.
A resident with dementia, dysphagia, anxiety, and severe cognitive impairment experienced increasing leg and hip pain, outward rotation of a leg, non-verbal signs of pain with movement, and a marked decline in mobility, including no longer getting out of bed. Nursing and hospice notes documented escalating pain, new morphine use, and pre-medication before care, and CNAs reported that the resident screamed in pain and required more assistance after a potential fall. Despite facility policy requiring provider notification for changes in condition and staff reports of pain and functional decline, there was no documentation that the physician was notified of the resident’s increased pain and reduced mobility, resulting in a deficiency for failure to notify the provider of a change in condition.
A resident with intact cognition and a history of schizoaffective disorder approached a table in a common area where two other residents were seated, including a resident with mild cognitive impairment and documented behavioral issues such as poor impulse control, verbal and physical aggression, and a habit of grabbing women’s hands as they walked by. After a brief verbal exchange about space at the table, the aggressive resident grabbed and forcefully squeezed the other resident’s hand, causing significant pain, bruising, numbness in several fingers, and pressure from a ring digging into the skin. Another resident witness reported that the aggressive resident appeared very angry, twisted the victim’s hand with both hands, and looked like he wanted to hurt her. Staff and residents described the aggressive resident as possessive of his preferred seating area and objects, and as someone who routinely grabbed women’s hands in the common area, yet the incident occurred unwitnessed by staff, resulting in the facility’s failure to keep the victim free from physical abuse by another resident.
Facility staff failed to report an injury of unknown origin as a potential abuse/neglect event to the abuse coordinator and State Survey and Certification Agency, contrary to facility policy and state law. A resident with severe cognitive impairment, dementia, and functional dependence developed significant leg and hip pain, outward rotation of a leg, and increased pain with movement after staff heard about a potential fall. Nursing and hospice documentation showed escalating pain, new opioid orders, and the resident remaining in bed with pain during care, while CNAs and an LPN reported the resident’s pain and functional decline to nursing staff. Despite these findings and the facility’s stated procedures for investigating and reporting such incidents, no report of the injury of unknown origin was submitted to the State Agency.
A resident with moderate cognitive impairment, severe obesity, muscle weakness, and a recent history of falling out of bed sustained a major injury after staff moved a floor mat during care and failed to replace it. A nurse later rounded on the resident but did not notice the missing mat, and the resident was found on the floor next to the bed with a traumatic subdural hemorrhage and loss of consciousness. The record also noted the resident was using a standard-size bed despite body habitus and the bed was not in a low position.
A resident who was cognitively intact and used a wheelchair was involved in a staff prank in her room when CNAs hid under her bed and another CNA set up a cell phone to record without her permission. The resident said she agreed to the prank but not to being recorded, and she felt uneasy because she did not know what had been filmed or whether it was shared online. Her record also showed prior trauma symptoms related to an earlier prank video and triggers involving certain staff and discussion of the event.
Failure to Assess Self-Administration of Bedside Medications: Three residents had inhalers or nasal sprays at the bedside and reported self-administering them, but the EMR lacked documentation of a self-administration assessment and lacked physician orders authorizing bedside storage or self-administration. Two residents had COPD and one also had Parkinson's disease with moderate cognitive impairment. Staff stated they were unaware of the bedside medications and confirmed that an assessment and physician order should be in place before residents self-administer medications.
A common area at the end of a hallway was used as storage for unused furniture and equipment, including bed frames, dressers, wheelchairs, and shower chairs, and access was blocked with tape and cones. Several alert and oriented residents said the space had previously been used for tables, chairs, puzzle activities, and private visits with family and friends, but it had remained unavailable for resident use while management said it was being addressed.
Failure to complete annual CNA performance reviews. Record review showed two CNAs did not have documentation of a performance review within the past 12 months, and the facility could not provide records showing the reviews were completed. The NHA and DON said annual skills competency fairs were used for CNA reviews, but the clinical nurse educator confirmed the reviews were not completed for the two CNAs.
Failure to Follow EBP During Wound Care: An LPN and the wound care nurse did not wear gowns during wound care for a resident with a heel wound who was on EBP, despite a door sign indicating gown and glove use for high-contact care. The LPN touched the wound after removing the heel boot and dressing while wearing only gloves, and the wound care nurse removed a saturated dressing without a gown. Staff interviews showed the LPN and wound care nurse knew the resident was on EBP, while a CNA did not understand the EBP sign and believed only gloves were needed for some care.
A resident with severe cognitive impairments and a history of falls experienced seven falls over two months due to inadequate supervision and inconsistent implementation of care-planned interventions. The facility failed to ensure the resident's bed was in a low position and did not consistently assist with transfers, contributing to repeated falls and a hip fracture. Despite the resident's memory deficits, the facility relied on ineffective verbal reminders, leading to the resident's decline and placement on hospice services.
Two residents were sexually abused by a CNA in the facility. One resident, who was cognitively impaired, was found in a compromising position with the CNA, who later confirmed the abuse. Another resident, who was visually impaired, reported that the CNA put something in her hand, which she identified as his penis. The facility's policy on abuse and neglect was not effectively implemented, leading to a failure to protect the residents and a delay in reporting the incidents.
A resident known to be at risk for falls sustained a left femur fracture after the facility failed to ensure her floor alarm was properly reset and turned on. Staff were aware of the need to reset the alarm but did not ensure it was in the on position, leading to the fall.
The facility had a medication error rate of 7.7%, with errors including a CNA-Med failing to check vital signs before administering Nebivolol and an RN crushing Metoprolol Succinate ER tablets against manufacturer guidelines.
Failure to Notify Resident Representative of Change in Condition and Increased Pain
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s representative of a significant change in condition, specifically increased pain and functional decline. Facility policy for Interact-Change in Condition Evaluation required staff to review the medical record, consult with interdisciplinary staff and family members or healthcare proxies as needed, and clarify advance directives when appropriate. Despite this policy, there was no documentation in the electronic medical record (EMR) that the resident or her representative was informed of the resident’s increased pain or that treatment decisions were reviewed with them. The resident involved was over 65 years old, had diagnoses including unspecified dementia, dysphagia, and anxiety, and was documented on the MDS as having severe cognitive impairment with a BIMS score of 5/15. She required maximal assistance with toileting and dressing and moderate assistance with mobility. Nursing notes documented that she complained of right leg pain on one date and later was yelling out, had a furrowed brow, and complained of left hip pain, for which PRN Tylenol and aspercreme with lidocaine were administered. Hospice notes showed that as-needed morphine was added to her plan of care and that the hospice nurse spoke with the resident’s daughter, and later that a new morphine order was placed after the facility nurse notified hospice of increased left hip and groin pain. Subsequent hospice documentation described outward rotation of the right leg, non-verbal signs of pain with inward rotation, pain with care and rolling in bed, and that staff were pre-medicating with morphine prior to care. Interviews with staff further described the change in the resident’s condition. An LPN reported that around the beginning of February the resident stopped getting out of bed and complained of pain in her left side, despite previously ambulating with one-person assistance and a walker. CNAs reported hearing about a potential fall and observed that after this incident the resident heavily favored one side, had weakness, screamed out in pain, complained of hip and leg pain, grimaced frequently, and was no longer getting out of bed, with pain limiting her ability to sit up. They stated they reported the pain to the nurse. The DON stated that standard steps after a fall included assessing the resident, notifying the provider, resident representative, hospice if applicable, and management, and that in this case the hospice nurse spoke to the representative when there was an increase in pain and morphine was needed. However, the resident’s EMR did not contain documentation that the resident’s representative was notified of the increased pain or that the facility discussed the change in condition and related treatment decisions with the resident or her representative.
Failure to Notify Physician of Resident’s Change in Condition and Increased Pain
Penalty
Summary
The deficiency involves the facility’s failure to notify a resident’s physician of a change in condition, specifically an increase in pain and decreased mobility. Facility policy, as outlined in the Interact-Change in Condition Evaluation procedure, required staff to review the resident’s record, gather information from interdisciplinary staff and others, and notify the provider of changes in condition as indicated. Despite this policy, there was no documentation that the resident’s physician was notified when the resident experienced increased pain and functional decline. The resident involved was over 65 years old, admitted with diagnoses including unspecified dementia, dysphagia, and anxiety, and had severe cognitive impairment with a BIMS score of 5/15. She required maximal assistance with toileting and dressing and moderate assistance with mobility. Nursing notes documented that she complained of right leg pain on one date and later was yelling out, had a furrowed brow, and complained of left hip pain, for which PRN Tylenol and aspercreme with lidocaine were administered. Hospice notes documented an increase in left hip pain radiating to the groin, a new morphine order, outward rotation of the right leg, non-verbal signs of pain with inward rotation, and that she had not been out of bed for about a week, with staff pre-medicating with morphine prior to care. Interviews with staff further described the change in the resident’s condition. An LPN reported that around the beginning of February the resident stopped getting out of bed and complained of pain in her left side, but the EMR did not show documentation that the physician was notified that the resident was not getting out of bed as often due to increased pain. CNAs reported that the resident had previously walked with assistance but, after a potential fall, heavily favored one side, had weakness, screamed out in pain, and complained of hip and leg pain, and that they reported this pain to the nurse. The DON stated that standard steps after a fall included assessing the resident and notifying the provider, among other actions, and said she mentioned the potential fall to the provider; however, there was no documentation that the physician was notified of the resident’s increased pain, constituting the cited failure to notify the provider of a change in condition.
Failure to Protect Resident From Physical Abuse by Another Resident in Common Area
Penalty
Summary
The deficiency involves the facility’s failure to protect a cognitively intact resident from physical abuse by another resident. The facility’s Abuse and Neglect policy states that residents must be free from abuse by anyone, including other residents. Despite this, a physical altercation occurred in a common area when one resident approached a table where two other residents were seated. According to the victim, the assailant shook his fists at her, told her there was not enough room, and then grabbed and forcefully squeezed her hands for about two minutes after she challenged him to "go ahead and try it." A witness reported that the assailant grabbed the victim’s left hand, twisted it with both hands, appeared very angry, and looked like he wanted to hurt her, describing the interaction as the assailant taking things too far and trying to show off his strength. The victim was an older adult with schizoaffective disorder (bipolar type), anxiety, and depressive episodes, but was documented as cognitively intact with a BIMS score of 15/15 and independent in ADLs and mobility. She reported immediate left hand pain rated 7/10, described as pinched nerve pain with shocks, and later reported that three fingers went numb and took a couple of weeks to regain feeling. She also stated that a ring on one finger dug into her hand during the squeezing. Subsequent assessments documented bruising on the backs of both hands and ongoing tingling in three fingers. The victim reported that she had tried to tell her nurse about the incident but was told the nurse already knew from a CNA and was not allowed to report it directly, and she later told the social services worker she wanted to file a restraining order against the assailant. The assailant was an older resident with mild cognitive impairment (BIMS 11/15) and a documented history of behavior symptoms, including poor impulse control, verbal and physical aggression, antagonistic behaviors toward roommates and peers, and the need for staff to intervene to protect the rights and safety of others. Staff and another resident reported that he habitually grabbed mostly women’s hands as they walked by and held on until they had to shake their hands free. Staff also described him as possessive of items and space, including a preferred spot in the common area next to a small table, and noted that he became upset when he perceived others encroaching on what he believed was his. The assailant himself stated that he did not get along with the victim, considered her obnoxious, and admitted that he squeezed her hands because he wanted her to know he was in control. These known behaviors and triggers, combined with his established pattern of grabbing women’s hands in the common area, preceded and contributed to the physical abuse incident in which the victim was not kept free from abuse by another resident. Additional information from resident and staff interviews further described the environment and interpersonal dynamics leading up to the incident. A witness resident stated that the victim approached the table to talk with him, that a few words were exchanged, and that the assailant then grabbed and squeezed the victim’s hand hard enough to cause injury, with the ring digging into her hand. He also confirmed that the assailant had a habit of grabbing women’s hands as they passed by his usual seating area. Nursing staff and CNAs corroborated that the assailant was possessive of his preferred spot and objects, and that he liked to grab women’s hands. The interdisciplinary team note characterized the event as a potential abuse incident in which the victim sat too close to the assailant, who then squeezed her hand. Despite the facility’s policy and the assailant’s documented behavioral history and triggers, the victim was not protected from physical abuse by this resident in the common area. The victim’s mental health care plan, initiated shortly after the incident, documented that she had poor self-awareness and boundaries and could be intrusive with others, which could lead to frustration among peers. Interventions included monitoring interactions with peers and assisting in redirecting and de-escalating as needed. The assailant’s care plan, in place prior to the incident and later revised, documented behavior symptoms such as verbal and physical aggression, argumentative behavior, and the need for staff to monitor his interactions with peers, redirect, de-escalate, and separate him from peers as needed, as well as to intervene to protect the safety of others. Despite these identified needs and risks, the incident occurred in a common area without staff witnessing the altercation, and the victim sustained bruising and reported significant pain and numbness in her hand and fingers as a result of the assailant’s actions.
Failure to Report Injury of Unknown Origin as Potential Abuse/Neglect
Penalty
Summary
Facility staff failed to report an alleged violation of potential abuse/neglect, specifically an injury of unknown origin, to the facility’s abuse coordinator and the State Survey and Certification Agency as required by facility policy and state law. The facility’s Abuse and Neglect policy states that all alleged or suspected abuse/neglect events, including injuries of unknown origin, must be promptly reported and investigated, with designated agencies, including the State Survey and Certification Agency, notified in accordance with state law. The policy further requires that results of all investigations be reported to the administrator and to the state survey and certification agency within five working days of the event. Review of the State Agency reporting portal showed no report submitted by the facility regarding the resident’s injury of unknown origin. The resident involved was an individual over age 65 with diagnoses including unspecified dementia, dysphagia, and anxiety, and had severe cognitive impairment with a BIMS score of 5/15. The resident required maximal assistance with toileting and dressing and moderate assistance with mobility. Nursing documentation showed that on one date the resident complained of right leg pain, and on a later date the resident was yelling out, had a furrowed brow, and complained of left hip pain, for which PRN Tylenol and topical aspercreme with lidocaine were administered. Hospice notes documented increased pain in the left hip radiating to the groin, a new order for morphine, and later a noticeable outward rotation of the right leg with non-verbal signs of pain on inward rotation. Hospice documentation also indicated the resident had not been out of bed for about a week, had pain with cares and rolling in bed, and that staff were pre-medicating with morphine prior to care. Interviews with staff indicated awareness of a potential fall and subsequent pain, but no corresponding report of an injury of unknown origin to the State Agency. An LPN reported that around the beginning of February the resident stopped getting out of bed and complained of pain in her left side. CNAs described the resident as confused but ambulatory with a walker and one-person assistance prior to the incident, and reported hearing about a potential fall. After this potential fall, CNAs observed the resident heavily favoring one side, experiencing significant pain in the hip and leg, grimacing, and being unable to get out of bed, and they stated they notified the nurse when the resident was in pain. Despite these observations and the facility’s stated investigative and reporting process as described by the DON, nurse manager, and NHA, the injury of unknown origin associated with the resident’s pain and functional decline was not reported to the facility’s abuse coordinator or to the State Survey and Certification Agency.
Missing Fall Mat and Bed Safety Failure Leads to Major Injury
Penalty
Summary
The facility failed to ensure that fall interventions were consistently implemented for a resident who was at risk for falls and had moderate cognitive impairment, severe obesity, muscle weakness, right knee pain, and a right lower extremity hematoma. The resident had been admitted after a prior fall at home from rolling out of bed while asleep and required maximum assistance from staff for mobility and repositioning in bed. On the evening of the incident, staff moved the resident’s floor mat to provide care but did not replace it afterward. A nurse later rounded on the resident and observed her sleeping, but did not notice or correct that the floor mat was missing. The resident was then found face down on the floor next to the bed after another resident heard a noise and alerted the nurse. The resident’s fall resulted in a traumatic subdural hemorrhage with loss of consciousness and required immediate surgery. The record also states that the resident had been using a standard-size bed despite her body habitus, and that the bed was not in a low position at the time of the fall.
Unauthorized Video Recording and Prank in Resident Room
Penalty
Summary
The facility failed to prevent abuse for one resident when certified nurse aides involved the resident in a prank and created a video in the resident’s room without obtaining permission to record. The resident was cognitively intact, used a manual wheelchair, and required staff assistance with lower body dressing. During the incident, one CNA hid under the resident’s bed with a blanket, another CNA positioned a cell phone against the wall to record, and other CNAs were present in the room while waiting for another staff member to enter so the prank could be carried out. The resident stated she agreed to help with the prank on another CNA, but she did not give permission for the phone to be set up or for anything to be recorded in her room. She reported that the phone was angled toward her bed while she sat in her wheelchair and that she could not see what was being recorded. After the prank, while staff were transferring her and removing her shorts, she realized the phone was still recording and told the CNA. She said the CNA apologized and pushed buttons on the phone, but did not show her what had been recorded. The resident said the situation made her feel very uneasy because she did not know what had been filmed or whether it had been posted online. The resident’s record showed a psychosocial care plan related to reliving trauma from a prior prank involving staff members, with symptoms including feeling on guard, detached, and easily startled. A trauma assessment documented that she continued to be affected by the earlier prank video and identified interacting with certain staff members and hearing the event discussed as triggers. The facility investigation documented that the CNAs violated the facility’s photography and video policy by attempting to video or take photos in the resident’s room without written consent, even though the facility concluded the recording was deleted and did not include the resident on screen.
Failure to Assess Self-Administration of Bedside Medications
Penalty
Summary
The facility failed to ensure that self-administration of medications was clinically appropriate for three residents who had inhalers or nasal sprays at their bedsides without documented assessments or physician orders authorizing self-administration. Resident #1 had diagnoses including chronic respiratory failure and COPD, and the record showed an order for albuterol sulfate inhaler as needed for shortness of breath or wheezing. During observation, the resident was holding an inhaler and said he used it whenever he felt short of breath, but the EMR did not show an assessment to determine whether he could safely administer his own medications, and there was no physician order allowing self-administration or bedside storage. Resident #110 also had diagnoses including chronic respiratory failure and COPD. During observation, the resident had an Anoro Ellipta inhaler on the table next to her recliner and said she self-administered it every morning. The EMR did not contain documentation of an assessment for safe self-administration, and there was no physician order for the inhaler or approval for it to be kept at the bedside. Resident #4 had diagnoses including Parkinson's disease and COPD, and the MDS showed moderate cognitive impairment with a BIMS score of 12 out of 15. During observation, the resident had normal saline nasal spray and fluticasone propionate nasal spray at the bedside and said he self-administered both independently. The EMR did not show an assessment for safe self-administration, and there was no physician order for either nasal spray or approval for bedside storage. Staff interviews confirmed they were unaware of the bedside medications, stated that assessments should be completed before self-administration, and said medications should not be left at the bedside without a physician order.
Common Area Blocked by Stored Equipment
Penalty
Summary
The facility failed to provide a safe, clean, sanitary, and comfortable environment on the 700 unit by not keeping the common area at the end of the 700 hallway available for resident use. During the initial tour, multiple pieces of unused equipment and furniture, including bed frames, dressers, wheelchairs, and shower chairs, were stored in the area, and access was blocked with yellow tape and two yellow cones. The area remained a storage space and was not accessible to residents throughout the survey period. During a group interview, seven alert and oriented residents said the area had been used as storage since summer 2025 and had previously contained tables and chairs where residents could meet with family and friends. One resident said she previously used the area for a puzzle table because her room was too small for one, and another said she had used it for private conversations with friends and family. Residents reported they had raised the concern with management and were told the issue was being worked on, but it had not been resolved. The MTD confirmed the area was being used to store furniture and equipment because rooms that were vacated required deep cleaning or renovations, and the facility’s three sheds were full. The NHA stated she was aware of the residents’ concerns and that residents had submitted a petition asking for the area to be cleared for use.
Failure to Complete Annual CNA Performance Reviews
Penalty
Summary
The facility failed to complete an annual performance review for two of three certified nurse aides reviewed and did not provide documentation of regular in-service education based on those reviews. Record review showed CNA #1 was hired on 3/12/24 and CNA #2 was hired on 9/19/24, but when surveyors requested performance review records on 1/29/26, the facility was unable to provide documentation showing that either CNA had a performance review completed in the past 12 months. During interviews, the NHA and DON #1 stated that a skills competency fair was conducted annually and used to complete CNA performance reviews, with the NHA saying the fair occurred in June 2025 and DON #1 saying it occurred in summer 2025, though she was unsure of the exact date. The clinical nurse educator stated that an annual performance review was not completed for CNA #1 or CNA #2 and said she did not know why those reviews were not completed.
Failure to Follow EBP During Wound Care
Penalty
Summary
The facility failed to maintain an infection control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of disease on one unit. The deficiency involved Resident #10, who had a wound on the right heel and was identified as being on enhanced barrier precautions (EBP) by a sign posted on the resident’s doorframe indicating staff should wear a gown and gloves for high-contact care. During observation, an LPN entered the resident’s room to administer medication and, after obtaining permission, held the resident’s feet, removed the heel suspension boot, removed the wound dressing, touched the wound surface, and pressed on it. The LPN wore gloves but did not don a gown before touching the resident’s heel wound. The wound care nurse later entered the room, removed the dressing from the resident’s heel wound, disposed of the saturated dressing in the trash, and stepped out of the room without putting on a gown. Interviews confirmed the staff understood the resident was on EBP but did not follow the required gown use during wound care. The LPN stated she should have worn a gown before touching the heel wound. The wound care nurse said she forgot to put on a gown before removing the dressing. A CNA stated she did not know what the EBP sign meant and believed only gloves were required for incontinence care and showers. The IP and DON stated gowns and gloves were required for close contact care and wound care for residents on EBP.
Failure to Prevent Falls for High-Risk Resident
Penalty
Summary
The facility failed to provide adequate supervision and timely interventions to prevent multiple falls for a resident known to be at high risk for falls. The resident, who had severe cognitive impairments and a history of falls, experienced seven falls over a period of less than two months. These falls were often related to the resident's attempts to self-transfer in and out of bed, particularly around meal times, and were compounded by the resident's incontinence and memory deficits. Despite being aware of the resident's routine and risk factors, the facility did not consistently implement care-planned fall interventions, such as ensuring the bed was in a low position and using a pool noodle for safety. The resident's care plan included various interventions to mitigate fall risks, such as reminders to use a call light, ensuring appropriate footwear, and monitoring for changes in gait and cognition. However, these interventions were not effectively implemented or updated in response to the resident's repeated falls. For instance, the resident was found without the recommended gripper socks or with the pool noodle improperly placed, and staff failed to consistently assist with transfers before and after meals. The facility's failure to adapt and enforce these interventions contributed to the resident's continued falls, one of which resulted in a hip fracture. The facility's documentation and incident reports revealed inconsistencies in the timing and assessment of falls, as well as a lack of timely review by the interdisciplinary team. The resident's falls were often unwitnessed, and the root causes were not adequately addressed. Despite the resident's significant memory deficit and impulsivity, the facility continued to rely on verbal reminders and education, which were ineffective given the resident's cognitive impairments. This lack of proactive and consistent intervention ultimately led to the resident's decline and the decision to place the resident on hospice services.
Failure to Protect Residents from Sexual Abuse by CNA
Penalty
Summary
The facility failed to protect two residents from sexual abuse by a certified nurse aide (CNA). Resident #2, who was cognitively impaired and physically dependent, was sexually abused by CNA #1. The incident was discovered when another CNA entered the room and found CNA #1 in a compromising position at the resident's bedside. The resident was lying in bed fully clothed, and CNA #1 was positioned with his right knee on the bed and his left leg on the floor, facing the resident at the level of her face. When the other CNA entered, CNA #1 jumped off the bed, adjusted his pants, and pulled his shirt down. The resident later confirmed the abuse during an interview. Resident #3, who was cognitively intact but visually impaired, reported that she was also sexually abused by CNA #1 before his suspension. She stated that CNA #1 put something in her hand, which she identified as his penis. This incident was reported to the police, and the facility was informed by the local police and adult protective services about CNA #1's confession to the police regarding the abuse of Resident #3. The facility's policy on abuse and neglect was not effectively implemented, as evidenced by the failure to protect the residents from abuse and the delay in reporting the incidents. The facility's investigation revealed that CNA #1 had been working in the facility since April 2024 and had completed abuse and neglect education before beginning orientation. However, there were no indications that he would engage in sexually abusive behavior, and he was considered a lazy worker by the facility staff.
Removal Plan
- CNA #1 was suspended immediately after the incident was reported and terminated.
- CNA #1 was reported to the appropriate governing agencies, and complaints were filed on his license.
- The facility began education on neglect and abuse to the nursing care staff, including all direct care staff.
- 75% of the direct care staff training was completed, and the remaining staff training was completed.
- Facility-wide education on abuse and neglect was conducted.
- The facility expanded their interview sample and initiated a facility-wide education on abuse and neglect.
Failure to Ensure Proper Functioning of Fall Prevention Alarm
Penalty
Summary
The facility failed to ensure that a floor alarm, which was a care-planned fall intervention for a resident known to be at risk for falls, was properly reset and turned on. This failure led to the resident sustaining a fall that resulted in a fracture of her left femur. The incident occurred when the floor alarm was found to be in the off position at the time of the fall, and staff were not alerted to the resident's movements in her room. Staff interviews confirmed that they were aware of the need to reset the alarm by switching it to the off position and then returning it to the on position, but it was unclear when the alarm was last reset and why it was in the off position at the time of the fall. The resident involved, an 81-year-old with a history of muscle weakness, dementia with behaviors, and previous falls, was moderately cognitively impaired and used a manual wheelchair. She required assistance for most activities of daily living and had been using the floor alarm as an effective fall prevention measure. On the day of the fall, the resident was found sitting on the floor between her bed and the sink area, having attempted to walk towards her door. Initially, she denied pain or injury, but subsequent x-rays revealed a left femur fracture, leading to her transfer to the emergency room. Interviews with staff, including an LPN and a CNA, indicated that they were familiar with the alarm system and had received recent re-education on its use. However, the investigation revealed that the alarm was not properly reset, which directly contributed to the resident's fall. The DON and NHA confirmed that the alarm had been effective in preventing falls for this resident in the past, but the failure to ensure it was turned on at the time of the incident resulted in the deficiency.
Removal Plan
- The facility interviewed all staff on duty who were involved in care for the resident on the day of fall and a few days prior to the fall.
- Inspection of the floor alarm device determined the alarm device was in an off position at the time of the fall and therefore did not alert the staff about the resident's movement in the room.
- All interviewed staff reported that the alarm was functioning well and they heard the sound of it during their shift.
- Staff was aware that in order to reset the alarm after it was triggered, it was necessary to switch it to the off position and return it to an on position.
- It was unclear when the alarm was reset for the last time and why it was in the off position at the time of the fall.
- The last interaction with the resident was reported around 6:30 p.m., about 30 minutes prior to the fall, when a staff member assisted the resident with care.
- All direct care staff who were involved in Resident #58's care and had access to the alarm device were educated on how to reset it and to make sure it was turned on.
- The device was to be checked at the beginning of every shift and on an as needed basis.
- Staff were to ensure it was in the on position after the reset.
- A log was initiated to ensure every shift checked the alarm.
- The interdisciplinary team (IDT) met to review the fall for the Resident #58.
- Medications, care routines, non-pharmacological interventions and resident preferences were reviewed.
- The IDT recommended adding the following interventions and continuing to monitor: Bariatric bed for extended sleep surface, improve lighting in the room, and add an air mattress.
- The facility completed an audit and identified other residents in the building who were at risk for falls.
- Thirteen identified residents were reviewed for appropriate fall interventions and care plans were updated to ensure the accuracy of the interventions.
- Nursing leadership re-educated the nursing staff in regards to reviewing the care plan and Kardex (tool utilized by staff to provide comprehensive care of the residents) as well as the importance of following and implementing interventions outlined in these documents in an effort to reduce the risk of falls for facility residents.
- Audits were initiated to verify fall prevention interventions outlined in the care plans for residents identified to be at risk of falls were in place accordingly via direct observations when rounding as well as via interviews with staff.
- The director of nursing (DON) was responsible for completing the audits weekly for the next four weeks, one a month for the next two months and quarterly for the next three quarters.
- A monthly Report Out, summarizing the findings of the audits, was to be completed and provided to the Quality Assurance Performance Improvement (QAPI) Committee.
- The QAPI Report Out was to be reviewed by the QAPI Committee for compliance and trends and to make additional recommendations as needed for continued improvement.
Medication Administration Errors
Penalty
Summary
The facility failed to ensure the medication error rate was not five percent or greater, resulting in a medication error rate of 7.7%. Specifically, two errors were identified out of 26 opportunities for error. One error involved a certified nurse aide with medication aide authority (CNA-Med) who administered Nebivolol to a resident without checking the resident's blood pressure or heart rate, as required by the physician's order. The CNA-Med stated that the medication administration record (MAR) did not display the necessary heart icon or further instructions to check vital signs before administering the medication. Another error involved a registered nurse (RN) who administered Metoprolol Succinate extended-release tablets to a resident by crushing the medication and mixing it with applesauce, contrary to the manufacturer's recommendations that the medication should be swallowed whole and not chewed or crushed. The RN had checked the resident's vital signs before administering the medication, which were within normal limits, but failed to follow the proper administration guidelines for the extended-release medication. Interviews with the director of nursing (DON) and unit manager (UM) revealed that the medication administration process had lapses, including the failure to properly enter medication orders into the electronic medical record (EMR) and the lack of adherence to physician's orders. The DON and UM acknowledged the importance of following physician's orders and the potential impact of not doing so on resident safety and medication efficacy. They also noted that education had been provided to staff regarding the proper administration of extended-release medications and the need to check vital signs when required by physician's orders.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 211 citations issued within 25 miles in the last 12 months — including the 5 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Loveland
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Green House Homes At Mirasol, The | 1.5 mi | ★★★★★ | 0 | 0 |
| Riverbend Health And Rehabilitation Center | 2.1 mi | ★★★★★ | 13 | 0 |
| North Shore Health & Rehab Facility | 3.7 mi | ★★★★★ | 1 | 0 |
| Berthoud Care And Rehabilitation | 4.3 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society -- Fort Collins Village | 8.6 mi | ★★★★★ | 12 | 0 |
Every risk area ranked, a do-first checklist, and your local survey patterns
Built specifically for Good Samaritan Society -- Loveland Village.
100% money-back within 48 hours.
Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.