Average — CMS composite of the measures below.
A standard survey is most likely before around September 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 Rehabilitation And Nursing Center Of The Rockies during CMS and state inspections, most recent first.
A resident with cognitive impairment and neurological conditions was found with a medication cup containing prescribed tablets and a capsule left on their bedside table. An LPN had documented the medications as administered in the MAR without observing the resident swallow them, after unsuccessfully attempting to wake the resident and leaving the medications at the bedside. Facility policy required staff to stay with residents until medications were swallowed and to document only after administration, but these procedures were not followed.
A resident with hypertension did not receive any doses of Cardura as ordered, yet the MAR inaccurately reflected that the medication was administered on several occasions. Nursing staff failed to document the withholding of the medication or the reasons for it in the EMR, and there was no official physician hold order. This resulted in inaccurate medical records and a lack of clarity regarding the resident's medication status.
Two residents experienced deficiencies when the facility failed to thoroughly investigate an injury of unknown origin and allegations of staff-to-resident verbal and mental abuse. One resident, who was fully dependent for transfers, sustained a leg fracture after being transferred without a mechanical lift, but staff did not document or assess the injury in a timely manner. Another resident reported feeling abused by staff, but the facility did not conduct a comprehensive investigation or follow-up, and the staff involved continued to provide care to the resident.
Two residents did not receive adequate supervision or person-centered interventions to prevent accidents and falls. One resident, requiring a mechanical lift for transfers, was manually transferred by a CNA, resulting in undiagnosed leg fractures and delayed treatment. Another resident with severe cognitive impairment and repeated falls was not provided with individualized fall interventions, and staff failed to update care plans or systematically review the effectiveness of interventions after each fall.
The facility did not provide follow-up or communicate outcomes to residents regarding grievances raised in resident council meetings or through individual complaints. Although some actions were taken, such as staff education and cleaning, residents were not informed of these resolutions and were unclear about the grievance process. Staff interviews confirmed that documentation and communication of grievance outcomes to residents were lacking.
A resident with multiple complex medical conditions was not given the opportunity to choose her attending physician after her previous PCP stopped providing services. The facility assigned the resident to its contracted physician without documented consent or providing alternative options, and staff interviews confirmed that the process for selecting a new physician was not clearly communicated.
Two residents were administered psychotropic medications without individualized care plans or documentation of specific behaviors to justify their use. The facility used generic templates for behavior monitoring and non-pharmacological interventions, failing to address each resident's unique triggers, preferences, and symptoms as identified in assessments and staff interviews.
A resident with multiple medical conditions left the facility against medical advice due to dissatisfaction with care and environment. The facility did not document physician notification regarding the discharge request or the actual AMA discharge, nor did staff document attempts to address the resident's concerns or discuss alternative discharge plans. Required AMA discharge procedures and documentation were not followed.
A resident with major depressive disorder and cognitive impairment did not receive a neurocognitive evaluation as recommended by the PASRR Level II determination. The care plan and physician orders lacked documentation of the required assessment, and staff interviews confirmed that the evaluation was neither scheduled nor completed.
A resident with moderate cognitive impairment and a history of depression did not receive a personalized activity program as outlined in their care plan. Despite documented interests in reading, animal therapy, religious services, and outdoor activities, the resident was observed spending extended periods alone without engagement, and there was no evidence of participation in scheduled activities. Staff interviews and record reviews confirmed that the resident's preferences and needs were not consistently addressed.
A resident with a history of bipolar disorder, depression, and alcohol dependence exhibited fluctuating symptoms of depression and suicidal ideation, as documented in multiple MDS assessments. Despite these symptoms and physician orders for counseling, the facility did not consistently assess, monitor, or provide timely behavioral health services, and staff failed to document or act upon high PHQ-9 scores or expressions of suicidal ideation.
Facility leadership failed to provide sufficient oversight, resulting in delayed investigation and reporting of abuse allegations, untimely response to an injury of unknown origin, and inadequate monitoring of a resident with worsening depression and suicidal ideations. Staff were aware of these issues, but appropriate actions were not taken, and protocols were not followed.
Surveyors identified multiple infection control failures, including housekeeping staff not performing hand hygiene between rooms, improper separation of clean and soiled laundry, staff handling plastic drinking cups in a way that risked contamination, unsanitary tracheostomy care, and a urinary catheter drainage bag being stored in a resident's bathtub with urine still inside and tubing in a soap dish.
The facility failed to provide timely and person-centered assistance with meals for three residents. One resident, who required maximum assistance, was left without help for extended periods, leading to distress. Another resident, needing meal setup due to cognitive deficits, waited 43 minutes for assistance. A third resident, requiring encouragement and setup, was not adequately supported, resulting in poor food intake.
The facility failed to ensure the safety of two residents by not attaching foot pedals to their wheelchairs during transportation, posing a fall risk. Despite being identified as high fall risks, the residents were observed being pushed without foot pedals, requiring them to hold their feet up. Interviews revealed a lack of a system to ensure foot pedal availability and use, contributing to the deficiency.
The facility failed to ensure adequate supervision and implementation of fall interventions for a resident, resulting in a fall and wrist fracture. Despite care-planned measures like bolsters and a fall mat, these were not consistently in place. Staff interviews revealed a lack of awareness and understanding of the interventions, contributing to the deficiency.
The facility failed to manage the pain of two residents according to professional standards, as physician's orders for pain medications lacked documented parameters for administration. This led to inconsistent and potentially inadequate pain management, as confirmed by staff interviews and record reviews.
Failure to Ensure Proper Medication Administration and Documentation
Penalty
Summary
A deficiency occurred when nursing staff failed to follow professional standards of medication administration for a resident with multiple neurological and cognitive diagnoses, including encephalopathy, vascular dementia, and spastic hemiplegia. The resident required staff supervision and cueing due to moderate cognitive impairment. During an observation, a medication cup containing three white tablets and one brownish capsule was found on the resident's bedside table, which was later identified as Baclofen and Valerian root. The medications had been documented as administered in the resident's medication administration record (MAR), despite the fact that the resident had not taken them. Record review showed that the resident did not have an assessment for self-administration of medications, and care plans required staff to administer medications as ordered and provide necessary cues due to cognitive impairment. Interviews with the DON and nursing staff confirmed that the nurse responsible had left the medications at the bedside after unsuccessfully attempting to wake the resident, intending to return but failing to do so. The nurse had documented the medications as given in the MAR without observing the resident swallow them, contrary to facility policy and professional standards. Further interviews revealed that staff were aware of the correct procedures, which included staying with the resident until medications were swallowed and documenting only after administration. The DON confirmed that the nurse did not follow these procedures and that there was no documentation of medication refusal or self-administration capability for the resident. The incident was identified during a survey, and the facility's policy was clear that medications should not be left at the bedside and must be administered and documented accurately.
Failure to Accurately Document Medication Administration and Withholding
Penalty
Summary
The facility failed to maintain accurate medical records and documentation for one resident regarding the administration of Cardura, a medication prescribed for hypertension. The resident, who was cognitively intact and required assistance with most activities of daily living, was discharged from the hospital with an order for Cardura. The physician's order for Cardura remained active for over two months, but the medication was not administered during this period. Despite this, the medication administration records (MARs) inaccurately documented that the resident received several doses of Cardura, while other opportunities were marked as 'other/see nurse's notes.' Nursing staff interviews revealed that the medication was not actually administered, and the documentation of administration was done in error. Staff also failed to document the reason for withholding the medication in the electronic medical record (EMR), and there was no official physician hold order for Cardura. Progress notes indicated that the medication was unavailable and that the physician was aware, but this was not consistently or accurately reflected in the MAR or EMR. The DON confirmed that the resident did not receive any doses of Cardura and that the medication had never been delivered to the facility. The facility's policy required that medication administration be documented as per physician order and that any withheld drugs be appropriately documented on the MAR. In this case, the staff did not follow these procedures, resulting in inaccurate records and a lack of clear documentation regarding the resident's medication status. The breakdown in process led to discrepancies between what was recorded and what actually occurred regarding medication administration.
Failure to Investigate Injury of Unknown Origin and Allegations of Staff Abuse
Penalty
Summary
The facility failed to initiate a thorough investigation of an injury of unknown origin involving a resident who was cognitively intact and required total assistance for transfers and mobility due to multiple medical conditions, including autoimmune disease, arthritis, edema, and a history of stroke. The resident reported sustaining an injury when a male CNA transferred her without a mechanical lift, resulting in pain, swelling, and ultimately a diagnosis of right distal tibia and fibula fractures. Despite the resident's ongoing complaints of pain and visible swelling, documentation in skin assessments and progress notes did not reflect these observations, and staff failed to conduct or document a timely and thorough assessment of the injury. Staff interviews revealed that CNAs noticed the resident's complaints of pain and visible bruising but did not consistently report these findings to nursing staff, and there was no designated place in CNA charting to document new injuries. When a nurse was informed of the injury, he observed swelling and bruising but did not perform a full assessment, notify the physician or family, or document the findings, assuming that all parties were already aware due to pending Xrays. Other nursing staff stated that any change in a resident's condition, such as a swollen ankle, should prompt a full assessment, documentation, and notification of the physician and family, as well as reporting to facility leadership to rule out potential abuse, but these steps were not followed in this case. Additionally, the facility failed to recognize, address, and thoroughly investigate allegations of staff-to-resident verbal and mental abuse reported by another resident. The resident reported feeling mentally and verbally abused by nursing staff, including being accused of medication-seeking behavior and being yelled at by a CNA. Despite reporting these concerns to the social services director and other leadership, there was no formal follow-up, and the staff members involved continued to work with the resident. The facility's investigation did not include interviews with other residents or staff, observations of interactions, or documentation of unofficial investigations, resulting in an incomplete response to the allegations.
Removal Plan
- Interview the resident by a clinical resource and the corporate licensed clinical social worker; provide psychosocial support and offer additional mental health support.
- Suspend the NHA and RN; suspend the CNA.
- Conduct education with the NHA, the SSD, and the DON on how to identify instances and allegations of abuse and the difference between a concern and forms of abuse; complete competencies.
- Provide education to the RN and CNA regarding the differences between concerns and forms of abuse and how to report appropriately; ensure the CNA does not return to work until education and return demonstration is provided in person.
- Initiate interviews with all residents who can participate to ensure all allegations of abuse are identified and thoroughly investigated; for residents who cannot be interviewed, reach out to the emergency contact/resident representative to discuss concerns; if an interview cannot be completed, have social services complete an observation to identify signs of psychosocial distress or change in mood; complete all interviews/observations.
- Educate all staff on identification of allegations of abuse versus customer service and abuse reporting, including differentiating potential abuse allegations from concerns/customer service issues; ensure any employee unable to complete education in person is educated prior to their next scheduled shift.
- Have social services or designee complete weekly audits on random residents, including resident interviews about abuse/observations of abuse and record review; if allegations are identified, notify the abuse coordinator per regulations, complete a thorough investigation with interventions to prevent recurrence, complete state occurrence reporting and police reporting; for concerns, complete corrective action; record audits on an audit form; promptly report discrepancies to the administrator; report results to the quality assurance committee.
- Have the director of nursing services or designee interview employees weekly for comprehension about types of abuse and signs of mental abuse, the difference between customer service concerns and allegations, and immediate reporting.
- Provide weekly oversight to review investigations and audit whether managers understand the difference between customer service concerns and allegations.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure a safe environment free from accident hazards and did not provide adequate supervision to prevent accidents for two residents. One resident, who was cognitively intact and required a sit-to-stand mechanical lift for transfers due to musculoskeletal impairments and a history of stroke, was manually transferred by a CNA without the required lift device. During this transfer, the resident experienced a popping sound in her leg, followed by pain, swelling, bruising, and redness. Despite these symptoms, the facility did not assess her pain or change in condition, nor did they provide timely treatment or X-rays. The injury was only properly addressed after the resident reported increased pain to her community physician, who then ordered X-rays and facilitated a hospital transfer, where fractures of the right distal tibia and fibula were diagnosed. The facility also failed to update the resident's care plan to reflect the new fracture as a risk factor and did not investigate the injury when it was first reported by the resident and observed by staff. Another resident with severe cognitive impairment, a history of repeated falls, and an above-the-knee amputation was not provided with person-centered fall interventions tailored to her cognitive deficits. Despite multiple unwitnessed falls, the interventions implemented primarily focused on visual cues such as signs and colored tape to prompt the resident to use her call light and lock her wheelchair brakes. Therapy and nursing documentation indicated that the resident had significant deficits in memory, executive functioning, and safety awareness, which limited her ability to benefit from interventions requiring memory recall and judgment. Staff interviews revealed that additional interventions, such as frequent checks and toileting, were verbally communicated but not documented in the care plan, and there was no evidence of a systematic review of why previous interventions failed after each fall. The facility's interdisciplinary team did not consistently review or update care plans to include effective, individualized interventions based on the residents' needs and cognitive abilities. There was a lack of documentation and follow-up regarding staff observations of injuries and pain, and the process for implementing and communicating fall interventions was not clearly defined or consistently followed. These failures resulted in preventable injuries and inadequate supervision for residents at risk for accidents and falls.
Failure to Communicate Grievance Resolutions to Residents
Penalty
Summary
The facility failed to provide appropriate follow-up, response, and rationale to residents regarding grievances raised during resident council meetings and through individual complaints. According to the facility's grievance policy, the grievance official or designee is required to respond to concerns within three working days, acknowledging receipt and describing steps taken toward resolution. However, record reviews and interviews revealed that while grievances were documented and some actions were taken (such as staff education or cleaning the patio), there was no evidence that the facility communicated the outcomes or resolutions back to the residents or the resident council. Interviews with residents who regularly attended resident council meetings indicated that they were unaware of how grievances were handled after being raised. Residents reported that while department heads sometimes addressed issues during meetings, there was no follow-up or feedback provided regarding the resolution of their concerns. Specific issues brought up by residents included call light response times, unchanged linens, cigarette butts in the smoking area, cold food, delayed room trays, poor communication from therapy, and cleanliness of rooms and bathrooms. Despite these concerns being documented in meeting minutes and grievance forms, residents stated they did not know the outcomes or how to file grievances properly. Staff interviews confirmed the lack of follow-up. The activities director stated that department managers were supposed to bring back resolutions to the next resident council meeting, but this did not consistently occur. The social services director, who served as the grievance official, acknowledged that documentation of follow-up with residents or families was missing from grievance forms for several months. This failure to communicate resolutions left residents uninformed about the actions taken in response to their concerns.
Failure to Honor Resident's Right to Choose Attending Physician
Penalty
Summary
The facility failed to honor a resident's right to choose her own attending physician when her previous primary care provider (PCP) stopped seeing residents at the facility. According to the facility's Resident Rights policy, residents have the right to select their personal attending physician and be informed about how to contact them. However, when the resident's PCP's clinic closed, the facility did not provide the resident with options or documentation to select a new physician, instead assigning her to the facility's contracted physician without her documented consent. The resident involved was cognitively intact, as evidenced by a perfect BIMS score, and had multiple complex medical conditions, including chronic kidney disease, a history of cervical cancer, short bowel syndrome, severe sepsis, and several mental health diagnoses. The resident expressed that she valued making personal choices and reported that she was not given the opportunity to choose her new physician after her previous provider left. Facility records indicated that the resident was notified of her physician's departure and that she wished to transfer to the facility's provider, but there was no documentation showing she was informed of her right to choose or that her permission was obtained for the assignment. Interviews with facility staff revealed that the process for selecting a new physician was not clearly communicated to the resident, and the facility did not provide alternative options due to the abrupt departure of the previous medical group. Staff acknowledged that the resident should have been informed about the process for choosing a different physician and that the facility only had one contracted physician available at the time. The lack of documentation and communication regarding the resident's right to choose her attending physician led to the deficiency.
Failure to Individualize Psychotropic Medication Use and Behavior Monitoring
Penalty
Summary
The facility failed to ensure that two residents were free from chemical restraints and that psychotropic medications were used only with appropriate, individualized, and least restrictive approaches. For both residents, the care plans and documentation did not include resident-specific behaviors, triggers, or person-centered interventions related to the use of psychotropic medications. Instead, the facility relied on generic templates for behavior monitoring and non-pharmacological interventions, which were not tailored to the individual needs or documented behaviors of the residents. For one resident with severe cognitive impairment, anxiety, and depression, the care plan interventions and medication orders referenced monitoring for generic symptoms such as tearfulness and nervousness, but there was no documentation in the medical record, medication administration records, or progress notes to indicate that the resident exhibited any behaviors justifying the continued use of psychotropic medications. The resident expressed feelings of loneliness and anxiety related to her husband’s absence, and staff reported that reassurance and facilitating communication with her husband were effective interventions. However, these specific expressions and interventions were not reflected in the care plan or behavior monitoring documentation. For another resident with moderate cognitive impairment and major depressive disorder, the care plan and physician orders also used generic behavior monitoring and interventions, failing to address resident-specific behaviors such as isolation, obsessions, need for routine, and hoarding tendencies identified in the PASRR evaluation. The documentation did not indicate any behaviors that would justify the use of psychotropic medications, nor did it reflect the resident’s preference for solitude or the triggers identified by family and staff. Staff interviews confirmed that behavior monitoring and interventions were not individualized, and that staff primarily used generic templates rather than customizing care to the residents’ needs.
Failure to Document and Notify Physician During AMA Discharge
Penalty
Summary
The facility failed to provide and document adequate discharge preparation and notification for a resident who left the facility against medical advice (AMA). The resident, who had diagnoses including anxiety, a patella fracture, and hypertension, was admitted following a fall and subsequently left the facility with her representative due to dissatisfaction with facility conditions. The discharge care plan indicated a desire to return home or transfer to another facility, but there was no evidence in the electronic medical record (EMR) that the physician was notified of the resident's or representative's request to discharge, nor was there documentation explaining why the physician could not be reached until the following day. Additionally, there was no documentation that the physician was notified after the resident left AMA. The EMR also lacked evidence that staff attempted to discuss the resident's concerns or reasons for leaving, or that alternative discharge plans were explored. An AMA discharge form was present but was not signed by the representative. Staff interviews confirmed the absence of required documentation and indicated that the expected process for AMA discharges, including physician notification and progress notes, was not followed in this case.
Failure to Implement PASRR Level II Neurocognitive Evaluation Recommendation
Penalty
Summary
The facility failed to incorporate and arrange for the recommendations outlined in the Pre-Admission Screening and Resident Review (PASRR) Level II determination for a resident with a diagnosis of major depressive disorder. Specifically, the PASRR Level II evaluation recommended that the resident receive a neurocognitive evaluation to assess cognitive functions and the impact of neurological conditions. However, the resident's care plan did not include this recommendation, and there was no physician order or documentation indicating that a neurocognitive evaluation had been scheduled or completed since the resident's admission. Record review showed that the resident was cognitively impaired and had a history of dementia and major depressive disorder, with ongoing use of antidepressant medications. Despite the PASRR Level II recommendation, progress notes and computerized physician orders lacked any reference to a neurocognitive evaluation. Staff interviews confirmed that the social services director was responsible for implementing PASRR recommendations but was unable to find evidence that the evaluation had been arranged or performed. The only related documentation was a behavioral health progress note by a licensed clinical social worker, which did not meet the requirements for a neurocognitive evaluation as defined by professional standards.
Failure to Provide Individualized Activity Program for Resident
Penalty
Summary
The facility failed to provide an ongoing, individualized activity program for one resident, resulting in unmet needs and interests as identified in the resident's care plan and assessments. The resident, who was moderately cognitively impaired with diagnoses including dementia with agitation, anxiety disorder, and insomnia, expressed that it was important to have access to reading materials, music, animal visits, religious services, and opportunities to go outside. Despite these preferences being documented, there was no evidence that the resident was consistently offered or able to participate in these activities. Observations revealed that the resident spent significant time alone in his room without engagement in activities, even when group activities such as animal therapy were occurring nearby. On one occasion, a therapy dog visited other rooms on the unit but did not visit the resident's room, despite his documented interest in animal therapy. Staff interviews confirmed that the resident had become more withdrawn following the death of his spouse and that he required reminders and encouragement to participate in activities, but there was no documentation or observation of such efforts being made during the review period. Record review further indicated that, although the resident's care plan included interventions such as inviting him to religious activities, offering animal therapy, and encouraging outdoor time, there was no documentation in the electronic medical record that these interventions were implemented. Staff acknowledged the importance of activities for residents' well-being but did not provide evidence that the resident's individualized needs and preferences were being met as required by facility policy.
Failure to Assess and Monitor Resident with Suicidal Ideation and Depression
Penalty
Summary
The facility failed to ensure that a resident with a history of mental disorder and psychosocial adjustment difficulties received appropriate treatment and services to attain the highest practicable mental and psychosocial well-being. The resident, who had diagnoses including bipolar 2 disorder, depression, and alcohol dependence, exhibited fluctuating symptoms of depression and suicidal ideation as documented in multiple MDS assessments. Despite these documented symptoms, the facility did not consistently assess or monitor the resident for worsening signs of depression or suicidal ideation, nor did they provide timely behavioral health services as ordered by the physician. The resident expressed feelings of frustration, lack of autonomy, and dissatisfaction with his living situation and care, including issues with daily routines and access to preferred food and services. He reported feeling bad about himself, being a failure, and having thoughts of being better off dead or hurting himself during several assessment periods. However, there was no evidence that the facility followed up on these expressions with appropriate assessments, documentation, or interventions. The last documented psychotherapy visit was over a year prior, and although counseling was ordered, the resident was not seen by counseling services as required. Interviews with facility staff revealed a lack of awareness and follow-through regarding the resident's mental health needs. Staff members, including the social services director and MDS coordinator, acknowledged that they did not document or act upon high PHQ-9 scores or expressions of suicidal ideation. There was also a significant gap in behavioral health services due to provider absence, and no alternative arrangements were made for the resident to receive necessary mental health care. The facility's failure to identify, monitor, and address the resident's mental health symptoms and suicidal ideation constituted a deficiency in providing appropriate treatment and services.
Failure to Provide Effective Leadership, Timely Abuse Investigation, and Adequate Resident Monitoring
Penalty
Summary
The facility failed to administer its resources effectively and efficiently, resulting in multiple deficiencies related to leadership, abuse prevention, injury investigation, and mental health monitoring. Specifically, management did not provide sufficient leadership to address or avoid concerns, including the failure to promptly investigate and report allegations of abuse. Staff were aware of a potential verbal abuse incident and reported it to the DON and SSD, but facility leadership did not immediately investigate or implement interventions to prevent further abuse, despite the issue being discussed in morning meetings. Additionally, an injury of unknown origin was not reported or investigated in a timely manner. A CNA reported a resident's swollen ankle to a nurse, who failed to follow protocol by not completing a full assessment, not inquiring about the cause, and not notifying management, the physician, or the family. The injury, later found to be a fracture, was not reported to leadership until days later, and hospital records indicated the fracture was several weeks old. Furthermore, the facility did not adequately monitor a resident with worsening depression and suicidal ideations. The resident's MDS assessments showed increasing depression scores over several months, but no actions were taken by the SSD, and there was no evidence of psychotherapy since June 2022. Interviews with staff and management revealed that while some were aware of these issues, including the abuse allegation and the resident's mental health decline, appropriate actions were not taken. The interim NHA acknowledged that some concerns had gone unaddressed and unnoticed prior to his arrival.
Multiple Infection Control Failures Identified
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in multiple deficiencies across several units. Housekeeping staff were observed not performing appropriate hand hygiene between cleaning resident rooms, specifically failing to change gloves and sanitize hands after cleaning one room and before entering another. This was in direct violation of both CDC guidelines and the facility's own policies, which require hand hygiene before donning gloves and after removal, as well as between clean and dirty tasks. In the laundry room, staff did not keep clean and soiled laundry separate as required. Soiled laundry was observed crossing designated boundaries marked by black tape, with soiled items encroaching into areas meant for clean laundry. Additionally, soiled rags were stored in a cart located in the clean area, contrary to the intended separation of clean and dirty zones. The maintenance director acknowledged the improper placement and the need for a different location for soiled rags. Further deficiencies included improper handling of plastic drinking cups by staff, who were seen placing fingers inside cups while filling them with ice and placing cups face down on an unsanitized cart. Tracheostomy care for a resident was not performed in a sanitary manner, as the nurse failed to sanitize the table surface before placing clean supplies, did not change gloves or perform hand hygiene between dirty and clean tasks, and used a dressing that had fallen on an unsanitized surface. Additionally, a urinary catheter drainage bag for another resident was found stored in a bathtub with urine still inside, and the tubing was resting in a soap dish, which staff confirmed was not a sanitary practice.
Failure to Provide Timely Assistance with Meals
Penalty
Summary
The facility failed to provide timely and person-centered assistance with activities of daily living, specifically meal setup and eating, for three residents. Resident #3, who was severely cognitively impaired and required maximum assistance with eating, was observed on multiple occasions not receiving timely assistance. On one occasion, her meal was placed out of reach, and she was left without assistance for 24 minutes, during which she repeatedly hit the table in frustration. On another occasion, she was not assisted until almost ten minutes after her meal was served, despite her visible distress and attempts to reach for her food. Resident #12, who required supervision and assistance with meal setup due to a cognitive communication deficit, was also neglected. Her meal was served without the necessary setup, and she did not begin eating until 43 minutes later when a CNA finally noticed and cut up her food. This delay in assistance was contrary to her care plan, which specified the need for setup assistance due to her weak left arm and aversion to getting her hands dirty. Resident #9, who had moderate cognitive impairments and required meal setup and encouragement, was observed not receiving the necessary assistance during multiple meals. Her breakfast and lunch were served without any staff checking on her or encouraging her to eat, resulting in her consuming only a small portion of her meals. Despite her preference for finger foods and eating in her room, staff failed to provide the necessary setup and encouragement, leading to inadequate food intake.
Inadequate Supervision and Safety Measures for Wheelchair Use
Penalty
Summary
The facility failed to provide adequate supervision and ensure the safety of residents using wheelchairs, specifically by not attaching foot pedals to the wheelchairs of two residents. This deficiency was observed during a survey where Resident #10 and Resident #11 were pushed in their wheelchairs without foot pedals, causing them to hold their feet up off the floor. This lack of proper equipment use posed a safety hazard, as it could lead to falls or injuries. Resident #10, who has a history of cognitive communication deficit, generalized muscle weakness, repeated falls, and dementia, was observed being pushed into and out of the dining room without foot pedals on his wheelchair. The resident's care plan identified him as a high fall risk due to his weakness and impaired mobility, but it did not include specific interventions to ensure the use of foot pedals during transportation. This oversight in the care plan contributed to the deficiency. Similarly, Resident #11, diagnosed with spastic hemiplegia, abnormal involuntary movements, and other conditions, was also observed being transported without foot pedals on his wheelchair. The resident's care plan indicated a high fall risk and required frequent rounding and supervision, yet the absence of foot pedals during transportation was not addressed. Interviews with the DON and DOR revealed that while staff education on the importance of foot pedals was provided, there was no system in place to ensure their availability and use, leading to the observed deficiency.
Failure to Implement Fall Interventions
Penalty
Summary
The facility failed to ensure adequate supervision and implementation of person-centered fall interventions for Resident #2, who had a fall resulting in a left wrist fracture. Despite being identified as a medium fall risk and having specific interventions care planned, such as providing bolsters on the air mattress and a fall mat beside the bed, these measures were not consistently implemented. Observations revealed that the fall mat was often placed across the room and not beside the bed, and bolsters were missing from the mattress. Additionally, the resident's reacher was not within reach, contributing to the fall incident when the resident attempted to reach for bed controls without assistance. Interviews with staff, including a CNA and an RN, indicated a lack of awareness and understanding of the fall risk interventions for Resident #2. The CNA was unaware of the significance of the falling star sticker and the required placement of the fall mat and bolsters. The RN acknowledged the importance of these interventions but admitted they were not consistently in place. The DON and ADON confirmed that the interventions were discussed and documented during IDT meetings but were not verified to ensure they were implemented. The facility's failure to follow through on the documented fall interventions for Resident #2 led to the resident's fall and subsequent injury. The lack of consistent implementation of care-planned interventions and inadequate staff awareness and training contributed to the deficiency in providing a safe environment for the resident, as required by the facility's fall management policy.
Inadequate Pain Management Documentation
Penalty
Summary
The facility failed to manage the pain of two residents in a manner consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. Specifically, the facility did not ensure that pain medications had documented parameters for administration. Resident #7, who had diagnoses including left-sided paralysis and arthritis, reported frequent pain that interfered with daily activities. Despite being on a scheduled pain regimen, the resident indicated that the PRN Tylenol was ineffective, leading to loss of sleep. The physician's orders for both Tylenol and Norco did not specify the pain level parameters for administration, nor did they indicate the maximum allowable dosage of acetaminophen from all sources. This was confirmed by RN #1 during an interview, who acknowledged the lack of documented parameters for the pain medications. Resident #8, who had diagnoses including hemiplegia and chronic post-traumatic headache, also experienced frequent pain that interfered with daily activities. The physician's orders for Norco and Tylenol did not specify the pain level parameters for administration. The medication administration record (MAR) listed a numerical pain scale but did not specify the pain levels at which the medications should be administered. According to the MAR, Norco was administered for pain levels ranging from 2 to 7, without clear guidelines. This was confirmed by both CN #1 and RN #1, who acknowledged the absence of pain parameters in the physician's orders. The facility's failure to provide adequately detailed guidance for administering PRN pain medications led to inconsistent and potentially inadequate pain management for both residents. The lack of documented parameters for pain levels and maximum allowable dosages of acetaminophen contributed to the residents' ongoing pain and discomfort, as confirmed by staff interviews and record reviews.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
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Illustrative
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Nursing homes near Fort Collins
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Poudre Canyon Rehabilitation And Nursing, Llc | 0.5 mi | ★★★★★ | 0 | 0 |
| Storybrook Care & Rehabilitation | 0.5 mi | ★★★★★ | 4 | 0 |
| Creekside Village Rehabilitation And Nursing Llc | 0.9 mi | ★★★★★ | 36 | 3 |
| Columbine West Health And Rehab Llc | 2.4 mi | ★★★★★ | 0 | 0 |
| Centre Avenue Health And Rehab Llc | 2.4 mi | ★★★★★ | 1 | 0 |
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