Riverdale Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Brighton, Colorado.
- Location
- 2311 E Bridge St, Brighton, Colorado 80601
- CMS Provider Number
- 065378
- Inspections on file
- 23
- Latest survey
- February 19, 2026
- Citations (last 12 mo.)
- 5
Citation history
Health deficiencies cited at Riverdale Post Acute during CMS and state inspections, most recent first.
The facility failed to protect residents from resident-to-resident physical abuse and did not implement preventive behavioral interventions after two separate altercations on a men’s secured unit. In one event, a cognitively intact resident with dementia and a history of frequent aggressive behaviors struck another severely cognitively impaired resident in the face with a soda can, causing a skin tear and bruising, yet his care plan was only updated with immediate de-escalation actions and no new preventive strategies. In another event, a resident with severe dementia and a known history of physical and verbal aggression toward staff made contact with another resident’s head after a verbal exchange in the hallway, but his care plan did not address aggression toward other residents and was not revised with interventions to prevent recurrence. CNAs reported they were only instructed to keep the involved residents separated and were not given additional techniques, and an LPN stated she had not been informed about recent altercations, demonstrating that staff were not consistently informed or guided on preventive measures following these abuse incidents.
Surveyors found that medication and treatment carts were repeatedly left unlocked and unattended, including one treatment cart near the front entrance containing wound care supplies and prescription medications. On another occasion, an RN left a medication cart unlocked in a common area with a prefilled insulin syringe and multiple labeled medication cups containing different residents’ medications stacked on top of each other, including one cup with an unknown medication. Staff later confirmed that carts were expected to remain locked when not in use and that prepouring medications was not permitted, but these practices were not followed.
An LPN performed wound care for a resident without following basic infection control practices, including failing to perform hand hygiene before accessing the treatment cart, handling wound care supplies, and changing gloves. The LPN placed supplies and wound care scissors on an unsanitized bedside table, removed a soiled dressing from an open wound, then used the same contaminated gloves to open a sterile saline bottle and set it on the unclean surface. After removing the soiled gloves, the LPN again skipped hand hygiene before donning clean gloves, used saline and gauze to clean the open wound, and then used unsanitized scissors from the soiled table to cut antimicrobial dressing that was applied directly to the wound, and later to cut Velcro from an ace bandage applied over the resident’s arm and brace.
The facility failed to prevent falls and ensure safe transfers for three residents, leading to multiple falls and injuries. A resident with dementia and an unsteady gait experienced several falls due to inconsistent implementation of fall interventions. Another resident, requiring a mechanical lift for transfers, was improperly transferred by a single CNA, resulting in a fall. A third resident, needing a Hoyer lift, was involved in incidents where the lift protocol was not followed, leading to falls. These deficiencies highlight the facility's failure to adhere to care plans and safety protocols.
The facility failed to maintain safe food storage and sanitary kitchen conditions. Refrigerators were above safe temperatures, health shakes lacked expiration labels, and expired food was found. The kitchen had missing tiles, standing water, and a dirty ice machine filter. Staff interviews revealed unclear responsibilities for maintaining these standards.
The facility's binding arbitration agreement did not include provisions for the selection of a neutral arbitrator agreed upon by both parties or for a mutually convenient venue, as required by policy. Instead, the agreement specified that arbitration would be conducted by a contracted provider with the arbitrator chosen from their list, and the hearing held in the facility's county. Staff confirmed that residents were not given the opportunity to participate in selecting the arbitrator or venue.
A facility failed to provide a dignified dining experience by not adhering to residents' dietary preferences and using disposable cups for beverages. A resident on a puree diet did not receive the ordered menu items, and residents on the Aspen unit were served drinks in paper and styrofoam cups instead of plastic ones. Staff interviews revealed a lack of clarity regarding these practices.
A facility failed to protect residents from abuse, with incidents involving sexual and physical aggression. One resident was observed masturbating in a shared room, while another incident involved a physical altercation between two residents. A third incident saw a resident attempting to kick another in the dining room. Despite documented histories of inappropriate behavior, the facility's investigations were incomplete, and incidents were not reported as required. Care plans were not adjusted to prevent recurrence, and the facility's response was inadequate.
The facility failed to provide residents with mechanically altered diets as prescribed, leading to incorrect meal preparations that did not match dietary orders. Observations revealed that residents received meals inconsistent with their dietary needs, such as receiving crisp tostada shells instead of pureed beef tostadas and fruit crisps instead of peach slices. Staff interviews indicated a lack of training in the new IDDSI standards, contributing to the errors.
Three residents did not have comprehensive care plans addressing their specific needs, including supplemental oxygen use, PICC line management, and insomnia. One resident with schizoaffective disorder and vascular dementia lacked care plan interventions for oxygen and PICC line care, while two others with dementia and insomnia had no care plan focus on their sleep issues, despite being prescribed medications for insomnia. Staff confirmed these omissions during interviews.
The facility did not ensure that three residents or their representatives received a thorough explanation of the binding arbitration agreement or provided documented acknowledgement of understanding before signing. Interviews revealed that these individuals did not recall signing or understanding the agreement, and staff could not provide evidence of proper explanation or acknowledgement.
The facility failed to maintain proper infection control by not ensuring housekeeping staff followed hand hygiene protocols, neglected cleaning high-touch surfaces, and used improper cleaning techniques in resident bathrooms, including sharing toilet brushes between rooms. Additionally, staff did not implement Enhanced Barrier Precautions for a resident with a PICC line, with no PPE available and inconsistent understanding among staff about when EBP was required.
The facility did not ensure necessary maintenance and cleanliness in resident rooms, bathrooms, dining areas, and hallways, resulting in damaged furniture, water damage, pest presence, and unaddressed repair needs. Residents reported unresolved requests for cleaning and missing room furnishings, while staff interviews revealed a lack of awareness and follow-through on maintenance issues.
A cognitively intact resident with a history of inappropriate sexual behavior was witnessed by a CNA masturbating in another resident's room. The DON was informed, and the resident was relocated to a secured unit. However, the incident was not reported to the State Survey Agency as required, leading to a deficiency in compliance with state reporting requirements.
Resident meal tickets containing protected health information, including names and diet orders, were left unsecured in the kitchen and dining room, allowing a resident's representative to access and review them. Staff confirmed that such information should remain confidential and not be accessible to guests.
A resident with multiple chronic conditions and cognitive intactness was admitted with a physician's order for full code status, but the facility did not document the resident's refusal to complete a MOST form or any discussion of resuscitation preferences in the care conference notes or electronic medical record. Staff interviews and record reviews confirmed the absence of required documentation regarding the resident's resuscitation choices.
A resident with a PICC line for IV antibiotics did not have a physician's order for routine dressing changes, and there was no documentation that the dressing was changed for several weeks after insertion. The care plan lacked interventions for PICC line maintenance, and observations showed the dressing was soiled and pulling away from the skin. Staff interviews revealed the order for dressing changes was not obtained until prompted by surveyors.
A resident with multiple chronic conditions and wounds was not weighed upon admission as required by facility policy, and there was no consistent documentation of attempts to obtain weights or monitor nutritional status. Despite orders for weekly weights and staff acknowledgment of the need for follow-up when a resident refused, the EMR lacked evidence of these actions, resulting in inadequate monitoring of the resident's nutrition needs.
A resident with moderate cognitive impairment and a history of malnutrition and eating disorder was observed self-administering tube feedings without staff supervision or a documented assessment of her ability to do so safely. Care plans and physician orders did not authorize self-administration, and staff interviews confirmed that no formal evaluation had been completed. This resulted in a failure to ensure appropriate care and oversight for the resident's enteral nutrition.
A facility exceeded the acceptable medication administration error rate, with an LPN administering an incorrect dose of omeprazole via PEG tube and applying a lidocaine patch to the wrong shoulder for a resident with GERD and shoulder pain. The errors were attributed to not double-checking physician's orders and misunderstanding the resident's position during care.
A resident with advanced dementia and multiple medical conditions did not have hospice nursing and CNA visit notes, care plans, or other required hospice documentation accessible to facility staff. Staff interviews confirmed that hospice documentation was missing from the resident's binder and not uploaded to the EMR, hindering effective care coordination.
The facility did not post a complete and accessible list of contact information for all required State agencies and advocacy groups, including missing mailing and email addresses and certain agency contacts. Several alert and oriented residents reported not knowing how to file a complaint, and staff interviews revealed confusion over responsibility for maintaining these postings.
The facility failed to maintain a functioning alarm on the door to the secured patio, compromising resident safety. Observations showed the alarm was broken, allowing residents to potentially exit unnoticed. Staff interviews revealed a lack of training and communication regarding the alarm issue, which had persisted for months. The DON and NHA were unaware of the problem until the survey, indicating a breakdown in internal communication.
The facility failed to control a fly infestation in the kitchen and dining areas, with flies entering through an unscreened open door. Residents expressed discomfort, and staff acknowledged the unsanitary conditions despite efforts to address the issue.
Failure to Implement Preventive Measures After Resident-to-Resident Physical Abuse
Penalty
Summary
The deficiency involves the facility’s failure to protect residents from resident-to-resident physical abuse and to implement preventive measures after incidents. Facility policy states residents have the right to be free from abuse, including physical abuse, and that the abuse prevention program must protect residents from abuse by anyone, including other residents, and implement measures to address factors that may lead to abusive situations. Despite this, the facility did not develop or update behavioral care plans with preventive interventions following two separate resident-to-resident altercations on the men’s secured unit, and staff were not provided with new techniques beyond immediate separation of the involved residents. In the first incident, a cognitively intact resident with dementia and a history of frequent physical and verbal behavioral symptoms struck another resident in the face with a soda can in the men’s secured unit dining area. The victim, who had severe cognitive impairment, dementia with behavioral disturbance, and no documented behavioral symptoms on the most recent MDS, sustained a skin tear and bruising near the left eye. The facility’s investigation confirmed that the assailant resident made contact with the victim’s face using a soda can after a conflict over trash, and that the contact constituted substantiated abuse. The behavioral care plan for the assailant was revised only to reflect that an altercation had occurred and that staff de-escalated his aggressive mood by returning him to his room, but it did not include any new preventive interventions to avoid recurrence of aggression toward other residents. In the second incident, a resident with severe vascular dementia, behavioral disturbance, and a history of physical and verbal aggression toward staff made contact with another resident’s head in the hallway after both became verbally aggressive. The victim had moderate cognitive impairment, dementia with behavioral disturbance, bipolar disorder, and no prior documented behavioral symptoms on the MDS, and reported that the other resident cursed at him and then hit him, causing the aggressor to fall. The facility’s investigation acknowledged that the aggressive resident had a history of behaviors that could be triggered by feeling rushed, loss of control, unfamiliar staff, changes in routine, or unmet needs, and that without appropriate interventions his behaviors could escalate and place him and others at risk. However, there were no updates to the aggressive resident’s behavioral care plan to address aggression toward other residents, and no new interventions were added to prevent further recurrence. Staff interviews confirmed that CNAs were only told to keep the involved residents separated and were not given additional prevention techniques, and an LPN reported not being informed about recent altercations on the unit, limiting her ability to monitor and separate residents at risk of conflict.
Unlocked Carts and Unattended Prepoured Medications Left in Common Area
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards. Over multiple days, a treatment cart located near the front entrance was observed unlocked and unmonitored by nursing staff for extended periods. The contents of this treatment cart included wound care supplies and prescription medications, yet it remained accessible when no nurse was present. The facility was unable to provide a medication storage policy when requested during the survey. On another occasion, a medication cart was observed unlocked and unattended by the assigned RN. On top of this cart, surveyors observed a prefilled insulin syringe and several paper medication cups labeled with different residents’ names, each containing medications. These cups were stacked so that the bottom of one cup was in contact with another resident’s medications, and there was also a plastic medication cup containing an unknown medication at the top of the stack. These medications were left on the cart in a common area without the medication nurse in sight, and the RN later stated she had left the cart to go into the supply room. Staff interviews confirmed that both treatment and medication carts were expected to be locked when not being accessed and that prepouring medications was not allowed, but these expectations were not followed in the observed instances.
Failure to Follow Hand Hygiene and Aseptic Technique During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow proper infection prevention and control practices during wound care for a resident. During an observed wound care procedure, an LPN did not perform hand hygiene before opening the treatment cart, touching wound care supplies, or bringing those supplies and the physician’s wound care order into the resident’s room. The LPN placed wound care supplies and wound care scissors on the resident’s bedside table without sanitizing the table surface or the scissors. The LPN then donned gloves without prior hand hygiene and removed the resident’s soiled wound dressing, which had yellow discharge. With the same soiled gloves, the LPN opened a bottle of sterile saline and set it on the unclean bedside table, again without performing hand hygiene. After handling the saline bottle, the LPN removed the soiled gloves but did not perform hand hygiene before reaching into a box of clean gloves and donning a new pair. The LPN then poured saline on gauze to clean the resident’s open wound and picked up the unsanitized scissors from the soiled bedside table to cut antimicrobial dressing material, which was placed directly onto the open wound. The LPN did not sanitize the scissors before using them to prepare the dressing. The LPN continued the wound care by applying ointment, a foam-covered bandage, an ace wrap, and a hard plastic brace, and then used the same unsanitized scissors to cut off Velcro from another ace bandage applied over the brace and the resident’s arm. These actions occurred despite CDC guidance that failure to perform appropriate hand hygiene is a leading cause of health-care-associated infections and spread of multiresistant organisms.
Failure to Prevent Falls and Ensure Safe Transfers
Penalty
Summary
The facility failed to ensure that three residents remained as free from accidents as possible, leading to multiple falls and injuries. Resident #97, who was at risk for falls due to dementia, hearing impairment, and an unsteady gait, experienced several falls resulting in head injuries. Despite having a fall care plan in place, the facility did not implement new interventions after each fall until after the third incident. Even after introducing a soft helmet as an intervention, the facility did not ensure the resident wore it consistently, leading to further falls and injuries. Resident #37, who required a mechanical lift and two staff members for transfers due to hemiplegia and dementia, was improperly transferred by a single CNA without the use of a mechanical lift. This resulted in the resident being lowered to the floor during a transfer, contrary to the care plan and facility policy. The fall investigation revealed that the resident tripped over oxygen tubing and a floor mat, indicating a lack of adherence to the care plan and safety protocols. Resident #47, who required a Hoyer lift for all transfers due to multiple sclerosis and a history of traumatic brain injury, was involved in two incidents where the lift protocol was not followed. In one instance, the resident fell during a shower transfer when a CNA attempted to transfer him without the Hoyer lift, resulting in the resident hitting his head. In another incident, the resident was assisted to the floor during a transfer due to weakness, despite the care plan requiring the use of a Hoyer lift. These incidents highlight the facility's failure to adhere to established care plans and transfer protocols, leading to preventable falls and injuries.
Deficiencies in Food Storage and Kitchen Sanitation
Penalty
Summary
The facility failed to maintain safe and sanitary conditions in its food storage and preparation areas, as observed in the main kitchen and unit nourishment refrigerators. The nourishment room refrigerators were not kept at safe temperatures, with recorded temperatures consistently above the acceptable cold holding temperature of 41°F. Health shakes stored in these refrigerators were not labeled with pull or expiration dates, despite instructions to use the thawed product within 14 days. Additionally, expired food items, such as a turkey pot pie, were found in the freezer, indicating a lack of proper monitoring and removal of outdated products. The main kitchen environment was also found to be unsanitary. Observations revealed missing and damaged coving tiles behind the ice machine, which led to standing water pooling on the floor. The ice machine's aluminum filter was covered in brown debris, and a large section of the kitchen floor was missing tiles, exposing rough concrete. These conditions suggest a failure to adhere to professional standards for maintaining clean and sanitary food preparation areas. Interviews with staff, including the Director of Nursing (DON), Certified Nurse Aides (CNAs), the Dietary Director (DD), and the Nursing Home Administrator (NHA), revealed a lack of clarity and responsibility regarding the maintenance of refrigerator temperatures and cleanliness of the kitchen. The NHA was unaware of the unsanitary conditions and the lack of proper cleaning assignments for the ice machine filter. The dietary department was identified as responsible for monitoring refrigerator temperatures and expired products, but there was no evidence of corrective actions taken to address the deficiencies.
Arbitration Agreement Lacks Required Neutrality and Venue Provisions
Penalty
Summary
The facility failed to ensure that its binding arbitration agreement contained all required components as outlined in its own policy and federal regulations. Specifically, the agreement did not include language that allowed for the selection of a neutral arbitrator agreed upon by both parties, nor did it provide for the selection of a venue that was convenient to both parties. The agreement instead specified that arbitration would be administered by a contracted provider, with the arbitrator selected from a list provided by that provider, and that the hearing would be held in the county where the facility is located. This process did not allow residents or their representatives to participate in the selection of the arbitrator or venue, as required. Interviews with facility staff confirmed these omissions. The admission coordinator stated that the arbitration agreement did not inform residents of their right to speak with federal, state, or local surveyors or ombudsman, and that such information was only included in a separate admission agreement. The admission coordinator also confirmed that there was no language in the arbitration agreement regarding the selection of a venue by both parties. These findings demonstrate that the facility's arbitration agreement did not meet the required standards for neutrality and convenience for both parties.
Failure to Provide Dignified Dining Experience
Penalty
Summary
The facility failed to ensure that residents prescribed a puree diet received meals according to their preferences and prescribed diet orders. Specifically, Resident #26 did not receive the menu items he ordered, such as a cheeseburger, and instead was served mashed potatoes and puree meat. The resident's representative reported difficulty in finding the puree diet menu and noted that the resident often had to guess what he was eating. Observations during meal service confirmed discrepancies between the menu and the food served, with the puree test tray not matching the documented diet modification spreadsheet. Additionally, the facility did not provide residents on the Aspen unit with non-disposable beverage cups during meals. Observations showed that residents were served beverages in paper and styrofoam cups instead of plastic cups, which was inconsistent with the practice on the men's secured unit. Staff interviews revealed a lack of clarity regarding the reason for this discrepancy, with both a CNA and an LPN indicating that the kitchen consistently sent paper cups for the women's secured unit without a clear explanation. The facility's dietary director and nursing home administrator acknowledged the practice of pureeing leftover food from previous meals for residents on a puree diet. However, they were unaware of any concerns regarding the puree food items prior to the survey. The dietary director also indicated that staff had been educated to serve residents their preferred puree options, such as a puree burger, if requested. Despite this, the facility's failure to adhere to residents' dietary preferences and provide appropriate dining materials resulted in a deficiency in treating residents with respect and dignity.
Failure to Protect Residents from Abuse
Penalty
Summary
The facility failed to protect several residents from abuse, as evidenced by multiple incidents involving inappropriate and harmful interactions between residents. One incident involved a resident who was observed masturbating in the shared room of two female residents. Despite the presence of a care plan addressing the resident's history of sexually inappropriate behavior, the facility did not conduct a thorough investigation or implement effective interventions to prevent recurrence. The facility's documentation was incomplete, lacking interviews with other residents or staff, and the incident was not reported to the State Agency as required. Another incident involved a physical altercation between two residents in a hallway. One resident attempted to pass by another, resulting in a physical confrontation. Although staff intervened and no injuries were reported, the facility did not substantiate the incident as abuse, despite evidence of aggressive behavior. The care plans for both residents indicated a history of behavioral issues, yet no changes were made to address the risk of future altercations. A third incident involved a resident who attempted to kick another resident in the dining room. The assailant had a documented history of physical aggression, and staff were unable to redirect him effectively. The facility's investigation concluded that the incident did not constitute abuse, despite witness statements indicating otherwise. The resident was eventually discharged to the hospital due to his inability to be redirected, but the facility's response to the incident was inadequate in preventing harm to other residents.
Failure to Provide Mechanically Altered Diets as Prescribed
Penalty
Summary
The facility failed to ensure that residents who were prescribed mechanically altered diets received food prepared according to their diet orders. Specifically, residents who required puree and mechanical soft diets were not provided with meals that matched their dietary needs as indicated on their meal tray cards. The facility's policy stated that diet orders should match the terminology used by the food and nutrition services department, and the dietitian, nursing staff, and attending physician should regularly review the need for prescribed therapeutic diets. During meal service observations, it was noted that residents received meals that did not align with their dietary requirements. For instance, a resident with a mechanical soft-ground texture order received a crisp, fried tostada shell instead of a pureed beef tostada. Another resident received a fruit crisp instead of peach slices. Additionally, a puree plate served to a resident included peas, which should not have been pureed, and the puree meat had small visible lumps, indicating it was not of the correct consistency. Interviews with staff revealed that the facility was in the process of transitioning to the International Dysphagia Diet Standardisation Initiative (IDDSI) standards, but the staff had not yet been fully trained. The dietary director acknowledged that the modified diet textures were incorrect and that residents were at risk for choking if modified textures were served incorrectly. The dietary director also noted that the facility had not yet transitioned to using IDDSI levels, which contributed to the confusion and errors in meal preparation.
Failure to Develop Comprehensive Care Plans for Oxygen, PICC Line, and Insomnia
Penalty
Summary
The facility failed to develop comprehensive care plans for three residents, resulting in unmet needs related to supplemental oxygen, PICC line management, and insomnia. For one resident with schizoaffective disorder, vascular dementia, and cellulitis, the care plan did not address the use of supplemental oxygen or the maintenance and monitoring of a PICC line, despite physician orders and ongoing treatments for these conditions. Interviews with the resident, their representatives, and staff confirmed the absence of these critical interventions in the care plan, even though the resident required continuous oxygen and had a PICC line for IV antibiotics. Two other residents, both with dementia and additional diagnoses including insomnia, were also found to have incomplete care plans. Their care plans did not include any focus or interventions related to their insomnia, despite both being prescribed medications such as trazodone and melatonin specifically for sleep issues. Staff interviews confirmed that sleep patterns were being tracked and that insomnia was a known issue, but this was not reflected in the residents' care plans. The facility's policy requires that care plans be comprehensive, person-centered, and updated as residents' conditions change. However, record reviews and staff interviews revealed that these requirements were not met for the three residents in question, as their care plans lacked necessary interventions for significant medical and behavioral needs identified through assessments and physician orders.
Failure to Ensure Residents Understood Binding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement was thoroughly and accurately explained to residents and/or their representatives prior to signing, as required by facility policy. Specifically, three residents or their representatives signed the arbitration agreement without evidence that the terms and implications were explained in a manner they could understand, and without documented verbal acknowledgement of understanding. The facility's policy requires that the agreement be explained in consideration of language, literacy, and learning preferences, and that staff document a verbal acknowledgement of understanding, not just a signature. Interviews with the affected residents revealed that they did not recall signing the arbitration agreement or understanding its purpose. Staff interviews indicated that the admissions coordinator read the agreement aloud to residents or their responsible parties, but the facility was unable to provide documentation that residents or their representatives acknowledged understanding the agreement. Record review confirmed that the required documentation of understanding was missing for the identified residents.
Infection Control Lapses in Housekeeping and Enhanced Barrier Precautions
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program across all units, as evidenced by multiple observed lapses in housekeeping and staff practices. Housekeeping staff did not consistently follow appropriate hand hygiene protocols, such as sanitizing hands between glove changes, and were observed contaminating clean gloves by touching personal items like keys. High-touch surfaces in resident rooms, including door knobs, light switches, and call lights, were not cleaned or sanitized as required. Additionally, improper cleaning techniques were used in resident bathrooms, such as using the same toilet scrub brush for multiple rooms and cleaning from dirty to clean areas and back, which is contrary to recommended procedures. Staff interviews revealed a lack of clarity and consistency in infection control practices. The housekeeping supervisor acknowledged that only one toilet scrub brush was available per unit and expressed a desire for each room to have its own brush, indicating current practices did not meet expected standards. The supervisor also confirmed that high-touch surfaces should be cleaned daily, but observations showed this was not being done. Housekeeping staff were not consistently sanitizing their hands between glove changes, and the same cleaning tools were used across multiple rooms, increasing the risk of cross-contamination. The facility also failed to implement Enhanced Barrier Precautions (EBP) for a resident with a peripherally inserted central catheter (PICC). Staff did not wear gowns or gloves during high-contact care activities with this resident, and there was no personal protective equipment (PPE) available in or outside the resident's room. Interviews with nursing and restorative staff indicated confusion about when EBP was required and inconsistent application of these precautions. The infection preventionist and DON provided differing accounts regarding the resident's need for EBP, with the DON stating EBP was only in place during active medication administration through the PICC line, while the infection preventionist indicated EBP should be used for any resident with an indwelling device.
Failure to Maintain Safe, Sanitary, and Comfortable Environment
Penalty
Summary
The facility failed to maintain a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, as required by its own Safe and Homelike Environment policy. Observations revealed multiple areas in disrepair, including nine dining room chairs with ripped and peeling seat cushions, and four dining room tables with scratched and peeling surfaces exposing the underlying particle board. In the Mountain View hallway, rotted wood was found along the bottom of a double doorway frame, and the ceiling near the exit sign showed water spots and was bowing downward. Resident rooms and bathrooms were found with significant maintenance and cleanliness issues. One room had raised and rough patches on the wall, holes, scuff marks, and trash on the floor. Another room had dried liquid spills and a yellow chunky substance splattered on the wall, while a third room had a large hole in the wall with peeling paint and broken plaster. Bathrooms were observed with hard water staining, separated baseboards, corrosion, water damage, and evidence of a leaking toilet. In one bathroom, a towel was placed on the floor, and when lifted, 15 to 20 gnats were observed. Additional issues included missing curtains, broken heating vents, and toilet tank lids that did not fit, leaving openings into the tank. Interviews with residents indicated that some were unable to see trash baskets or wall conditions, and requests for cleaning (such as removal of a dead moth) were not fulfilled. One resident reported that curtains had been removed and not replaced, contributing to a cold room environment. Staff interviews revealed that the nursing home administrator was unaware of the maintenance concerns, and the maintenance director had not received work orders or been made aware of specific issues in certain rooms. The maintenance director acknowledged ongoing repair needs but cited the age of the building and competing priorities as reasons for delays.
Failure to Report Potential Sexual Abuse Incident
Penalty
Summary
The facility failed to report an incident of potential sexual abuse involving a resident to the State Survey Agency (SSA) as required by state law. The facility's policy mandates that all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property be identified, investigated, and reported within the timeframes required by federal requirements. However, in this case, the facility did not adhere to these requirements. The incident involved a 65-year-old resident who was cognitively intact and had a history of inappropriate sexual behavior. On a specific date, a CNA witnessed the resident masturbating in another resident's room while the other residents were asleep. The CNA relocated the resident and informed him that such actions were not permissible. The Director of Nursing (DON) was notified and spoke with the resident, who agreed to relocate to an all-male secured unit. Despite these actions, the facility did not report the incident to the SSA. Interviews with the DON and the Nursing Home Administrator (NHA) revealed that the incident was not reported to the SSA because the NHA consulted with a clinical consultant who advised that the incident was not considered abuse. The NHA acknowledged that any allegations of abuse should be reported to the SSA within 24 hours, but in this case, the incident was not reported, leading to a deficiency in compliance with state reporting requirements.
Failure to Secure Resident Meal Tickets and Protect Confidential Information
Penalty
Summary
Facility staff failed to maintain the confidentiality of resident medical records by leaving resident meal tickets, which contained protected information such as resident names and physician-prescribed diet orders, in unsecured locations within the main kitchen and dining room. During meal preparation and service, these meal tickets were observed on both sides of the serving counter and on top of the steam table, making them easily accessible to anyone in the area. A resident's representative was seen picking up and looking through the meal tickets in both locations, searching for a specific resident's meal ticket. Staff interviews confirmed that the meal tickets contained protected information, including resident names, room numbers, and diet orders, and that guests should not have access to them. The dietary director acknowledged that resident privacy was not maintained in this instance, and the nursing home administrator stated that this issue had not been previously brought to his attention. The regional clinical resource noted that while staff were trained on resident privacy, it was unclear if meal tickets were specifically included in that training.
Failure to Document Resident's Resuscitation Preferences and MOST Form Refusal
Penalty
Summary
The facility failed to accurately document a resident's resuscitation preferences and refusal to complete a medical orders for scope of treatment (MOST) form upon admission. The resident, who was over 65 years old and had multiple diagnoses including COPD, chronic respiratory failure, diabetes, opioid dependence, history of blood clots, hypertension, and pressure ulcers, was cognitively intact and dependent on care for hygiene and bed mobility. Despite a physician's order for full code status being present, there was no documentation in the care conference summary or progress notes indicating that the resident's resuscitation choices or refusal to sign the MOST form were discussed or recorded. Staff interviews revealed that the DON stated the resident declined to initiate a MOST form at admission and that this was supposedly documented in care conference notes. However, a review of the care conference notes and the electronic medical record did not show any documentation of the resident's declination or discussion of resuscitation choices. The RCR confirmed that, in the absence of a completed MOST form, the default order would be for full code status. An email from the RCR further confirmed the lack of documentation regarding the resident's refusal or discussion of resuscitation preferences.
Failure to Obtain Orders and Provide Routine PICC Line Maintenance
Penalty
Summary
The facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice regarding the maintenance of a peripherally inserted central catheter (PICC) line. Specifically, the facility did not obtain a physician's order for routine PICC line dressing changes until several weeks after the line was placed, and there was no documentation that the dressing had been changed from the time of insertion until the order was obtained. The resident's care plan also lacked any focus or interventions related to the PICC line or its maintenance. The resident, who was over 65 years old and had diagnoses including schizoaffective disorder, vascular dementia, and cellulitis, was admitted with a PICC line for IV antibiotics. Interviews with the resident and her representatives confirmed that the PICC line was placed for antibiotic administration. Observations revealed that the PICC line dressing was visibly soiled, pulling away from the skin, and the date on the bandage was mostly washed away, indicating it had not been changed as required. The resident reported that the dressing had not been changed for several days, and staff interviews indicated uncertainty about the presence of a physician's order for dressing changes. Record review showed that while there were orders for PICC line placement, radiographs, and flushing, there was no order for dressing changes until it was added during the survey. Staff interviews confirmed that the order for weekly dressing changes was not in place until prompted by the survey, and there was no documentation of dressing changes in the electronic medical record during the relevant period. This failure to follow professional standards and obtain necessary orders resulted in the deficiency.
Failure to Monitor and Document Resident Weight Upon Admission
Penalty
Summary
The facility failed to ensure that a resident with multiple medical conditions, including COPD, chronic respiratory failure, type 2 diabetes, opioid dependence, hypertension, and pressure ulcers, received appropriate monitoring of nutritional status upon admission. Although facility policy required residents to be weighed upon admission and at intervals determined by the interdisciplinary team, there was no documented admission weight for the resident, nor were there consistent attempts to obtain a weight as required. The only recorded weight was from a prior hospital stay, and the resident's usual body weight was unknown. The care plan and physician orders indicated the need for weekly weights, but the electronic medical record did not show evidence of these weights being taken or of repeated attempts to weigh the resident, except for a single documented refusal during the nutritional risk assessment. Staff interviews revealed that weighing residents upon admission was standard protocol, and that if a resident refused, further follow-up by nursing staff was expected. A CNA reported difficulty weighing the resident due to the need for two staff members and the resident's discomfort, but there was no documentation in the medical record of these attempts or refusals beyond the initial assessment. The lack of documented efforts to obtain the resident's weight and monitor for trends, as well as the absence of recorded weights in the medical record, resulted in a failure to meet the resident's nutritional monitoring needs as outlined in facility policy.
Failure to Assess and Supervise Resident Self-Administering Tube Feedings
Penalty
Summary
The facility failed to ensure that a resident with a feeding tube received appropriate assessment and supervision while self-administering tube feedings. The resident, who was under 65 years old and had diagnoses including moderate protein-calorie malnutrition, an eating disorder, and adult failure to thrive, was observed independently administering her own bolus tube feedings on multiple occasions without staff present. The resident had a moderate cognitive impairment and required supervision or assistance for most activities of daily living, though she was independent with eating. Review of the resident's care plans and physician orders indicated that she required enteral nutrition and that staff were to check tube placement and provide supervision for safety. The care plans also noted that the resident was private and refused staff assistance with tube feedings, but there was no documented assessment confirming her ability to safely self-administer her feedings. Additionally, there were no physician orders authorizing the resident to self-administer her tube feedings. Interviews with staff, including an LPN and the DON, confirmed that the resident did not allow staff to administer her feedings and that no formal assessment had been completed to determine her competency in self-administration. Both staff members stated that supervision should have been provided during feedings and that a physician's order was necessary for self-administration. The lack of assessment, documentation, and supervision constituted a failure to provide appropriate care and services for the resident with a feeding tube.
Medication Administration Error Rate Exceeds 5%
Penalty
Summary
The facility failed to maintain a medication administration error rate below five percent, as required by professional standards and regulations. During observations, it was found that the medication error rate was 6.06%, with two errors identified out of 33 opportunities. Specifically, an LPN administered only 20 mg of omeprazole to a resident via PEG tube, instead of the prescribed 40 mg dose. Additionally, the same LPN applied a lidocaine patch to the resident's right shoulder, contrary to the physician's order to apply it to the left shoulder. These actions were directly observed during medication administration. Interviews with the LPN revealed that the errors occurred due to a misunderstanding of the resident's position and a failure to double-check the medication dosage. The LPN acknowledged administering only one capsule of omeprazole instead of two and placing the lidocaine patch on the wrong shoulder. The DON confirmed that physician's orders should be double-checked during medication administration. The resident involved had a history of GERD and required medication via PEG tube, as well as topical pain management for shoulder pain.
Failure to Maintain Accessible Hospice Documentation for Resident
Penalty
Summary
The facility failed to ensure that hospice agency notes regarding the care of a resident receiving hospice services were easily accessible to facility staff, which impeded effective coordination of care. According to the contract between the facility and the hospice provider, both parties were required to maintain complete, detailed, and readily available clinical records for each hospice patient. However, review of the resident's records revealed that the hospice binder only contained documentation from the hospice social worker and lacked nursing notes, CNA visit documentation, the hospice plan of care, and other required records. Additionally, the resident's electronic medical record did not contain any hospice provider progress notes. Interviews with staff confirmed that hospice staff were expected to place visit notes in the hospice binder and communicate care provided to facility staff, but this was not consistently done. The LPN and CNAs reported that hospice CNA visit notes were missing from the binder, and some hospice staff did not always communicate the care provided. The DON and regional clinical resource also acknowledged that the hospice binder should contain comprehensive documentation, including visit summaries and care plans, but these were absent for the resident in question. The resident involved was an elderly individual with respiratory failure, vascular dementia, and adult failure to thrive, who was dependent on staff for most activities of daily living and had significant cognitive impairments.
Incomplete and Inaccessible Posting of State Agency and Advocacy Group Contact Information
Penalty
Summary
The facility failed to post, in an accessible and understandable manner, a complete list of names, addresses (mailing and email), and telephone numbers of all pertinent State agencies and advocacy groups as required. Observations revealed that while some information, such as the abuse coordinator, ombudsman contact, state agency phone number and website, and residents' rights, was posted in the lobby, the postings did not include the mailing and email addresses of the State Agency or contact information for adult protective services, the state licensure office, and the Medicaid fraud control unit. Additionally, the information that was posted was not in a readable font size or placed in an area with ease of access for residents. Interviews with six alert and oriented residents who regularly attended resident council meetings indicated that none of them knew how to file a complaint with the State Agency. Staff interviews revealed a lack of clarity regarding responsibility for maintaining the postings, with the social services director stating she occasionally updated ombudsman information but was not responsible for the main postings, and the nursing home administrator acknowledging responsibility but unable to locate information regarding the Medicaid fraud control unit.
Failure to Maintain Functioning Door Alarm in Secured Unit
Penalty
Summary
The facility failed to ensure that the alarm on the door to the outside secured patio was functioning properly, leading to a deficiency in maintaining a safe environment free from accident hazards. Observations revealed that the alarm on the back door of the all-male secured unit was broken and did not audibly alert staff when the door was opened. This door, which was not visible from the nurse's station and lacked camera surveillance, provided direct access to a courtyard with uneven surfaces. The malfunctioning alarm allowed residents to potentially exit the facility unnoticed, posing a significant safety risk. Interviews with staff members, including several CNAs, indicated that the alarm had not been functioning for several months, and staff had not been trained on how to set or reset the egress door in the secured unit. The CNAs reported that they had to manually monitor the door to prevent residents from exiting unsupervised, which was challenging given the number of residents and the layout of the unit. The staff also mentioned that the previous maintenance director had been informed of the issue, but no action was taken to fix the alarm. The DON and NHA were unaware of the broken alarm until the survey, highlighting a communication breakdown within the facility. The lack of a functioning alarm system and inadequate staff training on the door's security features contributed to the deficiency. The facility's failure to address the alarm issue in a timely manner compromised the safety and supervision of residents in the secured unit.
Fly Infestation in Kitchen and Dining Areas
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in a fly infestation in the kitchen and dining room areas. Observations revealed that the back door of the kitchen, which led to the area where trash dumpsters were kept, was open and lacked screens, allowing flies to enter the kitchen and dining room. Several flies were observed in the kitchen during meal preparation and in the dining room during meal service, landing on tables and residents. Interviews with residents highlighted their dissatisfaction with the fly problem. One resident expressed discomfort with flies landing on her while eating, and another resident was observed carrying a fly swatter to combat the flies during meals. Residents reported that they had complained about the issue to management, but the problem persisted, affecting their dining experience. Staff interviews confirmed the ongoing issue with flies. A dietary aide mentioned that the kitchen door was left open to allow steam to escape, contributing to the fly problem. The dietary manager acknowledged the unsanitary conditions caused by the flies and the potential for food contamination. Despite efforts such as using insect zappers and hiring an exterminator, the facility had not resolved the infestation, partly due to its location in a cattle community.
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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