Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Rock Canyon Respiratory And Rehabilitation Center during CMS and state inspections, most recent first.
A resident with dementia and a history of aggressive behavior struck another cognitively impaired resident in the dining area after attempting to take her food. Staff and care plans documented the assailant's behavioral risks, including wandering and food-seeking, but did not fully address triggers related to resistance from others. The incident resulted in physical abuse, with no injuries noted, and both residents were unable to recall the event due to cognitive impairment.
Housekeeping staff failed to consistently disinfect high-touch surfaces and perform proper hand hygiene, including after glove changes and when cleaning resident bathrooms. Additionally, a nurse did not follow manufacturer guidelines for disinfecting a glucometer, using only one wipe and not maintaining the required contact time. These actions resulted in lapses in the facility's infection prevention and control program.
Two residents with significant cognitive and physical impairments were unable to consistently reach their call lights while in bed, despite facility policy requiring call lights to be accessible. Staff observations and resident interviews confirmed that call lights were often placed out of reach, and care plans specifically noted the need for call lights to be accessible due to the residents' ADL deficits and risk for pressure ulcers. Staff interviews revealed inconsistent practices and a lack of awareness regarding the adequacy of call light cord lengths.
A resident with multiple psychiatric and medical diagnoses was observed repeatedly exhibiting symptoms of tardive dyskinesia, such as constant lip smacking, while on antipsychotic medications. Nursing staff and the social services director were aware of these symptoms but failed to document them or notify the physician or psychiatrist, and required monitoring assessments were not accurately completed. This resulted in a lack of appropriate monitoring and reporting of adverse medication effects.
A resident with multiple complex medical conditions received topical steroid and antifungal creams for a rash based on a physician's order that did not specify the dosage to be applied. Nursing staff applied the creams using their own judgment, leading to inconsistent administration practices. The lack of a clear dosage in the order was not identified or clarified before administration, resulting in a failure to meet professional standards of medication administration.
A resident with severe contractures and anoxic brain damage did not consistently receive prescribed bilateral hand splints for contracture management, as observed on multiple occasions. Staff failed to document the application and fit of the splints, and the care plan lacked specific interventions for checking splint placement. Responsibility for restorative care had shifted among staff, leading to inconsistent implementation of physician orders and facility policy.
An LPN failed to properly prime an insulin pen before administering Humalog insulin to a resident with diabetes and hypertension. The pen was not primed with the needle attached as required by manufacturer guidelines, resulting in a significant medication error.
A resident with cognitive and mental health impairments was involved in a drug sting operation orchestrated by the NHA, who provided money for the resident to purchase methamphetamines from another resident. The resident experienced mental anguish, fear, and discomfort as a result, and was not provided with adequate support or a private counseling environment following the incident. The facility failed to document an internal investigation or update the resident's care plan to address the incident.
A resident with impaired decision-making skills and a history of falls experienced four falls over three months, resulting in a fractured nose. The facility failed to update and implement individualized fall interventions, such as ensuring proper footwear and call light accessibility. Observations and staff interviews revealed inconsistencies in adhering to the care plan, contributing to the resident's repeated falls and injuries.
The facility failed to provide adequate nutrition and hydration for two residents, resulting in significant weight loss. One resident lost 14 pounds in six weeks due to insufficient meal assistance and lack of new interventions despite ongoing weight loss. Another resident was not weighed upon admission, leading to inappropriate nutritional interventions based on an incorrect hospital weight. Staff interviews revealed inconsistencies in documentation and oversight of residents' nutritional intake and weight monitoring.
The facility failed to manage tube feeding properly for several residents, including those in a vegetative state and on respirators. Containers were not labeled with necessary information, and prescribed formulas were not administered as per physician orders. Instead, Jevity 1.5 was used without proper documentation, and water flushes were not given at the correct rate. Feeding pumps were also not calibrated, and staff interviews revealed a lack of communication and adherence to orders.
The facility's QAPI program failed to address compliance concerns, resulting in repeated deficiencies in areas like the resident call system and ADL care. Issues with nutrition and hydration led to actual harm, including severe weight loss and incorrect tube feeding administration. The NHA admitted to inadequate monitoring processes and the need for dietician training.
The facility failed to provide necessary ADL services and meal assistance for several residents. Residents in vegetative states and with severe cognitive impairments were not repositioned or provided with toileting care as required. Additionally, a resident did not receive adequate meal assistance, leading to missed meals. Staff interviews confirmed inconsistencies in care provision.
The facility failed to provide a working call light system for two residents and in the shower facilities. A resident with severe cognitive impairment was found without a call light and reported that staff did not respond to a service bell. Another resident, initially assessed as unable to use a call bell, was later provided with one. Additionally, the shower rooms lacked a functioning call light system, with an emergency button that did not work.
The facility failed to maintain the dignity and privacy of two residents. One resident was left exposed in bed for two hours with the door open, while another was repeatedly observed in the dining room with improperly positioned clothing, exposing him to others. Staff did not take action to cover or assist the residents, leading to a deficiency in care.
The facility failed to provide a clean, comfortable, and homelike environment for its residents, with issues such as peeling paint, broken blinds, improperly labeled closet spaces, and poor furniture condition. Residents expressed dissatisfaction, and staff interviews revealed inconsistencies in maintenance requests and cleaning responsibilities.
The facility failed to maintain proper sanitation in the secure unit kitchen, leading to pest harborage conditions. Observations revealed dirty walls and floors under the dish machine, a pest glue trap with roaches, and live cockroaches behind the cove base. Staff interviews indicated a lack of a cleaning list and inadequate cleaning practices.
The facility failed to maintain accurate and complete medical records for three residents regarding their Medical Orders for Scope of Treatment (MOST) forms. The forms lacked mandatory signatures and proper documentation of verbal consents, revealing gaps in the process of obtaining and documenting these consents.
The facility failed to ensure the call light system was functioning properly for all 27 residents on the secure unit. A resident with multiple medical conditions confirmed that the call light system in his room did not work. Staff performed 15-minute checks due to the non-functional call light system, but these checks were not documented. The maintenance supervisor acknowledged the call light system was not functional, and staff interviews revealed a lack of awareness about its functionality.
The facility failed to follow the appropriate procedure for a facility-initiated discharge for a resident who requested an appeal. Despite the resident's multiple medical conditions and concerns about managing pain and oxygen needs, the facility did not properly document or address the appeal request. Interviews with staff revealed a lack of communication and proper procedure in handling the resident's appeal, resulting in a deficiency in care.
The facility failed to ensure a resident with dementia received appropriate treatment and services, as staff did not implement wandering interventions listed in the care plan or consistently document the resident's wandering behavior and interventions used. The resident frequently entered other residents' rooms and triggered an alarmed exit door without staff intervention or redirection.
The facility reported a medication error rate of 6.25%, exceeding the acceptable threshold of 5%. Two RNs failed to prime insulin pens before administering Lispro insulin to two residents, contrary to manufacturer guidelines and facility policy.
The facility failed to ensure residents were free from significant medication errors by not priming insulin pens before administration. Two residents received incorrect doses of insulin due to this oversight by the nursing staff.
The facility failed to maintain an infection control program by not ensuring that a glucometer was cleaned in a sanitary manner. An RN used PDI Sani Hand wipes instead of the required EPA-registered disinfectant wipes, leading to a failure in preventing potential infection transmission. Interviews revealed discrepancies between the facility's policy, the manufacturer's guidelines, and the actual practice observed.
A resident with normal cognitive function was involved in an inappropriate relationship with a respiratory therapist, including holding hands, kissing, and exchanging suggestive texts. Despite the facility's policy against abuse, the incident was not classified as abuse, leading to a deficiency in protecting the resident.
Failure to Prevent Resident-to-Resident Physical Abuse in Secured Unit
Penalty
Summary
A deficiency occurred when the facility failed to protect a resident from physical abuse by another resident. The incident took place in the secured unit dining area, where one resident with a history of behavioral disturbances and dementia attempted to take food from another resident. When the second resident refused, the first resident struck her in the head. Staff present separated the residents, and the victim was assessed with no injuries noted. Both residents were unable to recall the incident due to cognitive impairment. The resident who committed the abuse had documented behavioral issues, including aggression, wandering, and attempts to take food from others. His care plan noted these behaviors and included interventions such as providing his meal immediately upon seating and redirecting him as needed. However, the care plan did not specifically address the trigger of resistance or argument when he tried to take items from others. Staff interviews confirmed that this resident frequently wandered, attempted to take food from others, and could become aggressive if confronted or not redirected promptly. There was also a prior incident where this resident fell while trying to take food from another resident, resulting in injury to himself. The victim of the abuse was also severely cognitively impaired and required supervision or assistance for most activities of daily living. She did not have a history of behavioral issues and was not involved in previous incidents. Staff and representatives confirmed that she would become upset if others tried to take her belongings but had not previously had altercations with other residents. The facility's failure to anticipate and prevent the interaction between these two residents, despite known behavioral risks, led to the occurrence of physical abuse.
Infection Control Deficiencies in Housekeeping and Glucometer Disinfection
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program on one of four units, as evidenced by multiple deficiencies in housekeeping and clinical practices. Housekeeping staff did not consistently follow proper cleaning techniques for resident rooms and high-touch surfaces. Observations revealed that a housekeeper neglected to disinfect high-touch areas such as bed remotes, call lights, light switches, over-bed tables, and nightstands. Additionally, the housekeeper did not perform hand hygiene after removing gloves and before donning new gloves, despite facility policy and CDC guidelines requiring hand hygiene at these points. The housekeeper also used a toilet brush outside of the toilet bowl, which is not in accordance with facility procedures, and failed to clean the base of the toilet. The housekeeper admitted to not always cleaning high-touch areas and not documenting which rooms required additional cleaning, relying instead on memory. Interviews with staff confirmed gaps in training and adherence to infection control protocols. The housekeeper stated she had received hand hygiene education but had developed poor habits from previous employment. She was unaware that the toilet brush should not be used outside the toilet bowl and did not consistently clean all required high-touch areas. The housekeeping and laundry manager and the director of nursing both confirmed that hand hygiene should be performed after glove changes and that high-touch areas must be cleaned daily, but these practices were not consistently followed by staff. In addition to housekeeping deficiencies, clinical staff failed to properly disinfect individual glucometers according to manufacturer guidelines. A registered nurse was observed cleaning a resident's glucometer with only one disinfectant wipe and not allowing the device to remain wet for the required four-minute contact time. The nurse believed a two-minute drying time was sufficient, which does not meet the manufacturer's instructions. The clinical nurse resource and infection preventionist both acknowledged that glucometers should be cleaned according to manufacturer recommendations, but the observed practice did not align with these standards.
Failure to Ensure Call Lights Were Within Reach for Two Residents
Penalty
Summary
The facility failed to provide reasonable accommodation for mobility and accessibility by not ensuring that two residents' call lights were within reach while they were in bed. According to facility policy, call lights are to be placed within the resident's reach before staff leave the room. However, multiple observations revealed that both residents had their call lights positioned out of reach on several occasions, including being placed on the floor, clipped above the head with no slack, or left on a side table or under a pillow, making it difficult or impossible for the residents to access them when needed. One resident, who was severely cognitively impaired and required substantial to maximal assistance for most activities of daily living, reported that her call light was often too far away, requiring her to rely on her roommate for assistance. Observations confirmed that her call light was sometimes on the floor or stretched tightly above her head, and staff did not consistently reposition it within her reach after providing care. Her care plan specifically included the intervention to keep the call light within reach due to her risk for pressure ulcers and ADL deficits. The second resident, who had a history of stroke, repeated falls, and muscle wasting, also required significant assistance and reported difficulty reaching his call light. He stated that he had informed staff about the issue, and observations showed his call light was sometimes clipped above his head or under his pillow, both out of his reach. Staff interviews indicated awareness of the need to keep call lights accessible, but also revealed inconsistent practices and a lack of awareness about the specific issues with these residents' call light cord lengths.
Failure to Monitor and Report Tardive Dyskinesia in Resident on Antipsychotic Medications
Penalty
Summary
The facility failed to ensure that a resident receiving antipsychotic medications was free from chemical restraints and received appropriate monitoring for side effects, specifically tardive dyskinesia. The resident, who had diagnoses including schizoaffective disorder, bipolar disorder, and cognitive impairment, was observed repeatedly smacking her lips, a symptom consistent with tardive dyskinesia, during multiple observations over several days. Despite these visible symptoms, there was no documentation in the resident's medical record, medication administration records, or progress notes indicating that these symptoms were recognized, monitored, or reported to the physician. Staff interviews revealed that nursing staff, including RNs and LPNs, were aware that the resident had been exhibiting signs of tardive dyskinesia since admission. However, this information was not documented in the resident's records, nor was it communicated to the attending physician or psychiatrist. The facility's policy required monitoring and documentation of side effects, including tardive dyskinesia, and completion of the Abnormal Involuntary Movement Scale (AIMS) assessment quarterly. The most recent AIMS assessment did not reflect the observed symptoms, and there was no evidence of ongoing monitoring or timely notification to medical providers regarding the resident's condition. Additionally, the social services director acknowledged awareness of the resident's tardive dyskinesia but did not communicate this to the physician or psychiatrist. The resident's care plan included interventions for monitoring side effects, but these were not implemented as required. The lack of documentation and communication resulted in a failure to ensure the resident was appropriately monitored for adverse effects of antipsychotic medications, as required by facility policy and professional standards.
Failure to Specify Dosage in Physician's Order for Topical Medications
Penalty
Summary
The facility failed to ensure that services provided to a resident met professional standards of quality, specifically regarding the administration of medicated creams for a skin rash. The physician's order for the resident directed staff to mix prednisone cream and antifungal cream and apply to the affected body area every shift, but did not specify the dose or measurement for each cream. This omission left nursing staff without clear guidance on the amount of medication to administer, which is contrary to both professional standards and the facility's own medication administration policy requiring the 'five rights,' including the right dosage. The resident involved had significant medical conditions, including vascular dementia, hemiplegia, type 2 diabetes, and mesothelioma, and was dependent on staff for all activities of daily living. Observations noted the presence of a rash on the resident's abdomen and other body areas. Staff interviews revealed inconsistency in how the creams were applied: one nurse used a measured amount based on personal judgment, while another applied a thin layer to cover the affected areas, also relying on personal judgment. Both nurses indicated that the order was unclear regarding the specific amount to use. The Director of Nursing confirmed that a key component of a prescription is the amount to administer and stated that nurses should clarify incomplete orders with the physician before administering medication. However, the lack of a specified dose in the physician's order was not identified or addressed prior to administration, resulting in the deficiency.
Failure to Consistently Apply and Document Hand Splints for Resident with Contractures
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received appropriate treatment and services to increase or maintain ROM and prevent further decline, as required by physician orders and facility policy. Specifically, the resident, who had diagnoses including anoxic brain damage and contractures of the upper and lower extremities, was observed multiple times without the prescribed bilateral hand contracture soft splints in place. The resident was dependent for all activities of daily living and was in a persistent vegetative state, requiring staff to provide passive ROM and apply hand splints as ordered. Observations over several days revealed that the resident's hands were consistently found without the soft splints, despite a physician's order for their use and regular checks for fit and skin integrity. Documentation of passive ROM was inconsistent, with some days lacking any record of care, and there was no documentation indicating whether the hand protectors were applied or checked for fit. The care plan did not include specific interventions for checking the placement of the hand splints, and staff training records indicated that staff were instructed to apply the hand protectors daily, but this was not consistently done in practice. Interviews with staff confirmed that the responsibility for applying the splints and providing passive ROM had shifted from a restorative nurse aide to CNAs and the therapy department, following the departure of the restorative nurse aide. Staff acknowledged challenges in applying the splints due to the resident's contractures and occasional removal of the splints by the resident, but also admitted that documentation and consistent application of the splints were lacking. The rehabilitation resource noted that refusals and application of splints were not adequately documented in the care plan.
Failure to Properly Prime Insulin Pen Before Administration
Penalty
Summary
A deficiency occurred when a licensed practical nurse (LPN) failed to properly prime an insulin pen before administering a dose of Humalog insulin to a resident. According to manufacturer guidelines, priming the insulin pen with the needle attached is necessary to remove air from the needle and cartridge, ensuring the correct dose is delivered. During observation, the LPN dialed two units and pushed on the cartridge before attaching the disposable needle, then dialed the prescribed dose and administered the insulin to the resident without priming the pen with the needle in place. The resident involved was under 65 years old, had diagnoses including hypertension and diabetes, and was cognitively intact with a BIMS score of 15. The resident required assistance with some activities of daily living. The failure to follow proper insulin administration technique was confirmed through staff interviews and review of manufacturer instructions, which specify that the needle must be attached before priming to ensure accurate dosing.
Resident Subjected to Mental Abuse During Administrator-Led Drug Sting
Penalty
Summary
The facility failed to protect a resident from mental abuse and anguish when the nursing home administrator (NHA) orchestrated a drug purchase involving the resident. The resident, who had developmental disabilities, dementia, depression, anxiety, and schizophrenia, was approached by the NHA after staff found a pipe used for methamphetamines in his possession. The NHA asked the resident to participate in a sting operation to identify the source of drugs within the facility, providing him with $20 to purchase methamphetamines from another resident while the NHA observed. The NHA then confiscated the drugs and pipe and notified the police. The resident reported feeling compelled to participate in the drug purchase to prove he was not a drug dealer, and subsequently experienced fear, discomfort, and mental anguish. He expressed concerns about being arrested or discharged from the facility, and reported that staff referred to him as a drug dealer. The resident also stated that he was not informed of the potential consequences of participating in the sting operation, and that he was unhappy with the counseling services provided afterward, as they were not conducted in a private setting and did not address his emotional needs. The facility's own abuse prevention policy required residents to be free from all forms of abuse, including mental abuse, and mandated immediate investigation and support for affected residents. However, there was no documentation of an internal investigation into the incident, and the resident's care plan did not reflect interventions related to the incident. Interviews with staff confirmed awareness of the NHA's actions, but no further investigation or support was documented for the resident involved.
Failure to Implement Individualized Fall Interventions for Resident
Penalty
Summary
The facility failed to maintain a safe environment for Resident #20, who was at risk for falls due to severely impaired daily decision-making skills and other health conditions. Despite being identified as a fall risk upon admission, the facility implemented generalized fall risk interventions that were not tailored to the resident's specific needs. Over a three-month period, Resident #20 experienced four falls, with the last fall resulting in a fractured nose. The facility did not consistently update the resident's care plan with new interventions following each fall, nor did they ensure staff consistently implemented the identified interventions. Observations during the survey revealed several deficiencies in the implementation of fall interventions for Resident #20. The resident was not always wearing appropriate non-slip footwear, and there was no call light in her room, despite these being part of her fall prevention plan. Interviews with staff indicated a lack of consistent adherence to the care plan, with CNAs acknowledging the need for proper footwear but failing to ensure it was worn. Additionally, the facility's fall investigations did not consistently document whether the resident was wearing appropriate footwear at the time of each fall. The facility's failure to update and implement individualized fall interventions was further compounded by inadequate documentation and communication. The resident's care plan was not updated with new interventions after each fall, and there was no documentation of family decisions regarding room changes or wheelchair modifications. Interviews with the DON and MDSC highlighted discrepancies in the care plan, such as the inappropriate inclusion of a call light intervention for a resident without a call light. These oversights contributed to the repeated falls and injuries sustained by Resident #20.
Failure to Ensure Adequate Nutrition and Hydration
Penalty
Summary
The facility failed to ensure adequate nutrition and hydration for two residents, leading to significant weight loss and lack of proper care. Resident #23, who was admitted at nutritional risk, lost 14 pounds in six weeks. Despite initial interventions such as nutritional supplements and fortified foods, the facility did not adequately encourage, cue, or assist the resident during meals. Observations showed that the resident was not offered alternatives or refills and was not provided a new meal after spilling his food. The care plan did not reflect the ongoing weight loss, and no new interventions were considered when the resident continued to lose weight. Resident #1 was not weighed upon admission, which is a critical step in establishing a baseline for nutritional assessment. The facility relied on an incorrect hospital weight, which was not verified, leading to inappropriate nutritional interventions. The resident, who was dependent on tube feedings, experienced significant weight loss, and the facility failed to adjust the feeding regimen based on an accurate weight. The RD had requested a weight to determine the correct amount of tube feeding, but this was not obtained until 36 days after admission. Interviews with staff revealed a lack of proper documentation and oversight in monitoring residents' nutritional intake and weight. The CNAs were responsible for documenting meal consumption, but there were inconsistencies in the records. The dietary manager and registered dietitian consultants acknowledged the need for accurate weights and proper meal assistance, but these were not consistently provided. The facility's failure to adhere to its own policies and procedures regarding weight monitoring and nutritional support contributed to the deficiencies identified in the report.
Deficiencies in Tube Feeding Management
Penalty
Summary
The facility failed to ensure proper management and care for residents with percutaneous endoscopic gastrostomy (PEG) tubes, leading to several deficiencies in tube feeding management. Specifically, the facility did not label tube feeding containers with necessary information such as the resident's name, room number, date, start time, formula type, feeding rate, and nurse initials. This oversight affected multiple residents, including those in a persistent vegetative state and those dependent on respirators, highlighting a lack of adherence to professional standards and facility policies. Additionally, the facility did not provide the prescribed formula as per the computerized physician orders (CPO) for several residents. Instead of administering Fibersource HN, the residents were given Jevity 1.5, which was not an equivalent formula. This substitution was made without proper documentation or physician orders, as the facility was experiencing a backorder of Fibersource HN. The registered dietitian was unaware of the discrepancies between the physician's orders and the actual formula being administered, which could potentially lead to nutritional imbalances. Furthermore, the facility failed to provide water flushes at the prescribed rate for some residents, and the feeding pumps were not calibrated as required. Observations revealed that the water flushes were either not administered at the correct rate or not documented properly. Staff interviews indicated a lack of communication and understanding of the physician's orders, with some staff members not questioning incorrect orders or failing to label feeding containers due to busy shifts. These deficiencies in tube feeding management could lead to serious health complications for the residents involved.
Ineffective QAPI Program Leads to Repeated Deficiencies
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program to address and rectify compliance concerns, particularly in areas affecting residents' quality of life and care. The QAPI committee did not adequately identify or prioritize performance improvement plans (PIPs) for issues such as the resident call system and activities of daily living (ADL) care for dependent residents. These deficiencies were repeatedly cited in surveys, indicating a pattern of non-compliance. Additionally, the facility did not effectively address concerns related to nutrition and hydration, resulting in actual harm to residents, including severe weight loss and incorrect administration of tube feedings. Interviews with the nursing home administrator (NHA) revealed that the interdisciplinary team met monthly for QAPI meetings, but significant issues like tube feedings were not identified as concerns. The NHA acknowledged the lack of an effective process for monitoring and managing tube feedings and recognized the need for training from the registered dietician. Despite discussions on falls and weight loss, the facility failed to implement effective interventions to prevent falls and maintain a working call light system, further contributing to the deficiencies.
Deficiencies in ADL Assistance and Meal Support
Penalty
Summary
The facility failed to provide necessary services for residents who were unable to carry out activities of daily living (ADLs), affecting six out of 13 residents reviewed. Specifically, the facility did not ensure timely repositioning and toileting/incontinence care for several residents. For instance, Resident #10, who was in a persistent vegetative state and dependent on two staff members for all ADLs, was not repositioned or provided with incontinence care during a two-hour and 18-minute observation period. Similarly, Resident #16, also in a persistent vegetative state, was not repositioned or provided with necessary care during the same observation period, despite being dependent on staff for all ADLs. Resident #14, who had multiple contractures and was dependent on a ventilator, was not repositioned or provided with incontinence care during a two-hour and 18-minute observation. Staff interviews revealed that residents were supposed to be repositioned and toileted every two hours, but this was not consistently done. Additionally, Resident #6, who had severe cognitive impairments and was dependent on staff for personal hygiene and mobility, was not repositioned or offered toileting care during a three-hour and 36-minute observation period. Resident #24, with similar dependencies, was also not repositioned or offered necessary care during a three-hour and 26-minute observation. Furthermore, the facility failed to ensure Resident #9 received assistance with meals. Despite being dependent on staff for all ADLs and requiring setup and supervision for eating, Resident #9 was not provided with adequate assistance during meal times. Observations showed that the resident left the dining area without eating, and no staff attempted to redirect or assist her. Interviews with staff indicated that Resident #9 needed cueing and encouragement to eat, but this was not provided, resulting in the resident not consuming her meals.
Deficiency in Call Light System for Residents and Shower Rooms
Penalty
Summary
The facility failed to provide a working call light system for two residents and in the shower facilities, which is a violation of their policy to ensure residents have a means of communication with nursing staff. Resident #24, who has severe cognitive impairment and multiple physical disabilities, was observed without a call light in his room and was found yelling for help. Despite being given a yellow service bell, the resident reported that staff did not respond when he used it. Staff interviews revealed that residents in the memory care unit, including Resident #24, did not have call lights due to concerns about safety and the residents' ability to use them. Resident #8, who has moderate cognitive impairments and is dependent on staff for most activities, was also found without a call light. Initially assessed as unable to use a call bell, the resident was later reassessed and provided with a bell. However, the initial lack of a call light system for Resident #8 highlights a failure in ensuring that residents have the necessary tools to communicate their needs effectively. Additionally, the men's and women's shower rooms on the memory care unit lacked a functioning call light system. A red button labeled 'emergency' was present but did not work when tested. Staff interviews confirmed that there was no alternative system in place for residents to call for assistance in these areas, and the maintenance supervisor acknowledged that the call light system in the shower rooms had not been functional for years.
Deficiency in Resident Dignity and Privacy
Penalty
Summary
The facility failed to maintain the dignity and respect of two residents, leading to deficiencies in their care. Resident #16, who is under 65 years old and has a history of traumatic brain injury, was observed lying in bed with his brief and the right side of his body exposed for two hours. During this time, the resident's bedroom door was left open, allowing passers-by to see him. Despite staff entering the room to administer medication and provide care, they did not cover the resident or close the door to ensure his privacy. Resident #28, a 69-year-old with diagnoses including morbid obesity and schizophrenia, was observed in the dining room with his clothing improperly positioned, exposing his intergluteal cleft. This occurred over three consecutive days, and no staff members were observed offering to adjust his clothing to prevent exposure. Although the DON mentioned that staff encouraged the resident to fix his clothing and offered assistance, these actions were not observed during the survey. Interviews with staff and residents revealed that the facility's policy on dignity and respect was not consistently followed. The DON acknowledged the issues but was unsure why staff left Resident #16 exposed and did not actively assist Resident #28 in adjusting his clothing. The facility's failure to ensure privacy and appropriate clothing for these residents resulted in a deficiency in maintaining their dignity and respect.
Failure to Maintain a Clean and Homelike Environment
Penalty
Summary
The facility failed to provide a clean, comfortable, and homelike environment for its residents. Observations revealed multiple deficiencies in the secure unit and rehabilitation unit, including peeling paint, chipped wood, and splatters on walls and floors. The common areas and resident rooms were not maintained in good repair, with issues such as broken blinds, missing handles on dressers, and improperly labeled closet spaces. Additionally, the common area furniture was found to be in poor condition, with cracked and worn surfaces. The outdoor patio area was littered with cigarette butts and burn marks, indicating a lack of cleanliness and maintenance. Interviews with residents highlighted their dissatisfaction with the state of their living environment. One resident expressed concerns about the broken handle on his dresser and the condition of his blinds, which did not adequately block out light. Another resident mentioned the old and worn-out furniture in his room and the presence of names written on his closet shelf from previous occupants. Staff interviews revealed that maintenance requests were not consistently submitted, and there was a lack of clarity regarding responsibilities for cleaning and labeling. The maintenance supervisor acknowledged the issues and indicated that some corrective actions were planned, such as repainting shelves and cleaning walls. However, the overall findings demonstrate a failure to maintain a safe, clean, and homelike environment for the residents, as required by regulations. The deficiencies observed and reported by residents and staff indicate systemic issues in the facility's maintenance and housekeeping practices.
Sanitation Issues in Secure Unit Kitchen
Penalty
Summary
The facility failed to store, prepare, and serve food in a sanitary manner in one of its two kitchens, specifically the secure unit kitchen. Observations revealed that the dish room sanitation was not maintained, leading to conditions that could harbor pests. The tile walls behind and under the dish machine tables were splattered with brown spots and small pieces of debris. A layer of black dirt and grime with pieces of debris and food crumbs was found on the floor under the dish machine and both dish machine tables, extending to the walls. Additionally, the black vinyl cove base under the clean dish table was pulled away from the wall in two spaces, and an undated pest glue trap with approximately 20 small roaches inside was found on the floor under the clean side dish table. Two dead and dried roach carcasses were also observed next to the pest glue trap, and two live cockroaches were found behind the cove base under the dirty side dish table when it was pulled away from the wall. Interviews with staff revealed that the dietary manager (DM) was aware of the need for a cleaning list but had not yet implemented one. The DM admitted that while the kitchen floors were cleaned daily, the area under the dish machine had not been specifically cleaned. The maintenance supervisor (MS) confirmed that the pest control company visited the facility regularly and placed sticky traps in areas likely to harbor pests, such as under the dish machine. However, the MS was unsure how long the pest sticky trap had been under the dish machine. The facility's failure to maintain proper sanitation in the dish room and eliminate pest harborage conditions led to the observed deficiencies.
Failure to Maintain Accurate Medical Records
Penalty
Summary
The facility failed to maintain accurate and complete medical records for three residents, specifically regarding the Medical Orders for Scope of Treatment (MOST) forms. For Resident #3, the MOST form indicated a wish to receive CPR but lacked the mandatory signature from the patient or legal decision maker, and there was no corresponding signature of who obtained the verbal consent. Similarly, Resident #22's MOST form, which indicated a wish for no CPR and comfort-focused treatment, also lacked the necessary signatures and had only a handwritten note of verbal consent from the POA without corresponding signatures. Resident #59's MOST form, which indicated a wish for CPR with selective treatment, also lacked the required signatures and had a handwritten note of verbal consent from the daughter and resident without corresponding signatures of who obtained the verbal consent. Interviews with staff revealed gaps in the process of obtaining and documenting verbal consents. An LPN stated that only one nurse needed to sign the form, while the medical records specialist was unaware that verbal consents required two signatures. The social work consultant confirmed that two staff members needed to witness verbal consents and sign the form, but acknowledged a gap in practice in ensuring these signatures were completed and reviewed during quarterly care conferences. This inconsistency in following the facility's policy and procedure for advanced directives led to the deficiencies noted in the report.
Non-Functional Call Light System in Secure Unit
Penalty
Summary
The facility failed to ensure the call light system was functioning properly for all 27 residents on the secure unit. The call light system in the secure unit was observed to be non-functional, with some call lights painted over and others not activating any notification system. Specifically, in Resident #111's room, the call light for the bed was non-functional, and the call light in the bathroom did not alert the nurses' station or activate the light over the resident's door. Staff performed 15-minute checks on residents due to the non-functional call light system, but these checks were not documented in the electronic medical record. Resident #111, a 65-year-old with multiple medical conditions including a fracture of the fourth vertebrae, encephalopathy, epilepsy, high blood pressure, muscle weakness, history of traumatic brain injury, and disorientation, was interviewed and confirmed that the call light system in his room did not work. The resident's care plan included interventions to encourage the use of the call light, but it did not address the non-functional call light system or provide alternative monitoring methods. Staff interviews revealed a lack of awareness about the call light system and its functionality. The maintenance supervisor acknowledged that the call light system on the secure unit was not functional and had not been in use for an unspecified period. The facility's policy for the secure unit assumed that residents with moderate to severe cognitive impairment could not use the call light system and required frequent checks by staff. However, Resident #111 had a call light with a pull cord in his bathroom and was able to explain its function, contradicting the facility's policy. The facility provided call light assessments for Resident #111, but there was no documentation on whether the call light remained in the resident's room or updates to the care plan.
Failure to Follow Discharge Procedure for Resident Requesting Appeal
Penalty
Summary
The facility failed to follow the appropriate procedure for a facility-initiated discharge for a resident who requested an appeal. The resident, who had multiple medical conditions including acute and chronic respiratory failure, anxiety disorder, and major depressive disorder, was given a 30-day notice of involuntary discharge. Despite the resident's request for an appeal, the facility did not properly document or address the appeal request in a timely manner. The resident had submitted a grievance form indicating his desire to appeal the discharge decision, but the facility's staff, including the social services assistant and the nursing home administrator, failed to follow up on this request appropriately. The resident had been involved in an incident with a female staff member, which was discovered in early February, and this incident was a contributing factor to the discharge decision. The resident expressed concerns about his ability to manage his pain and oxygen needs outside the facility. Despite these concerns, the facility did not ensure a safe and organized discharge plan, as required by their policy. The resident's care plan indicated that he was working towards self-reliance for discharge and had been receiving assistance with this process, but the facility did not adequately address his appeal or provide a clear discharge plan. Interviews with facility staff revealed a lack of communication and proper procedure in handling the resident's appeal. The social services assistant admitted to not being part of the discharge planning process and did not know how the 30-day notice of involuntary discharge worked. The nursing home administrator acknowledged that he had not saved a copy of the 30-day notice and was unaware of the resident's appeal request due to being out of town. The social services consultant and director also indicated that the grievance/appeal should have been addressed more promptly and involved the ombudsman. The facility's failure to follow its own policies and procedures for involuntary discharge and appeal resulted in a deficiency in the care provided to the resident.
Failure to Implement and Document Wandering Interventions for Dementia Resident
Penalty
Summary
The facility failed to ensure that a resident diagnosed with dementia received appropriate treatment and services to maintain her highest practicable physical, mental, and psychosocial well-being. Specifically, the facility did not implement wandering interventions as listed on the care plan for the resident and did not consistently document the resident's wandering behavior and the interventions used to determine their effectiveness. The resident, who had Alzheimer's disease, dementia, and bipolar disorder, was observed wandering into other residents' rooms and attempting to take their belongings without staff intervention or redirection. Additionally, the resident was not offered any activities or snacks as a diversion, as outlined in her care plan. Observations revealed that the resident frequently entered other residents' rooms and attempted to take personal items, such as a bath towel, without staff intervention. On multiple occasions, the resident was seen wandering in the dining room and attempting to interact with other residents' belongings without being redirected by staff. The resident also triggered an alarmed exit door multiple times, indicating a risk of elopement, but staff did not consistently document these incidents or the interventions used to address them. Interviews with staff members indicated a lack of awareness of the specific interventions listed in the resident's care plan for wandering behavior. The assistant director of nursing (ADON) acknowledged that the facility tried to schedule more staff to monitor and redirect residents but admitted that wandering behavior was not consistently documented unless it posed a safety hazard. The facility's follow-up documentation confirmed that the resident's wandering behavior placed her at significant risk and intruded on the privacy and activities of other residents, yet the interventions were not effectively implemented or recorded.
Medication Error Rate Exceeds Acceptable Threshold
Penalty
Summary
The facility failed to ensure the medication error rate was not greater than five percent, with a reported error rate of 6.25%. Specifically, two errors were identified out of 31 medication administration opportunities. The errors involved the administration of Lispro insulin to two residents without priming the insulin pens as per manufacturer guidelines. According to the Humalog Kwikpen (Lispro insulin) manufacturer guidelines, priming the pen is essential to remove air from the needle and cartridge to ensure the correct dose of insulin is administered. The facility's Medication Administration policy also mandates that medications be administered as prescribed and in accordance with manufacturers' specifications. In the first instance, a registered nurse (RN) administered Lispro insulin to a resident without priming the pen. The RN acknowledged that she did not prime the pen, believing it was only necessary for new pens or when visible air was present. In the second instance, another RN administered Humalog insulin to a different resident without priming the pen. This RN also admitted to not priming the pen before administration. Interviews with the Director of Nursing (DON) and the involved RNs confirmed that the proper procedure for priming insulin pens was not followed, leading to the medication errors.
Failure to Prime Insulin Pens Leads to Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically in the administration of insulin. Resident #53, a 74-year-old with heart disease and diabetes mellitus, was observed receiving an insulin dose without the pen being primed by RN #1. The nurse did not follow the manufacturer's guidelines for priming the insulin pen, which is necessary to remove air and ensure the correct dose is administered. Similarly, Resident #73, a 79-year-old with diabetes mellitus and moderate cognitive impairment, was also administered insulin without the pen being primed by RN #2. Both nurses failed to prime the insulin pens before administration, leading to potential medication errors. Interviews with the staff revealed a lack of adherence to proper insulin administration protocols. RN #1 admitted to not priming the pen unless it was new or had visible air, while RN #2 acknowledged the need to prime the pen before every administration but did not do so. The Director of Nursing confirmed that insulin pens should be primed with two units before dialing the dose to ensure the correct amount of insulin is administered. This oversight in following proper procedures resulted in significant medication errors for the residents involved.
Failure to Properly Disinfect Glucometer
Penalty
Summary
The facility failed to maintain an infection control program by not ensuring that a glucometer was cleaned in a sanitary manner. Specifically, a registered nurse (RN) used PDI Sani Hand wipes to clean the glucometer before and after checking a resident's blood glucose level. The facility's policy and the manufacturer's guidelines require the use of EPA-registered disinfectant wipes, such as bleach wipes or Sani Cloth Germicidal Wipes, which need to stay wet for two minutes to ensure proper disinfection. The PDI Sani Hand wipes used by the RN were not approved for disinfecting the glucometer, leading to a failure in preventing potential infection transmission. During interviews, the RN confirmed that she used PDI Sani Hand wipes and believed they needed to stay wet for two minutes. Another RN and the Director of Nursing (DON) stated that the correct procedure involved using bleach wipes or Sani Cloth Germicidal Wipes, which should be wrapped and kept wet for the recommended time. The discrepancy between the facility's policy, the manufacturer's guidelines, and the actual practice observed led to the deficiency in maintaining a proper infection control program, potentially exposing residents to infection risks.
Failure to Protect Resident from Abuse by Employee
Penalty
Summary
The facility failed to ensure Resident #76 was safe from abuse by an employee. The resident, who had normal cognitive function with a BIMS score of 15 out of 15, was involved in a relationship with a respiratory therapist (RT #1). The relationship included holding hands, kissing, and exchanging text messages, including suggestive photos. The resident reported that RT #1 had sneaked into the facility to see him and had asked him to erase the messages on his phone. Despite the resident's normal cognitive function, the employee was in a position of power and acted outside of her role as a care provider, which constituted abuse. The facility's policy on abuse prevention and reporting, dated April 2014, clearly stated that residents should be free from all forms of abuse, including sexual abuse, and that any staff member suspected of abuse should be suspended immediately. The facility's investigation, however, unsubstantiated the allegation of sexual abuse, stating that the relationship was consensual and did not meet the criteria for abuse. The employee was terminated for violating the facility's code of conduct, but the facility did not classify the incident as abuse. Interviews with various staff members and a frequent visitor confirmed the inappropriate relationship between the resident and the employee. The Director of Respiratory Therapy and the Director of Nursing both acknowledged the relationship and stated that it was a reportable offense. Despite this, the facility's final stance was that the relationship did not constitute abuse because the resident was not considered an at-risk adult. This discrepancy between the facility's policy and its actions led to the deficiency in protecting the resident from abuse.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
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What surveyors actually found near you
We read the 55 citations issued within 25 miles in the last 12 months — including the 2 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Pueblo
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Atlas Post Acute | 0.2 mi | ★★★★★ | 5 | 0 |
| Lakeshore Post Acute And Rehabilitation Center | 1.3 mi | ★★★★★ | 14 | 0 |
| Life Care Center Of Pueblo | 1.8 mi | ★★★★★ | 2 | 0 |
| High Plains Post Acute Llc | 2.1 mi | ★★★★★ | 6 | 0 |
| Vista Ridge Care And Rehabilitation | 4 mi | ★★★★★ | 20 | 1 |
Every risk area ranked, a do-first checklist, and your local survey patterns
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.