Thornton Care Center
Inspection history, citations, penalties and survey trends for this long-term care facility in Thornton, Colorado.
- Location
- 501 Thornton Pkwy, Thornton, Colorado 80229
- CMS Provider Number
- 065193
- Inspections on file
- 25
- Latest survey
- September 2, 2025
- Citations (last 12 mo.)
- 3
Citation history
Health deficiencies cited at Thornton Care Center during CMS and state inspections, most recent first.
Two residents with significant cognitive and physical impairments experienced multiple falls and injuries due to the facility's failure to provide adequate supervision, timely care plan updates, and individualized assessment. One resident suffered repeated falls, including a pelvic fracture and syncope, without prompt changes to her fall prevention plan or means to call for help in common areas. Another resident, with Alzheimer's and paralysis, was not assessed for safe use of a power wheelchair and fell during an outing, resulting in a spinal fracture. Staff interviews and record reviews revealed lapses in documentation, communication, and adherence to fall management policies.
Several residents reported uncomfortably high room and hallway temperatures, with some areas measured above 88°F. Despite repeated complaints to staff and management, there was no documentation of grievances or effective resolution. Staff acknowledged the persistent heat and limited ability to adjust cooling equipment, while residents described inadequate relief from fans and water coolers.
A resident's medical record lacked complete and accurate documentation for scheduled levetiracetam administration. An LPN initially could not locate the medication and used a code on the MAR, but after receiving the medication from another nurse, administered it without updating the EMR or adding a progress note. The DON confirmed the LPN was new and unsure how to document the event, resulting in incomplete records.
Two residents were repeatedly subjected to sexual abuse by another resident with a known history of public exposure and behavioral issues. Despite multiple reports and clear documentation of the perpetrator's behaviors, staff failed to implement effective, person-centered interventions or report incidents in a timely manner. The affected residents continued to experience discomfort and fear due to the facility's inadequate response and lack of targeted preventive measures.
The facility's QAPI program failed to effectively identify and address compliance concerns, leading to multiple deficiencies in areas such as resident choice, personal funds management, and maintaining a safe environment. Interviews revealed that significant issues were not promptly addressed, and systemic problems persisted despite efforts to improve communication and staff involvement.
The facility failed to maintain an effective infection control program, with deficiencies in PPE use, water management, and hand hygiene. A resident on Enhanced Barrier Precautions did not receive proper gown and glove use from staff during high-contact activities. The water management program lacked specific monitoring for Legionella, and staff did not consistently perform hand hygiene or sanitize equipment between resident interactions.
The facility failed to properly sanitize dishes and store food in the main kitchen. Observations showed that plate covers were not submerged in sanitizer for the required time, and a resident reported receiving dirty dishes. Additionally, raw chicken and ground beef were found undated in the walk-in refrigerator, and the facility did not follow proper labeling and storage practices. The DM acknowledged these issues, and the district supervisor suggested implementing a pull thaw system for better labeling.
The facility failed to honor the shower preferences of five residents, leading to a deficiency in care. Residents reported not receiving showers as preferred, with records confirming missed showers and lack of documentation. Staffing issues and documentation lapses contributed to the failure to meet residents' preferences.
The facility failed to maintain a homelike environment by not providing clean towels in multiple rooms, not cleaning a resident's closet with dried feces, and not addressing a clogged toilet in a timely manner. Residents reported a lack of towels, and staff interviews revealed confusion over responsibilities for maintenance issues.
The facility failed to provide adequate supervision and implement care-planned interventions for three residents, leading to safety hazards. A resident with dementia was observed without a required fall mat and transported in a wheelchair without foot pedals. Another resident was transferred without a gait belt, and a third resident was not properly assessed for safe smoking practices, despite evidence of unsafe behavior.
The facility failed to provide a varied and well-balanced diet for its residents, specifically for two residents who did not receive meals that met their preferences. One resident with severe cognitive impairments was not offered preferred Mexican foods, while another on a dysphagia diet was denied a requested ham and cheese sandwich due to dietary restrictions. Residents expressed concerns about repetitive menus and a lack of variety, which were not addressed by the facility.
The facility failed to provide residents with food that was palatable in taste, texture, appearance, and temperature. Residents reported issues such as cold, flavorless, and improperly cooked meals. Observations confirmed these complaints, with test trays showing over-salted tater tots, overcooked vegetables, and hard bread on sandwiches. Staff interviews acknowledged awareness of these concerns, and the dietary manager suggested changes in food preparation practices.
The facility failed to provide adequate access to personal funds for residents, with reports of limited availability on weekends and insufficient funds during weekdays. Residents were unable to access their money when needed, leading to canceled plans and inconvenience. Staff interviews revealed a lack of a process to replenish funds promptly, and the facility's prior administrator had restricted fund availability due to theft concerns.
The facility failed to properly store and manage medications, with issues including lack of disposal of medications after resident discharge, absence of date labels on opened medications, and expired medications not being discarded. Additionally, temperature logs for medication refrigerators were not maintained, indicating systemic issues in medication management practices.
The facility failed to investigate allegations of verbal abuse involving two residents. One resident reported feeling unsafe after being yelled at, but the facility only ensured they were separated in the dining room without further investigation. Another resident was involved in an altercation, but the facility did not document any investigation. The facility's actions did not align with its policy to ensure resident safety.
A resident with multiple medical conditions and cognitive impairment was discharged to the ED without proper documentation or education about the discharge. The facility issued a 30-day notice due to the resident's behavior, but an immediate discharge was executed after an incident with staff. The facility failed to follow its discharge planning policy, lacking necessary documentation and communication with the resident.
A facility failed to reassess a resident's status after a hospital transfer, preventing their return. The resident, with multiple health issues and moderate cognitive impairment, was transferred due to behavioral concerns. The facility did not document unmet needs or reassessment, leading to a deficiency in discharge planning.
A resident with severe cognitive impairments and multiple diagnoses was discharged without a proper discharge summary, which should have included a recapitulation of their stay and a final status summary. The resident left the facility to visit a family member in the hospital and did not return, and while medications were provided, the necessary discharge documentation was not completed.
The facility failed to provide necessary services for two residents, one dependent on staff for bathing and another legally blind needing meal assistance. A resident missed several scheduled showers due to staffing shortages, while another struggled to locate food on her plate as staff did not specify food locations, contrary to her care plan.
A resident with a history of diabetes and venous thrombosis sustained a skin tear on the left shin from a fall, which went untreated by the facility until several days later. Despite daily skin monitoring records indicating no concerns, the injury was not identified or documented in the electronic medical record, nor was the physician notified until 12/12/24. Staff interviews revealed a lack of awareness of the injury, highlighting a deficiency in timely treatment and care according to professional standards.
A resident with multiple health conditions did not receive new eyeglasses in a timely manner due to the facility's failure to initiate a funding request after an eye exam. Despite having a prescription since October, the request was delayed until December, and the glasses were not ordered, as confirmed by staff interviews.
Two residents in a LTC facility experienced significant medication errors. One resident was given hydralazine instead of hydroxyzine for itching due to a mix-up in medication orders, which was not caught by staff. Another resident received excessive acetaminophen dosages, exceeding safe limits, due to a lack of monitoring and adjustment of medication orders. These errors were due to failures in verification and oversight by the facility's staff.
A facility failed to ensure hospice agency notes for a resident were accessible to staff, affecting care coordination. The resident, over 65 with acute kidney failure and dementia, was receiving hospice services. Despite scheduled visits from hospice staff, recent notes were missing from the facility's EMR, as confirmed by staff interviews. This documentation lapse led to a deficiency in care coordination.
A resident in a therapeutic stipend program at an LTC facility experienced a delay in receiving payment for services rendered in November. The resident, who was cognitively intact and required assistance with daily activities, participated by calling Bingo and working in the soda store. The delay was due to the activity director's error in submitting the payment request, resulting in the stipend being paid in December.
A resident with dementia and other medical conditions was not provided with a personalized activity program to meet her needs and interests. Despite her care plan indicating preferences for activities like reading the Bible and attending religious services, observations showed she was often alone without engagement. The activity director was unaware of her specific interests, and records lacked documentation of offered activities.
A facility failed to provide consistent dialysis services for a resident, including accurate monitoring and documentation of pre- and post-dialysis weights. The resident, with multiple health conditions, required dialysis treatment, but the facility did not consistently document post-dialysis weights in the EMR or ensure thorough communication with the dialysis center. Staff interviews revealed inconsistencies in the process of acquiring and documenting dialysis communication forms.
The facility failed to administer pain medications timely for three residents, violating professional standards. One resident reported frequent delays, confirmed by records showing late administration of morphine, hydrocodone-acetaminophen, and acetaminophen. Another resident experienced inconsistent timing of acetaminophen doses, and a third resident's tramadol was often late. Staff interviews acknowledged the issue, but there was no documentation of physician notification or progress notes for late administrations.
The facility failed to manage pressure injuries for several residents, including a resident who developed multiple stage 2 to stage 4 pressure injuries and osteomyelitis due to inadequate assessment and treatment. Another resident was not properly assessed for pressure injury risk, lacked necessary interventions, and did not have an air mattress. Additional residents experienced similar failures in pressure injury assessment and timely treatment.
The facility failed to protect residents from physical abuse, including an incident where a CNA injured a resident, resulting in rib fractures and a pneumothorax. Additionally, two residents with known aggression histories were involved in a physical altercation, and another resident with cognitive impairment abused her roommate. The facility's investigations were delayed and lacked adequate interventions or monitoring strategies.
The facility's QAPI program failed to address compliance concerns, leading to serious harm from untreated pressure injuries and an abuse incident. The facility did not provide its QAPI policy during the survey, and repeat deficiencies were noted. Interviews revealed inadequate clinical oversight and staff training, with recent staff changes contributing to the issues.
Failure to Prevent Accidents and Provide Adequate Supervision for High-Risk Residents
Penalty
Summary
The facility failed to ensure that two residents at high risk for falls and injury received adequate supervision and assessment to prevent accidents. One resident with a history of neurocognitive disorder, brain injury, and moderate cognitive impairment experienced four falls within a short period, two of which required emergency department evaluation. After a fall resulting in a pelvic fracture, there were no immediate changes to the resident's fall prevention care plan, and the resident was allowed to participate in an outing on the same day as another fall. The resident was not provided with a means to call for assistance in common areas, and there was no assessment of her ability to understand or use fall prevention interventions, despite her cognitive deficits. Another resident with Alzheimer's disease, right-sided paralysis, and a history of falls was transported by her spouse to an appointment, during which she fell from her power wheelchair and sustained a head laceration and thoracic spine fracture. The facility had not assessed her ability to safely operate power-mobility equipment, nor was there documentation of care plan review or revision after the fall. There was also no evidence that the facility provided education to the spouse regarding safe transfers or supervision during outings. Facility policy required prompt assessment, care plan updates, and interdisciplinary team (IDT) review after falls, but documentation revealed delays or omissions in these processes. Staff interviews confirmed gaps in communication, monitoring, and documentation of fall reviews and interventions. The lack of timely care plan updates, supervision, and individualized assessment contributed to repeated falls and injuries for both residents.
Failure to Address Resident Grievances Regarding Excessive Room Temperatures
Penalty
Summary
The facility failed to honor residents' rights to voice grievances and to provide prompt efforts to resolve them, as required by policy. Three residents reported that their rooms and common areas were uncomfortably hot, with temperatures measured as high as 88.9 degrees Fahrenheit in some rooms and 84.4 degrees Fahrenheit in common areas. Despite these complaints, there was no documentation of grievances related to room temperatures, and residents stated that their concerns were reported to staff and management multiple times without resolution. Staff interviews confirmed that high temperatures were a known issue, and that only maintenance personnel could adjust cooling equipment, which was sometimes nonfunctional or turned off due to other resident complaints. Residents described persistent discomfort due to the heat, with one resident noting that her room thermometer frequently registered temperatures in the upper 80s and up to 94 degrees Fahrenheit. Residents reported that fans provided little relief and that their rooms were located far from water coolers, which were sometimes not operational or effective. Staff responses to the heat included providing extra ice and closing shades, but these measures did not address the underlying temperature issues. The facility administrator was unaware of any current complaints about room temperatures and did not have records of grievances, despite multiple residents stating they had reported their concerns.
Incomplete Medication Administration Documentation in EMR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident who was prescribed levetiracetam for seizure management. The medication administration record (MAR) for this resident showed a code indicating 'other/see progress notes' for two consecutive days, but a review of the progress notes did not reveal any documentation clarifying whether the medication was administered as ordered. The facility's policy requires that each medication administration be documented, and any deviations or issues be recorded in the resident's medical record. Interviews with staff revealed that the LPN responsible for administering the medication on those days was unable to locate the medication initially and used the code to indicate this. However, after another nurse provided the medication from the emergency supply, the LPN administered it but failed to update the documentation or add a corresponding progress note in the electronic medical record (EMR). The DON confirmed that the LPN, who was new to the facility, was unsure how to properly document the administration after entering the initial code, resulting in incomplete and inaccurate medical records for the resident.
Failure to Protect Residents from Sexual Abuse and Inadequate Staff Reporting
Penalty
Summary
The facility failed to protect two residents from sexual abuse by another resident, despite documented history and ongoing incidents. Resident #3, who had diagnoses including Wernicke's encephalopathy, alcohol-induced dementia, and impulse disorder, was known to have a history of exposing himself and masturbating in public, as documented in his care plan. Both Resident #2 and Resident #5, who were cognitively intact or had moderate impairment, reported multiple incidents where Resident #3 exposed his genitals to them in the hallway and near his room. These incidents were reported to staff, but the residents stated that no effective action was taken to stop the behavior, and the exposure continued. The facility's investigation into the reported abuse was inadequate. Although Resident #2 reported the incident to staff, there was a delay in reporting to the nursing home administrator. The facility ultimately unsubstantiated the abuse claim due to lack of witnesses and denial by Resident #3, despite both victims consistently describing repeated exposure and discomfort. Staff interviews revealed that some were aware of the behavior but did not report it, either because they did not perceive the residents as upset or because the exposure occurred in Resident #3's room with the door open. The activity director admitted to witnessing the behavior but failed to report it, and the activity assistant overheard a resident discussing the incident but did not escalate it to management. Resident #3's care plan acknowledged his behavioral risks but lacked person-centered interventions specifically designed to prevent him from exposing himself to others. Staff members were either unaware of interventions or only referenced general behavioral management strategies. The care plan did not include targeted measures to address the specific risk of public exposure, and staff responses were limited to reminders in the dining room, despite incidents occurring in hallways. As a result, the facility did not ensure the safety and well-being of the affected residents, who continued to feel unsafe and uncomfortable.
Ineffective QAPI Program and Multiple Deficiencies
Penalty
Summary
The facility failed to implement an effective Quality Assurance and Performance Improvement (QAPI) program to identify and address compliance concerns, impacting the quality of care, quality of life, and resident safety. The QAPI committee did not operate in a manner that effectively identified and addressed issues related to quality of care. The facility's policy outlined a comprehensive program designed to monitor and evaluate residents' care and health services systematically and continuously, but this was not effectively executed. The report highlights several deficiencies across various areas, including self-determination, management of personal funds, and maintaining a safe, clean, and homelike environment. Specific failures included not honoring resident choices, not compensating residents timely for work performed, and not managing personal funds accounts adequately. Additionally, the facility did not ensure a safe environment, failed to investigate allegations of abuse, and did not meet transfer and discharge requirements. There were also issues with providing appropriate treatment and services for activities of daily living, maintaining hearing and vision, and ensuring residents were free from accident hazards. Interviews with facility staff revealed that the QAPI committee met monthly, but significant issues were not always identified or addressed promptly. The Director of Clinical Services (DOCS) noted that smoking assessments were not completed and that enhanced barrier precautions were overlooked due to changes in facility leadership. The Nursing Home Administrator (NHA) acknowledged that the facility had not identified residents needing assistance at meal times as an issue, despite having a schedule for managers to observe dining rooms. The facility also failed to recognize concerns in the activities department, although efforts were being made to revamp it with a new activity director. The Regional Director of Operations (RDO) mentioned that floor huddles were instituted to encourage staff to discuss concerns openly, but systemic issues persisted.
Infection Control Deficiencies in PPE, Water Management, and Hand Hygiene
Penalty
Summary
The facility failed to maintain an effective infection control program, as evidenced by several deficiencies observed during the survey. Staff did not adhere to the Enhanced Barrier Precautions (EBP) when caring for a resident with a fistula who required dialysis. Specifically, a certified nurse aide (CNA) did not wear a gown while changing the resident's bedding and assisting with dressing, despite the presence of an EBP sign indicating the need for gown and glove use during high-contact activities. Interviews with staff revealed a lack of understanding and inconsistent application of EBP protocols, contributing to the deficiency. The facility's water management program (WMP) was also found to be inadequate. The Legionella Surveillance policy did not identify specific areas where Legionella could grow and spread, nor did it outline how to monitor and document control measures. Observations showed that unoccupied rooms with potential dead legs in the plumbing system were not properly flushed or monitored for waterborne pathogens. Interviews with the maintenance director revealed a lack of awareness regarding the requirements for Legionella surveillance, further highlighting the deficiency in the facility's WMP. Additionally, staff failed to follow appropriate hand hygiene practices during resident care and meal delivery. Observations indicated that CNAs did not perform hand hygiene between resident interactions or sanitize shared vital signs equipment between uses. During meal delivery, staff did not offer hand hygiene to residents or perform hand hygiene themselves after handling meal trays. These lapses in hand hygiene practices were confirmed through staff interviews, indicating a need for further education and adherence to infection control protocols.
Deficiencies in Dish Sanitization and Food Storage
Penalty
Summary
The facility failed to ensure proper sanitization of dishes in the main kitchen, as observed during a survey. The dietary manager (DM) was seen submerging plate covers in the sanitizer compartment of a three-compartment sink for only five to twenty-five seconds, contrary to the manufacturer's instructions which required at least one minute of contact time. This discrepancy was confirmed by the DM, who initially believed the plate covers were submerged for the correct duration. A resident reported frequently receiving dirty dishes with dried food spots, indicating a persistent issue with the dishwashing process. Additionally, the facility did not adhere to safe food storage practices in the walk-in refrigerator. Observations revealed undated bags of raw chicken and ground beef, as well as improperly labeled containers of raw chicken thighs and shredded parmesan cheese. The DM admitted that the meat was not labeled because it was leftover and used for staff meals, and acknowledged that the ham was stored incorrectly next to raw chicken. The district supervisor noted that the facility should implement a pull thaw system to properly label and date meat. These deficiencies highlight a lack of compliance with professional standards for food storage and sanitization, as outlined by the FDA Food Code and the facility's own policies. The failure to follow proper procedures for dish sanitization and food storage could potentially compromise the safety and quality of food served to residents.
Failure to Honor Resident Shower Preferences
Penalty
Summary
The facility failed to honor the shower preferences of five residents, leading to a deficiency in resident care. Resident #35, who was cognitively intact and dependent on staff for showers, reported not receiving a shower in the past four weeks despite her preference for weekly showers. The records confirmed that she had not received a shower since 11/18/24, and there was no documentation of any refusals or reasons for missed showers. Resident #39, also cognitively intact, preferred two showers a week but only received four in the past 30 days. She refused showers offered in the morning, preferring them in the late afternoon or evening. The records showed multiple instances where showers were marked as not applicable without explanation. Similarly, Resident #6, who required staff assistance for showers, preferred three showers a week but only received eight out of 12 opportunities in November 2024. The discrepancy between her care plan and actual shower schedule was noted. Resident #23, who required assistance with showering, had not received a shower in 17 days, despite his preference for three showers a week. The records showed only one documented refusal, with no explanation for other missed showers. Resident #33, with moderate cognitive impairments, also had not received a shower in 17 days, with records showing three refusals but no documentation for other missed showers. Staff interviews revealed issues with staffing and documentation, contributing to the failure to meet residents' shower preferences.
Deficiencies in Maintaining a Homelike Environment
Penalty
Summary
The facility failed to provide a comfortable and homelike environment for its residents, as evidenced by the lack of clean washcloths and hand towels in multiple rooms across the East and [NAME] units. Observations revealed that several rooms were missing these essential items, and residents reported that housekeepers removed dirty towels without replacing them with clean ones. Interviews with residents and staff indicated that the nursing staff was responsible for distributing towels, but this was not being done consistently, leading to residents having to use paper towels for personal hygiene. Additionally, the facility did not ensure timely cleaning of Resident #6's closet, which had remnants of dried feces on the floor, door, and wall. This issue arose after the resident experienced an accident while preparing for a colonoscopy months prior. Despite requests for cleaning, the feces remained, indicating a failure in maintaining a sanitary environment for the resident. The facility also failed to address a clogged toilet in a resident's bathroom in a timely and appropriate manner. Observations showed that the toilet was backed up with water and fecal matter, and despite a work order being placed, the issue persisted for several hours. Staff interviews revealed confusion over responsibilities for addressing such maintenance issues, with the maintenance director indicating that CNAs were expected to handle the situation without proper training or guidance on handling bodily fluids.
Inadequate Supervision and Care Planning in LTC Facility
Penalty
Summary
The facility failed to provide adequate supervision and implement care-planned interventions to prevent accidents for three residents. Resident #9, who had a history of falls and dementia, was observed multiple times without a fall mat beside her bed, despite a physician's order and care plan intervention requiring it. Additionally, Resident #9 was transported in a wheelchair without foot pedals, causing her feet to dangle, which was not addressed in her care plan. Resident #26, also with dementia and a history of falls, was similarly transported in a wheelchair without foot pedals, leading to her feet dangling during transport. The care plan for Resident #26 did not include an intervention to ensure foot pedals were used. Furthermore, Resident #26 was transferred from a chair to a wheelchair without the use of a gait belt, contrary to facility policy and her care plan, which required substantial assistance during transfers. Resident #24, who was cognitively intact and independent in activities of daily living, was not appropriately assessed for safe smoking practices. Despite evidence of smoking in his room and a history of unsafe smoking behavior, the facility failed to conduct timely smoking risk assessments and did not update his care plan to reflect the need for supervision during smoking.
Failure to Provide Varied and Preferred Diets
Penalty
Summary
The facility failed to provide a nourishing, palatable, and well-balanced diet that met the daily nutritional and special dietary needs of its residents, specifically for two residents out of a sample of 41. The deficiency was identified through observations, record reviews, and interviews, revealing that the facility did not offer a balanced menu with variety and failed to provide alternate items of preference when requested. Resident interviews and a resident group interview highlighted concerns about repetitive menus and a lack of variety, with specific complaints about the overuse of certain foods like chicken, rice, potatoes, and mixed vegetables. Despite having a food committee and voicing concerns during resident council meetings, residents felt their feedback was not being addressed. Resident #61, who had severe cognitive impairments and multiple health issues, was not provided with food that met his preferences, which included Mexican food, bananas, yogurt, and other specific items. His care plan was not updated to reflect these preferences, and staff did not offer encouragement or preferred items during meals. The resident's representative expressed concerns about his weight and eating habits, noting that the facility staff were unaware of his food preferences and did not provide a menu when requested. Resident #48, who had cognitive impairments and was on a dysphagia diet, requested a grilled cheese with ham sandwich but was only provided with a grilled cheese sandwich due to dietary restrictions. The registered dietitian initially denied the request for ham, citing safety concerns, but later acknowledged that the resident could have chopped ham. This incident highlighted a lack of communication and understanding of the resident's dietary needs and preferences, contributing to the deficiency in providing a well-balanced diet.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that residents consistently received food that was palatable in taste, texture, appearance, and temperature. Multiple resident interviews revealed dissatisfaction with the food quality, citing issues such as food being served cold, lacking flavor, and being improperly cooked. Specific complaints included grilled cheese sandwiches being microwaved instead of grilled, repetitive menus, and overcooked or tough meat. Residents expressed that attending food meetings did not result in improvements, and they felt their concerns were not being addressed by the facility. Observations during meal preparation and service confirmed the residents' complaints. During a continuous observation, it was noted that the temperature of the tater tots was 99 degrees F, and the mixed vegetables were 160 degrees F. A test tray evaluation revealed that the tater tots were over-salted, the vegetables were overcooked and bland, and the philly cheesesteak sandwich had hard, chewy bread with burnt cheese. These findings were consistent with resident complaints about the food being served cold and lacking in quality. Interviews with staff, including the nursing home administrator and dietary manager, acknowledged awareness of the food quality concerns. The dietary manager mentioned that the facility had recently switched food vendors, which might have affected residents' perceptions of food quality. Despite conducting test tray audits, the facility had not identified significant issues. The dietary manager suggested that assembling sandwiches during meal service and batch cooking tater tots could improve food quality, indicating a need for changes in food preparation practices.
Inadequate Access to Personal Funds for Residents
Penalty
Summary
The facility failed to ensure that residents had adequate access to their personal funds accounts, affecting four residents out of a sample of 41. Residents reported being unable to access their money on weekends and sometimes during weekdays due to the facility running out of funds. Interviews with residents revealed that they were unable to obtain money when needed, which led to canceled plans and inconvenience. Observations confirmed that the facility's banking hours were limited to weekdays, and staff interviews indicated that the resident council had voted to restrict access to funds on weekends. Staff interviews further revealed that there was no established minimum balance to trigger obtaining additional funds, leading to situations where residents could not access the requested amounts. The business office manager and activity director acknowledged the limitations in fund availability and the lack of a process to replenish funds promptly. The regional director of operations noted that the facility's prior administrator had restricted fund availability due to concerns about theft, but acknowledged that residents should have access to funds on weekends and that the resident council's restrictions should not override required access. The facility lacked a process to ensure funds were available when needed, contributing to the deficiency.
Medication Storage and Management Deficiencies
Penalty
Summary
The facility failed to ensure proper storage and management of medications in two medication storage rooms and two medication carts. Observations revealed that medications were not disposed of after residents were discharged, and medications were not labeled with the dates they were opened. Additionally, expired medications were not removed and discarded from the medication carts and storage refrigerators. The facility also failed to maintain temperature logs for the medication refrigerators, which is a critical aspect of ensuring medication efficacy and safety. During observations, it was noted that the medication storage refrigerators in both the [NAME] hall and East hall lacked temperature logs. Several medications, including Tuberculin Purified Protein Derivative and Insulin Glargine, were found opened without labels indicating the date they were opened. Medications labeled with discharged residents' names were still present in the storage, and some medications were found to be expired, such as Phenalephrine suppositories and Amlactin lotion. Nursing staff acknowledged the lack of proper labeling and the presence of expired medications, indicating a lapse in adherence to the facility's medication storage policy. Interviews with nursing staff and the Director of Nursing (DON) revealed a lack of clarity and responsibility regarding the maintenance of temperature logs and the removal of medications post-discharge. The DON confirmed that it was the night shift nurses' responsibility to check and record refrigerator temperatures and that medications should be removed on the day of a resident's discharge. However, the absence of a temperature monitoring log and the presence of expired and improperly labeled medications suggest a systemic issue in the facility's medication management practices.
Failure to Investigate Allegations of Verbal Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of verbal abuse involving two residents, Resident #37 and Resident #21. Resident #37, who had moderate cognitive impairment, reported feeling unsafe after being yelled at by another resident. The facility's response was limited to ensuring the two residents did not sit near each other in the dining room, without conducting a comprehensive investigation. There was no documentation of staff or resident interviews, and the nursing home administrator (NHA) did not provide evidence of an investigation before the survey exit. Resident #21, who was cognitively intact, was involved in an altercation with another resident, Resident #44. The incident involved yelling and aggressive behavior, but the facility did not document any investigation into the matter. The NHA claimed to have interviewed both residents, but there was no documentation to support this. The grievance form completed by the NHA did not include interviews with staff or other residents, and the facility failed to provide evidence of a thorough investigation. In both cases, the facility did not adhere to its policy of conducting a thorough investigation into allegations of abuse. The lack of documentation and failure to interview relevant parties indicate a deficiency in the facility's response to these incidents. The facility's actions did not align with its policy to ensure resident safety and prevent abuse.
Inadequate Discharge Process for Resident
Penalty
Summary
The facility failed to provide an appropriate discharge process for a resident, leading to a deficiency in their care. The resident, who was under 65 and had multiple medical conditions including diverticulitis, frontal lobe deficit, hemiplegia, major depressive disorder, anxiety disorder, and acute kidney failure, was discharged to the emergency department without proper documentation or education regarding the discharge. The facility's discharge planning policy required an effective discharge process focusing on the resident's goals and ensuring a smooth transition to post-discharge care, which was not followed in this case. The resident was documented as moderately cognitively impaired and had a history of physical and verbal behaviors directed at others. The facility issued a 30-day notice of involuntary discharge due to the resident's behavior, citing safety concerns for the resident and others. However, on the day of discharge, the resident was immediately discharged after an incident where he assaulted a staff member. The facility failed to document that the resident was provided education about his immediate discharge or that he understood it. The regional director of operations confirmed that the decision for immediate discharge was made after the resident fell and initially refused to go to the emergency department. The facility's management team decided on the immediate discharge due to the resident's behavior, but the necessary documentation and communication with the resident were lacking.
Failure to Reassess Resident Post-Hospital Transfer
Penalty
Summary
The facility failed to permit a resident to return after a facility-initiated transfer to the hospital, violating the discharge planning policy. The resident, under 65, had multiple diagnoses including diverticulitis, frontal lobe deficit, hemiplegia, major depressive disorder, anxiety disorder, and acute kidney failure. The resident required setup assistance with eating and was independent in other ADLs, with no active discharge plan. The resident was moderately cognitively impaired with a BIMS score of nine out of 15 and exhibited physical and verbal behaviors directed at others. The facility did not reassess the resident's status after the transfer to the emergency department, nor did it document any unmet needs that would prevent the resident's return. The regional director of operations stated that the resident had fallen and initially refused hospital transfer but later agreed. The facility management decided on an immediate discharge due to the resident's behavior, which included assaulting a staff member. The charge nurse communicated the discharge to the emergency department, but there was no documentation of reassessment or refusal of care in the resident's EMR.
Failure to Complete Discharge Summary for Resident
Penalty
Summary
The facility failed to ensure a discharge summary was in place for a resident who was discharged home with family. The discharge summary was supposed to include a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge. The facility's policy, last revised in October 2022, mandates that a discharge summary and post-discharge plan be developed when a resident's discharge is anticipated. However, for this resident, the electronic medical record did not contain documentation of a final summary of the resident's status or a recapitulation of their stay. The resident, who was under 65 years old, had diagnoses including congestive heart failure, pulmonary hypertension, severe protein-calorie malnutrition, and psychoactive substance abuse. The resident had severe cognitive impairments and was dependent on staff for personal hygiene. On the day of discharge, the resident left the facility to visit his mother in the hospital and did not return. The nurse on duty provided a one-day supply of medications and later arranged for the resident's mother to pick up additional medications. Despite these actions, the facility did not complete the required discharge summary documentation.
Deficiencies in Personal Hygiene and Meal Assistance
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene. Specifically, Resident #32, who was dependent on staff for bathing, did not receive her scheduled showers. Despite being scheduled for showers twice a week, records indicated that she missed several showers, with no documentation explaining the missed showers or any interventions attempted. Interviews with staff revealed that there were often staffing shortages, which led to missed showers, and that Resident #32 was generally cooperative and did not refuse care. Additionally, the facility failed to provide adequate meal assistance to Resident #48, who was legally blind. During meal observations, it was noted that staff informed the resident of the food items on her plate but did not specify their locations, leaving the resident to struggle to locate her food. This was contrary to the care plan, which required staff to inform the resident of the location of her food items. Interviews with staff confirmed that the resident needed assistance in identifying the location of her food to eat independently. These deficiencies highlight a lack of adherence to the facility's policies and procedures regarding personal hygiene and meal assistance for residents with specific needs. The failure to provide scheduled showers and appropriate meal assistance compromised the residents' ability to maintain personal hygiene and independence in eating, respectively.
Failure to Timely Treat Resident's Skin Injury
Penalty
Summary
The facility failed to provide timely treatment and care for a resident's skin injury, which was not addressed according to professional standards of practice. The resident, under 65 years old, with a history of type 2 diabetes and venous thrombosis, was cognitively intact and independent in activities of daily living. The resident sustained a skin tear on the left shin from a fall at his daughter's house. Despite daily skin monitoring records from 12/7/24 to 12/12/24 indicating no concerns, the skin tear was not identified or treated by the facility until 12/12/24. Observations on 12/11/24 and 12/12/24 revealed the untreated skin tear, and the facility's electronic medical record lacked documentation of the injury or notification to the physician prior to 12/12/24. Interviews with staff indicated a lack of awareness of the injury, with an LPN not noticing the injury during a medication round and an RN only becoming aware of the injury on 12/12/24. The facility's director of nursing provided undated wound education emphasizing the importance of immediate nurse notification, physician notification, risk management occurrence initiation, and appropriate documentation when a new skin breakdown is identified.
Failure to Provide Timely Vision Services
Penalty
Summary
The facility failed to ensure timely access to vision services for a resident, leading to a deficiency in maintaining the resident's vision abilities. The resident, a 69-year-old with diagnoses including hemiplegia, peripheral vascular disease, mood disorder, and chronic obstructive pulmonary disease, was admitted to the facility and had no cognitive impairment. Despite being independent in some activities of daily living, the resident required supervision or assistance with most others. The resident had an eye exam on October 21, 2024, which resulted in a new prescription for eyeglasses. However, the facility did not document the receipt of these glasses in the resident's electronic medical record. Interviews with facility staff revealed that the social services consultant acknowledged the delay in initiating the request for funding the eyeglasses, which should have been done shortly after the eye exam. The request for funding was not initiated until December 13, 2024, during the survey, and the eyeglasses had not been ordered by that date. A certified nurse aide also confirmed that she had not seen the resident wearing glasses and was unaware of the resident's need for them. This inaction resulted in the resident not receiving the necessary eyeglasses in a timely manner, as expected by the facility's procedures.
Medication Errors in LTC Facility
Penalty
Summary
The facility failed to ensure residents were free from significant medication errors, specifically involving two residents. For one resident, the facility did not order and administer the correct medication for itching. Instead of hydroxyzine, which was prescribed for itching, the resident was given hydralazine, a medication for high blood pressure. This error occurred due to a mix-up in medication orders, which was not caught by the staff, including the CNA-Med, the registered pharmacist consultant, and the nurse practitioner. The resident identified the error when the wrong medication was attempted to be administered, leading to the discontinuation of the incorrect medication order. Another resident received excessive dosages of acetaminophen, exceeding the recommended daily limit. The resident was prescribed multiple medications containing acetaminophen, which, when combined, resulted in dosages above the safe threshold. The facility's staff, including the RN and LPN, failed to monitor and adjust the medication orders to prevent this excessive dosage. The pharmacist also did not identify the potential for overdose during the medication regimen review. The errors were compounded by a lack of proper verification and oversight by the facility's staff and systems. The medication administration policy was not adhered to, and there was a failure in communication and coordination among the healthcare providers, pharmacists, and nursing staff. These lapses led to the administration of incorrect and excessive medications, posing potential risks to the residents involved.
Deficiency in Coordination of Hospice Care Documentation
Penalty
Summary
The facility failed to ensure that hospice agency notes regarding a resident's care were easily accessible to the facility staff, which hindered effective coordination of care with the hospice agency. The resident, who was over 65 years old and had diagnoses including acute kidney failure, a history of falling, and dementia, was receiving hospice services. The resident's care plan indicated that hospice staff, including a nurse and a certified nurse aide (CNA), were involved in the resident's care, with visits scheduled multiple times a week. However, the hospice documentation was not up to date, with the last notes from the hospice nurse and CNA being from several months prior. Interviews with facility staff revealed that the hospice nurse and CNA were visiting as scheduled, but the notes from these visits were not being properly documented in the facility's electronic medical record (EMR). The registered nurse (RN) responsible for the resident's care was unable to find any recent hospice notes in the EMR, and the health information specialist confirmed that there were no notes from the hospice agency for the resident. This lack of documentation and communication between the hospice agency and the facility staff led to a deficiency in the coordination of care for the resident.
Resident Payment Delay in Therapeutic Stipend Program
Penalty
Summary
The facility failed to ensure that a resident participating in the Resident Therapeutic Stipend Program was compensated in a timely manner for services rendered. The resident, who was cognitively intact and required assistance with daily activities, participated in the program by calling Bingo and working in the resident soda store. Despite completing her work program commitment log for November 2024, the resident did not receive her stipend until December 12, 2024, which was during the survey. The delay in payment was attributed to the activity director, who was new to the role and did not submit the payment request correctly for November 2024. This error caused a delay in the issuance of the stipend check, which was eventually cashed and deposited into the resident's petty cash account. The business office manager confirmed that there was inconsistency in receiving checks from corporate, which contributed to the delay in payment.
Failure to Provide Personalized Activity Program for Resident
Penalty
Summary
The facility failed to provide a personalized activity program for a resident, leading to a deficiency in meeting the resident's needs and interests. The resident, over 65 years old, with diagnoses including acute kidney failure, history of falling, and dementia, was observed multiple times without engagement in meaningful activities. Despite the resident's care plan indicating a preference for activities such as reading the Bible, listening to music, and participating in religious services, there was no evidence of these activities being offered or facilitated. Observations showed the resident alone in bed or in common areas without interaction or engagement in activities. Interviews and record reviews revealed that the resident's preferences for spiritual and sensory activities were not being met. The activity director, new to the facility, was unaware of the resident's specific interests and acknowledged the absence of sensory programs on the calendar. The resident's electronic medical record showed a lack of documentation for one-on-one activities, spiritual activities, or assistance in going outside, as per the resident's preferences. The activity director admitted to not having the resident on a one-to-one program and was unaware of the resident's enjoyment of outdoor activities.
Inconsistent Dialysis Documentation and Monitoring
Penalty
Summary
The facility failed to provide dialysis services consistent with professional standards of practice for a resident who required such services. Specifically, the facility did not consistently and accurately monitor pre- and post-dialysis weights for the resident, nor did they consistently document the resident's post-dialysis weight from the dialysis communication form in the resident's electronic medical record (EMR). Additionally, the facility did not ensure that communication forms between the facility and the dialysis center were obtained consistently and completed thoroughly. The resident in question, who was over 65 years old, had multiple diagnoses including ischemic cardiomyopathy, dysphagia, type 2 diabetes mellitus, heart disease, chronic kidney disease, and vascular dementia. The resident was dependent on staff for various activities of daily living and received dialysis treatment. A physician's order required the documentation of the resident's post-dialysis weights on specific days, but the facility failed to record these weights in the EMR on numerous occasions. Interviews with facility staff revealed that there was a lack of consistency in the process of acquiring and documenting dialysis communication forms. The registered nurse indicated that certified nurse aides were responsible for weighing the resident before dialysis, and the communication forms were supposed to be sent to and returned from the dialysis center with the resident. However, the director of nursing and the director of clinical services acknowledged that the facility's process for obtaining these forms was inconsistent, and the forms were not always reviewed or placed in the resident's EMR as required.
Failure to Administer Pain Medications Timely
Penalty
Summary
The facility failed to administer pain medications in a timely manner for three residents, as per physician orders, which is a violation of professional standards of practice. Resident #3, who was cognitively intact, reported that her medications were rarely administered on time, and she had filed grievances regarding this issue. The medication administration records confirmed multiple instances where her pain medications, including morphine sulfate, hydrocodone-acetaminophen, and acetaminophen, were administered outside the allowed time window, sometimes by several hours. Resident #1, also cognitively intact, expressed uncertainty about the timing of his pain medication administration, as different nurses administered them at varying times. The medication administration records showed that his acetaminophen doses were frequently given late, with delays ranging from minutes to several hours. This inconsistency in medication administration timing was not addressed by notifying the physician or documenting the deviations in the residents' medical records. Resident #2, who had moderate cognitive impairments, also experienced delays in receiving his pain medication, tramadol. The medication administration records indicated that his doses were often administered late, with delays extending up to nearly four hours. Interviews with nursing staff and facility leadership revealed an acknowledgment of the issue, with staff indicating that pain medications should be administered within a specific time window for effective pain management. However, there was no documentation of physician notification or progress notes for the late administrations.
Deficiency in Pressure Injury Management
Penalty
Summary
The facility failed to provide necessary treatment and services to manage pressure injuries and minimize risks for four residents, leading to a deficiency. Resident #3 was hospitalized multiple times between January and June 2024, during which he developed several pressure injuries ranging from stage 2 to stage 4, including osteomyelitis of the sacral wound. The facility repeatedly failed to assess Resident #3's wounds upon readmission, monitor the wounds, and obtain and implement treatment orders in a timely manner. This lack of action resulted in the resident being without treatment orders for significant periods, contributing to the worsening of his condition. Resident #5 also experienced inadequate care, as the facility failed to assess her wounds on admission and did not accurately assess her risk for pressure injury development. Despite having pressure injuries and being frequently incontinent, the resident was not identified as at risk for pressure injuries, and timely pressure prevention interventions and treatments were not implemented. Additionally, the resident did not have an air mattress, which was necessary to prevent further pressure injuries. Residents #4 and #12 faced similar issues, with the facility failing to ensure proper assessment and timely treatment of their pressure injuries. Resident #4 had an air mattress that was not inflated appropriately, increasing the risk of pressure injuries, while Resident #12's pressure injuries were not assessed on admission, and treatment was not ordered or provided in a timely manner. These failures in pressure injury management and prevention highlight significant deficiencies in the facility's care practices.
Removal Plan
- The director of nursing (DON) completed pressure injury assessments on two other residents and updated the plans of care.
- Current treatment orders were verified and treatment was completed as ordered.
- A community-wide audit of all residents was completed by the DON or designee to obtain a baseline on current skin concerns in the community. Any identified area was corrected.
- The DON completed an audit to ensure all treatments, supplies, and equipment were readily available for pressure injury treatments.
- The Director of Clinical Operations completed an audit of all air mattresses and support surfaces to ensure proper use in accordance with manufacturer's recommendations or resident preferences. All identified areas were corrected.
- The DON or designee initiated education with nursing staff regarding proper identification, documentation, and monitoring of pressure ulcers, as well as implementing interventions to prevent breakdown and completion of treatments as ordered for resident's skin injuries. Education to be provided to agency staff.
- The DON or designee to complete wound rounds and ensure documentation is inputted in the electronic health record.
- The DON or designee to complete wound dressing change observations and complete chart review for wound documentation for two residents to ensure that orders in place and are being followed as written, that staff is following appropriate infection control practices, that the physician is notified as needed, and that documentation is consistent throughout the chart. Identified concerns to be addressed with staff.
- The Nurse consultant or designee to complete a review of the resident's wound documentation to ensure that it is consistent with documentation from the wound physician and that the physician is being contacted as necessary for the wound. Identified concerns to be addressed with DON/designee.
- Any residents admitted to the facility or returning from the hospital will be assessed for any area of skin breakdown. Any areas identified requiring treatment will have orders verified or obtained and wound care appointments will be transcribed and overseen by nurse leadership. A review to include an additional skin check will be completed.
- DON or designee to report on wound data in the quality assurance performance improvement QAPI meeting. Identified concerns to be tracked and trended.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect residents from physical abuse, as evidenced by multiple incidents involving both staff and resident-to-resident interactions. In one case, a certified nurse aide (CNA) physically abused a resident by pressing his forearm into the resident's chest after the resident used a racial slur. This resulted in the resident suffering multiple rib fractures and a pneumothorax, requiring hospitalization. The facility's investigation into the incident was delayed, and there were inconsistencies in the documentation, including a lack of interviews with key staff members present during the incident. In another incident, two residents with known histories of aggression were involved in a physical altercation, resulting in one resident sustaining an eye injury. The facility's investigation revealed that both residents had a history of physical and verbal aggression, yet there were no new interventions added to their care plans following the altercation. The facility failed to implement adequate monitoring or behavior management strategies to prevent such incidents. Additionally, a resident with severe cognitive impairment and a history of aggressive behavior physically abused her roommate by twisting her arm and wrapping a call light cord around her neck. Despite previous aggressive incidents, there was no behavior care plan in place for the aggressor until after the incident. The facility's response to the abuse was inadequate, as the abuse was deemed unsubstantiated due to the aggressor's dementia, and there was a lack of documented frequent monitoring or intervention strategies in the care plans.
Deficiencies in QAPI Program and Resident Care
Penalty
Summary
The facility failed to implement an effective Quality Assurance Performance Improvement (QAPI) program to address and rectify compliance concerns, particularly in the areas of quality of life and care for residents. The QAPI committee did not adequately identify and address issues related to pressure injuries and abuse prevention. Specifically, the facility did not ensure timely assessment and intervention for pressure injuries, leading to a resident developing a wound infection with osteomyelitis, which resulted in immediate jeopardy and actual serious harm. Additionally, the facility failed to prevent an abuse incident where a staff member intentionally caused harm to a resident, resulting in multiple rib fractures and a pneumothorax. The facility's QAPI policy was not provided during the survey, indicating a lack of adherence to established procedures. The facility had a history of repeat deficiencies, with previous citations for pressure injuries and abuse prevention. Interviews with the nursing home administrator and the medical director revealed gaps in clinical oversight and staff training, particularly in wound care and abuse prevention. The use of agency staff and recent changes in wound care providers were noted as contributing factors to the facility's failures. The medical director, who was new to the facility, was unaware of the extent of the issues, highlighting a lack of communication and continuity in care practices.
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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