Winding Trails Post Acute
Inspection history, citations, penalties and survey trends for this long-term care facility in Boulder, Colorado.
- Location
- 2800 Palo Pkwy, Boulder, Colorado 80301
- CMS Provider Number
- 065267
- Inspections on file
- 25
- Latest survey
- December 4, 2025
- Citations (last 12 mo.)
- 4
Citation history
Health deficiencies cited at Winding Trails Post Acute during CMS and state inspections, most recent first.
Multiple residents were not protected from physical and verbal abuse by peers, including incidents of hitting, threatening notes, and verbal altercations. Staff were aware of the behaviors and some interventions were attempted, but not all incidents were investigated or addressed, and some residents reported feeling unsafe or that their concerns were disregarded.
A resident with multiple chronic conditions and a venous leg wound did not receive daily wound dressing changes as ordered by the physician. During observation, the dressing was found unchanged for three days, despite clear orders and staff awareness of the required daily care. Interviews with the wound care physician and DON confirmed the expectation for daily dressing changes, but no explanation was provided for the lapse.
The facility failed to protect several residents from physical and verbal abuse by other residents despite known behavioral histories and documented risk factors. A cognitively intact male with serious mental health diagnoses reported being struck in the face and having his beard pulled by a resident with schizophrenia and a history of delusions, hallucinations, sexually threatening and odd statements, and behaviors directed toward males; he also reported repeated death threats from this resident and stated he had informed staff. Another male with dementia and psychiatric conditions reported that the same resident threw water on his head and spoke to him aggressively, and a third cognitively intact male with anxiety and impaired coping reported receiving a written threat from this resident that she would enter his room and mutilate him while he slept, as well as her repeated entry into men’s rooms; he said he reported this but believed nothing would be done. The DON acknowledged being aware of this resident’s threatening notes to residents and staff and stated that the facility did not investigate every note. In addition, surveyors directly observed a verbal altercation in which a resident with PTSD and a very loud manner of speaking and another resident with anxiety and verbal aggression exchanged racial, discriminatory, and profane insults in a public area, in front of staff and other residents.
A resident with multiple chronic conditions, including vascular dementia, diabetes, neuropathy, atrial fibrillation, and hemiplegia, had a physician order for daily dressing changes to a venous wound on the left lower leg. The resident, who was cognitively intact and dependent on staff for several ADLs, reported that nursing staff were not changing the wound dressing. Surveyor observation found the leg dressing dated three days earlier, indicating it had not been changed per the daily order. During observed wound care, the ADON and an LPN removed the old dressing and noted red open and scabbed areas before cleansing and redressing the wound. The wound care physician confirmed the expectation for daily dressing changes by nursing staff, and the DON acknowledged she did not know why the dressing had not been changed and that staff were expected to follow the physician’s wound care orders.
The facility failed to maintain a surety bond that covered the entire balance of residents' personal funds, as required by policy. The bond was set at $14,000, insufficient to cover the account balance, which exceeded this amount from May to October 2024. The BOM acknowledged the need for increased coverage during the survey, and the NHA confirmed the facility's obligation to maintain adequate coverage.
The facility failed to address food concerns raised by residents during council meetings, as required by policy. Residents expressed dissatisfaction with snacks and meals, but there was no documentation of responses or resolutions. The NHA was unaware of the lack of follow-up by the AD, and no written responses were provided to the residents' grievances.
The facility failed to ensure food was palatable and attractive, with residents reporting cold, undercooked, or overcooked meals that were difficult to chew. A test tray evaluation confirmed issues with the food's texture and taste. The dietary manager and corporate dietary director acknowledged these problems, and the nursing home administrator was unaware of the residents' dissatisfaction. A performance improvement project was in place, but it did not address the palatability of the food.
The facility failed to ensure appropriate self-administration of medications for two residents. One resident was found with lidocaine tubes at the bedside without physician's orders or assessments for self-administration. Another resident had several medications left on the bedside table during a medication pass, also without orders or assessments. Interviews with the DON and an RN confirmed that no residents were assessed or allowed to self-administer medications, and medications should not be left at the bedside.
A facility failed to incorporate PASRR Level II recommendations into a resident's care plan. The resident, with multiple mental health diagnoses, was not provided with the recommended individual therapy services. The facility's care plan and records lacked documentation of these services, and there was no psychotherapy order despite medication prescriptions. Interviews revealed a lack of audits to identify residents needing PASRR Level II services, with the new SSD working to address program gaps.
A facility failed to provide individualized activities for a resident at the end of life, who had severe cognitive impairments and was dependent on staff for ADLs. The resident's preferences, such as listening to music and being around animals, were not incorporated into her care plan. Observations showed a lack of personalization in the resident's room, and staff interviews revealed a lack of awareness and implementation of the resident's preferences. The AD admitted to not having training on hospice care needs and only implemented a more homelike atmosphere during the survey.
A resident with limited mobility did not receive consistent ROM therapy due to the facility's failure to establish a restorative nursing program. Despite being cognitively intact and having specific medical conditions, the resident reported not receiving daily therapy as ordered, leading to feelings of weakness. Staff interviews revealed the program had not been in place, and training for restorative services only began shortly before the survey.
The facility failed to ensure that two residents understood the binding arbitration agreement before signing. One resident, with chronic conditions and under medication, did not recall signing and disputed the signature. Another resident, with cognitive impairments, did not understand the agreement. The marketing coordinator, lacking a clinical background, assumed understanding without proper documentation.
A resident with severe cognitive impairment was transferred to another facility without proper discharge planning or family notification. The family was not involved in the decision-making process and was not informed until after the transfer occurred, causing distress. Facility staff acknowledged miscommunication and a breakdown in the discharge process.
The facility failed to prevent two residents with known exit-seeking behaviors from eloping, resulting in one resident sustaining a fractured hip. The front door's wander-prevention system malfunctioned, and staff did not adequately monitor or check the functionality of wander-prevention devices. The facility's elopement policy lacked preventive procedures, and staff training on elopement prevention was insufficient.
The facility failed to protect four residents from physical abuse by two other residents with known aggressive behaviors. Despite being aware of these tendencies, the facility did not implement effective monitoring or redirection plans, leading to repeated incidents of physical abuse. Investigations were incomplete, and appropriate agencies were not notified.
The facility failed to provide effective pain management for two residents with chronic pain, leading to increased pain levels and affecting their daily activities and sleep. Both residents reported not receiving their prescribed pain medications consistently, with discrepancies in medication administration and documentation. The Director of Nursing acknowledged the issues and the lack of follow-up actions to obtain the medications or notify the physician.
The facility failed to ensure food items were stored and served under sanitary conditions in the main kitchen. Staff did not correctly test the chemical sanitizer used to clean equipment and surfaces, resulting in a solution that did not register the required 200 ppm. The issue was traced to the use of incorrect test strips.
The facility failed to effectively administer its resources, leading to significant deficiencies in resident safety and care. There were multiple instances of unreported and uninvestigated abuse, missed medications, and inadequate staff training for handling residents with mental health and substance abuse issues. Staff and residents reported a culture of fear and intimidation, with concerns being dismissed by the administration.
The facility failed to conduct and document a comprehensive facility-wide assessment, missing critical components such as staff competencies, training programs, and emergency preparedness details. The NHA acknowledged these deficiencies and was unaware of the required elements.
The facility failed to ensure an effective quality assurance program, leading to deficiencies in resident safety, pain management, abuse prevention, medication errors, and staff training. The QAPI committee did not adequately address critical issues, resulting in immediate jeopardy situations and actual harm to residents.
The facility failed to provide required training in dementia care, substance abuse, and behavior management to all staff, despite an increase in residents with these issues. The facility's assessment did not accurately reflect the resident population, and no documentation of the required training was found.
The facility failed to develop and implement policies and procedures that prohibit and prevent retaliation for abuse reporting. There was no signage regarding employees' right to non-retaliation, and the abuse policy did not include protection for employees against retaliation. Staff interviews confirmed the absence of such notices.
The facility failed to report multiple alleged abuse incidents involving residents to the proper authorities, including verbal threats and physical altercations. Despite documentation in nursing progress notes and facility investigations, there was no evidence that the State Agency or police were notified.
The facility failed to thoroughly investigate incidents of potential abuse involving three residents. One incident involved a physical altercation between two residents, while another involved a resident holding a blanket around another resident's face. The investigations were incomplete, lacking sufficient documentation, resident and staff interviews, and timely reporting to authorities.
The facility failed to ensure residents were free from significant medication errors, resulting in five residents not receiving all prescribed medications due to unavailability. Staff interviews revealed ongoing issues with the pharmacy and lack of timely refills, and the DON was unaware of these issues. The resident council also documented concerns about missing medications without follow-up.
The facility failed to ensure that CNAs received the required 12 hours of annual training based on performance evaluations and facility assessment. Documentation for the training was incomplete, and the regional director confirmed the lack of necessary records, citing new ownership as a factor.
A facility failed to honor a resident's right to refuse treatment by administering medications without his knowledge, leading to his refusal to eat and drink. Despite the resident's increased paranoia and aggression when given pills, the facility continued to disguise medications in his drinks, causing a significant decrease in his meal intake. Staff and the resident's guardian were aware of the practice, but the resident's right to refuse treatment was not communicated or respected.
Failure to Protect Residents from Abuse by Peers
Penalty
Summary
The facility failed to protect multiple residents from physical and verbal abuse by other residents, as evidenced by several documented incidents. One resident with schizophrenia and a history of behavioral symptoms, including delusions, hallucinations, and aggression primarily directed toward male residents, physically assaulted another resident by hitting him on the cheek and pulling his beard. This incident was witnessed by staff, and the victim, who had a history of being the target of altercations, reported feeling unsafe and described multiple threats and prior incidents involving the same aggressor. The aggressor had previously refused psychiatric services and medication, and her care plan included interventions such as redirection and frequent checks, but these measures did not prevent the abuse. Another resident reported being physically abused by the same aggressor, who threw water on his head. This resident, who was moderately cognitively impaired and had a history of behavioral issues, stated that staff were notified but did not take action. Additionally, a third resident received a threatening note from the aggressor, indicating intent to cause harm. This resident, who was cognitively intact but experienced anxiety and impaired coping, also reported the incident to staff but felt that no effective response was provided. The aggressor was known to leave threatening notes and enter male residents' rooms, causing fear among other residents. The report also documents a verbal altercation between two other residents, involving racial and discriminatory insults, which was witnessed by staff, residents, and surveyors. Staff interviews revealed that while some interventions such as redirection and frequent checks were attempted, staff did not consistently investigate or address all incidents of abuse, particularly those involving threatening notes. The DON acknowledged awareness of the threatening behavior but stated that not all incidents were investigated, as the notes were considered part of the aggressor's behavior and not deemed dangerous.
Failure to Provide Daily Wound Care per Physician Order
Penalty
Summary
The facility failed to provide wound care treatment in accordance with physician orders and the resident's care plan for one resident. The resident, under 65 years old, had multiple diagnoses including vascular dementia, type 2 diabetes, diabetic neuropathy, atrial fibrillation, and hemiplegia following a stroke. The resident was cognitively intact and required substantial assistance with daily activities. According to the physician's order, the resident's venous wound on the left shin was to be cleaned and dressed daily during the day shift. However, during an interview and observation, it was found that the wound dressing had not been changed for three days, as evidenced by the date on the dressing and confirmed by staff during the dressing change. Staff interviews confirmed that the wound care order required daily dressing changes, and the wound care physician expected nursing staff to perform this task if the wound care nurse or physician was not present. The DON was unable to provide an explanation for why the dressing was not changed as scheduled. The failure to follow the physician's order for daily wound care resulted in the resident's dressing remaining unchanged for three days, contrary to professional standards of practice and the resident's comprehensive care plan.
Failure to Protect Residents From Physical and Verbal Abuse by Other Residents
Penalty
Summary
The deficiency involves the facility’s failure to protect multiple residents from abuse, including physical and verbal abuse, primarily involving one resident with known behavioral issues. Facility policy defined abuse broadly, including resident-to-resident altercations, and required written procedures to prohibit and prevent abuse, neglect, and exploitation, as well as investigation and staff training. Despite this, the facility did not consistently act on known patterns of threatening and aggressive behavior by one resident toward male residents, nor did it investigate all threatening notes or verbal threats as potential abuse incidents. One incident involved a cognitively intact male resident with schizoaffective disorder, diabetes, major depressive disorder, PTSD, and a history of being the victim in altercations. He reported that another resident with schizophrenia, cognitive impairment, delusions, hallucinations, and a history of odd and sexually threatening statements had threatened him multiple times, including threats to kill him and cut him into small pieces in his bathroom. He stated that this resident had physically hit him by striking his cheek and pulling his beard when they returned from the smoking patio, and that he had reported these incidents to staff. He also reported that this same resident had hit another male resident. The behavior care plan for the aggressor resident documented delusions, hallucinations, refusal of care, sexual and odd statements, yelling at other residents, and behaviors mostly directed toward males, yet the facility did not prevent the subsequent physical contact and threats that occurred. Another male resident with dementia, psychotic and mood disturbances, depression, anxiety, and moderate cognitive impairment reported that the same aggressor resident had thrown water on his head months earlier and that he notified staff but "they did nothing." He also reported that she sometimes spoke to him in an aggressive way. A third cognitively intact male resident with cerebral atherosclerosis, sequelae of cerebral infarction, generalized anxiety disorder, anxiety, ineffective coping, and verbal aggression reported that the same aggressor resident entered his room and left a note stating she would come to his bedroom and cut his penis while he slept. He stated he should not be threatened in that way, reported it to staff, and believed nothing would be done, adding that she had threatened others verbally or with notes and went into men’s bedrooms, causing him fear. The DON, acting as abuse coordinator, acknowledged awareness that this resident passed threatening notes to residents and staff, characterized the notes as part of her behavior, stated she was not dangerous, and reported that the facility did not investigate every note she wrote. The deficiency also includes an observed incident of verbal abuse between two cognitively intact male residents. One resident with PTSD, severe major depressive disorder, COPD, diabetes, and a cognitive communication deficit, who had a care plan noting a loud voice often perceived as yelling and risk for verbal altercations, was speaking loudly near the nurse’s station. Another resident with anxiety, ineffective coping, and verbal aggression came out of his room and yelled racial and discriminatory insults and profanity at him, and the first resident yelled back using similar language. This altercation, involving racial and discriminatory insults, was witnessed by staff, other residents, and surveyors. Staff interviews confirmed that the loud resident often spoke in a way that disturbed others and that the verbally aggressive resident had prior arguments with him, usually initiated by the verbally aggressive resident, but the facility had not effectively prevented such abusive exchanges.
Failure to Perform Daily Ordered Wound Dressing Changes
Penalty
Summary
The facility failed to provide wound care treatment in accordance with physician orders and the resident’s person-centered care plan by not changing a venous leg ulcer dressing daily as prescribed. The resident, under 65 years old, had multiple diagnoses including vascular dementia, type 2 diabetes, diabetic neuropathy, atrial fibrillation, and hemiplegia following a stroke, and was cognitively intact with a BIMS score of 15. The resident required substantial to maximal assistance with toileting hygiene, dressing, transfers, and showering. A physician’s order dated 9/18/25 directed that the venous wound on the left shin be cleansed with wound cleanser, patted dry, treated with calcium alginate and an ABD pad, and wrapped with kerlix gauze every day shift. On interview, the resident reported that nursing staff were not changing the wound dressing and pointed to the dressing on the left calf. Observation on 10/1/25 showed the left calf wrapped in kerlix gauze with tape dated 9/28/25 and marked with a smiley face, indicating the dressing had not been changed for three days. During a wound care observation later that day, the ADON and an LPN removed the old dressing, revealing a calf wound with a generally red appearance, some beefy red open areas approximately quarter-sized with well-defined borders, and several quarter-sized scabbed areas. The LPN stated the wound was overall healing and then performed wound care per the existing order. The wound care physician confirmed the order for daily dressing changes and stated she expected nursing staff to change the dressing daily when she or the wound care nurse were not present. The DON stated she did not know why the dressing had not been changed as scheduled and acknowledged that nursing staff should follow the physician’s wound care orders.
Failure to Maintain Adequate Surety Bond for Resident Funds
Penalty
Summary
The facility failed to ensure the security of all personal funds of residents deposited with the facility by not maintaining a surety bond that covered the entire balance of the residents' personal needs account. The facility's policy required them to act as a fiduciary for the residents' funds, safeguarding and managing these funds according to established financial management policies. However, the surety bond in place was for $14,000, which was insufficient to cover the account balance that exceeded this amount on multiple occasions from May 2024 to October 2024. During interviews, the business office manager (BOM) acknowledged that the surety bond coverage was increased to $50,000 during the survey, with the bonding company making this increase retroactive to October 1, 2024. The BOM admitted that the need for increased coverage was recognized during the survey, as the balance totals had been greater than $14,000 at times over the past several months. The nursing home administrator (NHA) also confirmed that the facility should have maintained a surety bond covering the total balance in resident personal funds at all times.
Facility Fails to Address Resident Council Food Concerns
Penalty
Summary
The facility failed to provide a response, action, and rationale to residents involved in group grievances, specifically regarding food concerns raised during resident council meetings. The facility's policy requires that all grievances, complaints, or recommendations from resident or family groups concerning issues of resident care be considered and responded to in writing, including a rationale for the response. However, during a group interview with five alert and oriented residents, it was revealed that their concerns about the snacks provided by the facility were not addressed. The residents expressed dissatisfaction with the snacks, preferring different options or bringing their own, and felt that the facility did not provide prompt resolutions to their concerns. The resident council notes from June, July, October, and November 2024 were reviewed, showing that residents had repeatedly raised concerns about the quality and variety of food, including requests for infused water, fresh snacks, more protein at breakfast, and larger portion sizes. Despite these ongoing concerns, there was no documentation indicating that the facility had reviewed or approved the residents' concerns or provided any response or rationale. Interviews with the Nursing Home Administrator (NHA) revealed that the Activities Director (AD) was responsible for coordinating the resident council meetings and communicating concerns to the relevant departments. However, the NHA was unaware that the AD did not follow up with the residents to ensure their concerns were addressed, and there was no documentation of staff responses to the residents' concerns from the June or October meetings.
Deficiency in Food Palatability and Presentation
Penalty
Summary
The facility failed to consistently serve food that was palatable and attractive, as evidenced by multiple resident interviews and surveyor observations. Residents reported that the food was often served cold, with complaints about the taste and texture. One resident mentioned that the eggs were served cold and were terrible, while another stated that the food was not nutritious and did not meet their preferences. Additional complaints included food being undercooked or overcooked, difficulty in cutting and chewing the food, and the food not being fresh. The June and October 2024 resident council meeting notes also highlighted issues with the food being too spicy and the presence of too many processed foods, with no documentation of actions taken to resolve these grievances. Surveyors observed a test tray evaluation, which revealed that the cheese pizza was dry, crunchy, and bland, and the salad lacked variety. Interviews with the dietary manager and corporate dietary director confirmed issues with the pizza's texture and the salad's lack of garnish. The pork chop was reportedly stored in hot water to prevent drying, but residents found it hard to slice. The nursing home administrator was unaware of the residents' dissatisfaction with the food and noted that a performance improvement project was in place, but it did not address the palatability of the food. A food satisfaction survey was conducted, but it did not include questions about the taste, texture, and consistency of the meals served.
Failure to Ensure Appropriate Self-Administration of Medications
Penalty
Summary
The facility failed to ensure the self-administration of medications was clinically appropriate for two residents. Resident #4, who was cognitively intact with a BIMS score of 14 out of 15, was found with tubes of lidocaine on the bedside table and nearby rack, despite no physician's orders or assessments indicating the resident was able to self-administer medications. The care plan did not reveal any desire from the resident to self-administer medications. Similarly, Resident #60, also cognitively intact with a BIMS score of 14 out of 15, had several medications left on the bedside table during a medication pass, without any physician's orders or assessments for self-administration. The care plan for this resident also did not indicate a desire to self-administer medications. Interviews with the DON and RN #1 revealed that the facility did not assess or allow any residents to self-administer medications. The DON emphasized the importance of nursing staff observing residents as they took their medications to ensure proper administration. RN #1 reiterated that medications should not be left at the bedside, as they could be misused, discarded, or taken by other residents. The facility's policy on medication storage also required drugs to be stored in locked compartments, accessible only to authorized personnel.
Failure to Implement PASRR Level II Recommendations
Penalty
Summary
The facility failed to incorporate the recommendations from the Preadmission Screening and Resident Review (PASRR) Level II determination into the care planning and transition of care for a resident. The resident, who was over 65 years old and had diagnoses including renal insufficiency, dementia, anxiety disorder, depression, and bipolar disorder, was admitted with a PASRR Level II evaluation that recommended services such as individual therapy by a qualified community mental health professional. However, the facility did not include these recommendations in the resident's care plan, nor did they document any efforts to request or establish the recommended services. The facility's comprehensive care plan and electronic medical records did not reflect the PASRR Level II recommendations, and there was no physician's order for psychotherapy, despite the resident being prescribed medications for depression, anxiety, and psychosis. Interviews with the Social Services Director (SSD) and the Director of Nursing (DON) revealed that the facility had not conducted a thorough audit to identify residents with PASRR Level II recommendations, and the SSD acknowledged gaps in the program. The SSD, who had been in the position for only a month, was in the process of auditing all residents' PASRRs to ensure compliance with recommendations.
Failure to Provide Individualized Activities for End-of-Life Resident
Penalty
Summary
The facility failed to provide individualized activities for a resident at the end of life, who was identified as having severe cognitive impairments and was dependent on staff for activities of daily living. The resident's preferences, which included listening to music, being around animals, and keeping up with the news, were not incorporated into her care plan. Observations revealed that the resident's room lacked personalization and comforting activities, with no music or personal belongings present, except for a small stuffed animal. Staff interviews indicated a lack of awareness and implementation of the resident's preferences, with the CNA and LPN unaware of the resident's activity preferences and the AD lacking supplies to play music. The resident's representative confirmed that the resident was receiving hospice care and required comfort measures. Despite the facility's policy to provide a homelike environment and activities based on resident preferences, the care plan did not reflect the resident's identified preferences. The DON acknowledged the room's lack of personalization, and the RCR emphasized the expectation for staff to initiate care based on resident preferences. The AD admitted to not having training on the needs of hospice residents and only implemented a more homelike atmosphere during the survey, after reading about hospice care needs.
Inconsistent Restorative Nursing Program Leads to Deficiency
Penalty
Summary
The facility failed to provide appropriate treatment and services to a resident with limited mobility to maintain or improve their range of motion (ROM). Specifically, the facility did not establish a consistent restorative nursing program, which resulted in the resident not receiving the prescribed ROM therapy. The resident, who was cognitively intact and had diagnoses including heart disease, chronic respiratory failure, and muscle weakness, reported not receiving the daily ROM therapy as ordered, leading to feelings of weakness and loss of strength. The facility's lack of a restorative nursing program was confirmed through staff interviews. The physical therapist noted that the program had not been in place since October 2024, and efforts to train staff were only recently initiated. The nursing home administrator claimed a program existed, but the therapy consultant and other staff indicated otherwise, with training for restorative services only beginning shortly before the survey. The resident's records showed they received restorative services on only six days out of the past 30, highlighting the inconsistency in care delivery.
Failure to Properly Explain Binding Arbitration Agreements
Penalty
Summary
The facility failed to ensure that the binding arbitration agreement was thoroughly and accurately explained to two residents before they signed the agreement. The facility's policy requires that the terms and conditions of the agreement be explained in a manner that ensures understanding, taking into account the resident's language, literacy, and cognitive ability. However, the marketing coordinator, who was responsible for explaining the agreement, did not have a clinical background and assumed residents understood the legal terminology if they did not ask questions. There was no formal process to document the explanation or the residents' understanding. Resident #60, who was admitted with chronic respiratory failure, diabetes, and altered mental status, was found to be cognitively intact with a BIMS score of 13 out of 15. Despite this, the resident did not recall signing the arbitration agreement and later stated that the signature on the document was not his. The resident was under the influence of medications at the time of admission, which could have affected his cognitive capacity to understand the legal document. Resident #63, diagnosed with frontotemporal neurocognitive disorder, bipolar disorder, major depressive disorder, and anxiety disorder, had a BIMS score of 10 out of 15, indicating moderate cognitive impairment. This resident also did not recall signing the arbitration agreement and did not understand what it entailed. The primary care provider noted that understanding legal terminology requires a different level of cognition than making daily decisions, and individuals with cognitive impairments may not fully grasp such agreements.
Improper Discharge Planning and Family Notification
Penalty
Summary
The facility failed to develop and implement an effective discharge plan for a resident, leading to a deficiency in the discharge process. The resident, who had severe cognitive impairment and was at risk of wandering, was transferred to another skilled nursing facility without proper notification or involvement of the family. The facility's policy required a discharge summary and post-discharge plan to be developed with the assistance of the resident and their family, but this was not followed in this case. The resident's family was first approached by a social worker about the possibility of transferring the resident to a facility with a secured unit due to concerns about wandering. The family expressed a desire to tour potential facilities before making a decision. However, just two days after this initial conversation, the family was informed that the resident had already been transferred to a new facility without their prior knowledge or consent. This abrupt transfer caused distress to the family, who were not given the opportunity to choose a suitable facility or prepare for the move. Interviews with facility staff revealed that there was a breakdown in communication and process regarding the resident's discharge. The Director of Nursing and corporate consultant acknowledged that the discharge was not handled correctly, and the family was not provided with options or informed about the transfer in advance. The social services assistant admitted to miscommunication and a lack of proper discharge planning, resulting in the resident being moved without a discharge care plan or summary being completed.
Failure to Prevent Resident Elopement and Ensure Safety
Penalty
Summary
The facility failed to provide an environment free of accident hazards and did not ensure adequate supervision and assistance devices to prevent accidents for nine residents. Two residents with known exit-seeking behaviors eloped from the facility without the staff's knowledge. Both residents had physician orders for wander-prevention devices, but one was not wearing the device at the time of the elopement. The front door, equipped with a wander-prevention system, failed to lock or alarm, allowing the residents to leave the building. One resident fell and sustained a fractured hip, while the other was returned to the facility without injury. The facility did not have a plan to monitor the front door 24 hours a day, and the wander-prevention devices were not routinely checked for functionality. The facility's response to the elopement incident was inadequate. The receptionist was assigned to monitor the front door during the day, but there was no plan for monitoring the door after hours. Observations revealed that the front door did not alarm or lock when approached with a wander-prevention device, and the door took approximately two minutes to close once opened. Additionally, several residents with orders for wander-prevention devices did not have their devices checked for functionality each shift, and one resident assessed for a wander-prevention device did not have an order for its use. The facility's elopement policy did not include procedures to prevent elopement, and staff training on elopement prevention was insufficient. The facility's investigation into the elopement incident identified several contributing factors, including the absence of a receptionist at the front desk, residents leaving group activities without an escort, and the malfunctioning wander-prevention system. Despite these findings, the facility did not implement a comprehensive and effective plan to prevent future elopements. Interviews with staff revealed a lack of awareness of residents at risk for wandering and insufficient training on elopement prevention. The facility's failure to address these issues created a situation of immediate jeopardy for serious harm to the residents.
Removal Plan
- The Elopement and wandering policy was reviewed/revised by the director of nursing (DON) or Designee to ensure the facility is following policy.
- The DON or designee educated staff on the policy for Wandering, Elopement and Resident safety.
- The DON or designee educated staff on a new Elopement prevention policy.
- Staff not educated, including agency staff, will be educated by the NHA or designee before their next shift.
- Resident #2 was discharged from the facility and admitted to another facility.
- The NHA or Designee called the door company that services the wander guard system. They came out to adjust doors.
- A staff member has been stationed at the door until the door can be adjusted to function properly.
- The NHA will verify the door is working properly by checking the door with a wander-prevention device prior to discontinuing the front desk person monitoring the door.
- The elopement management binder, which includes pictures of residents with elopement risks, will be available at the front desk.
- All residents were reevaluated for elopement risk utilizing the elopement risk assessment form or evaluation in electronic record.
- Residents determined to require a wander guard have a consent, care plan, orders were updated to include placement of device monitoring every shift for function and placement.
- The DON or designee audited the elopement risk evaluations to match the care plans.
- The facility revised its pre-admission screening intake form to include a question about history and frequency of wandering and elopement.
- The DON or designee will audit new admissions for elopement risk and ensure appropriate interventions are in place by the next business day.
- The licensed nurses will be educated to implement elopement interventions if a resident was assessed at risk for elopement on admission.
- New hires will receive education on wandering and prevention, wander guards, elopement procedure, and resident safety on day one of employment.
- The facility revised the Elopement policy to include prevention of elopement.
- Facility staff were educated on the new policy.
- A Quality Assurance Performance Improvement (QAPI) Performance Improvement Project (PIP) was implemented to review and interpret all audit findings.
- The QAPI committee reviewed the elopement, policies and procedures and reviewed interventions that can be used for residents attempting to elope.
Failure to Protect Residents from Physical Abuse
Penalty
Summary
The facility failed to protect four residents from physical abuse by two other residents with known aggressive behaviors. Resident #6, who had a history of aggression and multiple mental health diagnoses, was involved in several altercations with other residents, including an incident where Resident #3 sustained head trauma requiring twelve staples. Despite being aware of Resident #6's tendency to wander into other residents' rooms and take their belongings, the facility did not implement an effective plan to monitor and redirect her behavior, leading to repeated incidents of physical abuse. Additionally, the facility did not take adequate measures to prevent physical abuse by Resident #14, who also had a history of aggressive behavior. Resident #14 pushed and hit Resident #15 after an accidental collision, but the facility failed to update care plans or notify appropriate agencies about the incident. The lack of staff training in mental health and dementia care further exacerbated the situation, as staff were not adequately prepared to handle residents with aggressive behaviors. The facility's investigations into these incidents were incomplete and lacked thorough documentation. There were no comprehensive resident or staff interviews, and the facility failed to notify the police, ombudsman, or State Agency about the incidents. This lack of proper reporting and investigation highlights significant deficiencies in the facility's ability to protect residents from abuse and ensure their safety.
Failure to Provide Effective Pain Management
Penalty
Summary
The facility failed to provide an effective pain management regimen for two residents with chronic pain, leading to increased pain levels and affecting their daily activities and sleep. Resident #17, who had a diagnosis of septic right knee, lumbar abscess, and chronic pain syndrome, reported not receiving her prescribed pain medication, Norco, consistently. Despite documentation indicating administration, the narcotic count sheet revealed missed doses, and the resident's pain levels were inaccurately recorded as zero. This inconsistency in medication administration and documentation resulted in the resident experiencing pain levels of 6 to 8 out of 10, affecting her sleep and mobility. Similarly, Resident #8, diagnosed with osteoarthritis and chronic pain, reported not receiving his prescribed pain medications, including Oxycodone and Neurontin, on several occasions. The resident's pain levels were frequently documented as zero, despite his report that his pain never went below a 4 out of 10. The facility's records showed multiple instances where the medications were not available and not administered, with no documented follow-up actions to obtain the medications or notify the physician for further orders. This led to the resident experiencing increased pain levels of 8 out of 10, affecting his sleep and mobility. The Director of Nursing (DON) acknowledged the discrepancies in medication administration and documentation for both residents. The DON confirmed that the pain medications were not consistently administered as ordered and that the facility had an emergency medication system that was not utilized. The DON also noted the lack of parameters for PRN pain medications and the need for comprehensive pain assessments. The facility's failure to ensure accurate pain assessments and consistent administration of pain medications resulted in both residents experiencing increased pain and a decline in their quality of life.
Failure to Ensure Proper Sanitization in Main Kitchen
Penalty
Summary
The facility failed to ensure food items were stored and served under sanitary conditions in the main kitchen. Specifically, the staff did not correctly and accurately test for the correct parts per million (ppm) of the chemical sanitizer used to clean equipment and surfaces where food was prepared. During an observation, two red tubs of quat (benzalkonium chloride) solution were found in the main kitchen, and the dietary director (DD) indicated that the solution should register 200 ppm. However, when tested, the solution did not register on the strip and remained at 0 ppm. The DD attempted to retest the solution multiple times with new test strips, but the results continued to show 0 ppm. The DD then contacted the company that installed the machine dispensing the quat solution to inspect the machine. The DD later discovered that the facility had been using the wrong test strips to test the solution. The correct test strips were obtained, and the quat solution then tested at 200 ppm. The test logs for February 2024 documented that the quat solution tested at 200 ppm each shift, but the DD acknowledged that these logs could not be accurate given the facility had been using the wrong test strips. The DD stated that she would educate the dietary staff on how to test the quat solution. The duration for which the facility had been using the wrong test strips was unknown.
Failure to Administer Resources Effectively and Ensure Resident Safety
Penalty
Summary
The facility failed to effectively administer its resources to ensure the highest practicable wellbeing for each resident. Specifically, the facility did not implement and maintain safety measures to prevent elopements, resulting in significant injury. Additionally, the facility failed to prevent, report, and investigate allegations of resident-to-resident abuse. There were multiple instances where residents were not protected from physical abuse, and allegations of abuse were not reported or investigated as required. For example, one resident was found with a blanket held around her head by another resident, and another resident was pushed down, resulting in head trauma and stitches. These incidents were not reported to the police, and staff were instructed to document the abuse as falls by the Director of Nursing (DON). The facility also failed to provide sufficient leadership to address and avoid multiple significant concerns, including the lack of follow-up on missed medications and abuse reports, and the intimidation of staff and residents who reported issues. The facility also failed to ensure residents were free from significant medication errors and did not implement an effective pain management program. Several residents reported missing multiple doses of their medications, including pain medications, and there was no follow-up from the administration. The facility admitted a large number of residents with mental health and substance abuse diagnoses but did not provide the necessary training for staff to handle these residents' behaviors. This lack of training and support led to inappropriate roommate pairings and increased incidents of abuse and neglect. Interviews with staff and residents revealed a culture of fear and intimidation, with staff being threatened with retaliation if they spoke to state surveyors. The Nursing Home Administrator (NHA) and DON were reported to dismiss concerns and not follow up on reported issues. The facility's quality assurance and performance improvement systems were ineffective, failing to conduct structured investigations and analyses of underlying causes of problems affecting quality of care, quality of life, and resident safety. The facility's administration did not adequately address the influx of residents with mental health issues, the need for smoking assessments and assistive devices, and the thorough investigation and reporting of abuse incidents.
Incomplete Facility-Wide Assessment
Penalty
Summary
The facility failed to conduct and document a comprehensive facility-wide assessment to determine the necessary resources for competent resident care during both day-to-day operations and emergencies. The assessment, last reviewed on 3/1/24, was found to be incomplete and missing several critical components. Specifically, it did not include staff competencies, training programs for new and existing staff, or information on the facility's wander prevention system. Additionally, the assessment lacked a facility or community risk assessment using an all-hazards risk approach, a description of the infection prevention and control program, a list of contracts, recruitment and retention strategies for medical practitioners, technology resources, and considerations for ethnic, cultural, or religious needs of the residents. During an interview, the Nursing Home Administrator (NHA) acknowledged that the facility assessment had many missing components and had not been fully completed on the template used. The NHA admitted that the assessment did not cover necessary trainings or competencies for different staff members, details on the facility's wander prevention system, or a facility map for emergency preparedness. The NHA was unaware that all these items needed to be included in the facility assessment, indicating a significant oversight in the facility's preparedness and resource planning processes.
Failure to Implement Effective Quality Assurance Program
Penalty
Summary
The facility failed to ensure an effective quality assurance program to identify and address compliance concerns, impacting the quality of life, quality of care, and resident safety. The QAPI program committee did not adequately identify and address issues such as resident safety with accident hazards, timely smoking assessments, and the provision of smoking assistive devices. Additionally, the facility did not secure chemicals and used razors safely, leading to immediate jeopardy situations and actual harm to residents. The facility also failed to manage residents' pain effectively, prevent abuse, and report allegations of abuse to the appropriate authorities. Furthermore, the facility did not ensure thorough investigations of abuse allegations and failed to prevent significant medication errors. The administration did not provide adequate follow-up actions, and the facility assessment was incomplete, failing to determine necessary resources for resident care during day-to-day operations and emergencies. Staff training was also insufficient, particularly in dementia care, substance abuse, and mental health, and nurse aides did not receive the required 12 hours of annual education. The QAPI policy was requested but not provided by the end of the survey. The facility had repeat deficiencies in several areas, including accident hazards, pain management, facility assessment, administration, and QAPI. Interviews with the NHA, DON, and MD revealed that the QAPI committee did not discuss or address critical issues in enough detail to identify and correct them. The NHA was unaware of several deficiencies, including the lack of timely smoking assessments, missed medications, and unavailability of medications. The MD was not informed about the facility accepting residents who smoked, multiple abuse allegations, and issues with obtaining medications timely. The MD also noted that the facility had not conducted training on substance abuse or dementia care despite the increased admission of residents with those diagnoses.
Failure to Provide Required Staff Training
Penalty
Summary
The facility failed to develop, implement, and maintain an effective training program for all staff based on the facility assessment and resident population. Specifically, the facility did not ensure that all direct and non-direct care staff received training in dementia care, substance abuse, and behavior management. The facility's In-Service Training Policy, revised in August 2022, required training in behavioral health and dementia management, with additional training in substance abuse as necessary based on the facility assessment. However, the regional director of clinical services (RDCS) was unable to provide documentation indicating that such training had been provided to the staff. Interviews with a frequent visitor, the social services director (SSD), and a restorative nurse aide (RNA) revealed that there had been an increase in admissions of residents with mental health diagnoses, behaviors, and substance abuse issues. Despite this, no training on mental health care, behavior management, or substance abuse had been offered to the staff. The facility assessment, last reviewed during the survey, did not identify substance abuse as part of the resident population served, despite multiple residents with known current or history of substance abuse. This lack of training and inaccurate facility assessment contributed to the deficiency identified by the surveyors.
Failure to Implement Non-Retaliation Policies for Abuse Reporting
Penalty
Summary
The facility failed to develop and implement written policies and procedures that prohibit and prevent retaliation for abuse reporting. Specifically, the facility did not post a conspicuous notice of employee rights, including the right of staff to be free from retaliation for reporting abuse. Additionally, the facility's abuse policy did not include protection for employees against retaliation for reporting abuse or neglect. This deficiency was identified through observations, record reviews, and staff interviews conducted by surveyors. During the survey, it was observed that there was no signage in the facility regarding employees' right to non-retaliation. The facility's Abuse and Neglect policy, revised in March 2018, was reviewed and found to lack any mention of retaliation protection. Interviews with the Director of Nursing (DON) and a Certified Nurse Aide (CNA) revealed that they were unaware of any posted notice indicating the facility's stance against retaliation for reporting abuse. The DON acknowledged that such a notice should have been posted, and the CNA confirmed that she had never seen any signage notifying staff of their right to be free from retaliation for reporting abuse.
Failure to Report Alleged Abuse Incidents
Penalty
Summary
The facility failed to report alleged violations of potential abuse to the proper authority in accordance with State law for eight residents. Specifically, the facility did not report an allegation of verbal abuse by one resident to another, nor did it report multiple allegations of physical abuse involving several residents. These incidents were not communicated to the nursing home administrator (NHA), director of nursing (DON), local police, or the State Agency as required by the facility's policy and state regulations. In one instance, a resident threatened another resident at the nurse's station, but the incident was not documented or reported. The NHA confirmed that the nurse involved did not report the threats as verbal abuse. In another case, a resident with a history of traumatic brain injury and other severe conditions physically assaulted another resident by holding a blanket around their face. This incident was also not reported to the appropriate authorities. Additional incidents included physical altercations between residents, such as one resident pushing another and causing a laceration, and another resident taking a cane and pulling hair. Despite these events being documented in nursing progress notes and facility investigations, there was no evidence that the State Agency or police were notified. The NHA and DON were unable to recall if these incidents were reported, and a review of the State Agency system confirmed no reports were submitted for these abuse incidents.
Failure to Investigate Potential Abuse Incidents
Penalty
Summary
The facility failed to ensure incidents of potential abuse were thoroughly investigated for three residents. Specifically, the facility did not thoroughly investigate a known physical abuse incident between two residents. Resident #6 repeatedly entered Resident #18's room, took his cane, and was subsequently involved in a physical altercation where Resident #18 pulled Resident #6's hair. The facility's investigation was incomplete, lacking sufficient resident and staff interviews, and did not adequately document non-verbal observations as claimed by the NHA. Additionally, the facility failed to investigate reports of physical abuse by Resident #6 towards Resident #7. Resident #6 was reported to have held a blanket around Resident #7's face, but there were no progress notes or an investigation file for this incident. The DON was not present during the incident and was unable to provide an investigation file, stating that the NHA, who was present, did not conduct an investigation or report the incident to the police and the State Agency. The facility's failure to conduct thorough investigations into these incidents of potential abuse highlights significant lapses in following their own Abuse and Neglect policy. The lack of proper documentation, resident and staff interviews, and timely reporting to appropriate authorities contributed to the deficiency in ensuring resident safety and compliance with regulatory standards.
Failure to Ensure Residents Were Free from Significant Medication Errors
Penalty
Summary
The facility failed to ensure that residents were free from significant medication errors, specifically errors of omission, for five residents. These residents did not receive all their prescribed medications due to the medications being unavailable or on order from the pharmacy. The facility's policy required immediate action when medications were unavailable, including notifying the physician and obtaining alternative treatment orders, but this was not consistently followed. For example, Resident #8 frequently did not receive medications such as clonazepam and oxycodone, and there was no documentation that the provider was notified for further orders when medications were unavailable. Similar issues were observed for Residents #9, #3, #17, and #21, with multiple instances of medications not being administered due to unavailability and lack of provider notification for alternative orders. Resident #8, who was cognitively intact, reported not receiving medications like clonazepam and oxycodone, which were documented as not given on multiple occasions due to being on order. Resident #9, with mild cognitive impairment, also had multiple medications not administered, including potassium chloride and Lasix, due to unavailability. Resident #3, with severe cognitive impairment, missed doses of medications like Ingrezza and Atenolol for similar reasons. Resident #17, who was cognitively intact, reported not always receiving medications such as Norco, and the narcotic count sheet revealed discrepancies in administration records. Resident #21, with severe cognitive impairment, also had multiple medications not given due to being on order. Staff interviews revealed that there were ongoing issues with the pharmacy not providing timely refills and not notifying the facility when medications could not be refilled. Licensed Practical Nurses (LPNs) reported borrowing medications from other residents and expressed concerns to the pharmacy consultant without resolution. The Director of Nursing (DON) was unaware of the medication availability issues and stated that nurses should call her, the pharmacy, and the provider if medications were not available. The resident council minutes also documented concerns about missing medications, but there was no follow-up on these concerns.
Failure to Provide Required Annual Training for CNAs
Penalty
Summary
The facility failed to ensure that certified nurse aides (CNAs) received the required 12 hours of annual training based on their performance evaluations and facility assessment. Specifically, CNAs #2, #3, #4, #5, and #6 did not receive the mandated training. The facility's policy, revised in August 2022, mandates regular in-service education for all staff, covering topics such as effective communication, resident rights, abuse prevention, infection control, behavioral health, and compliance. However, the training documentation provided did not include the length of abuse training, and additional annual training records were not available for the CNAs mentioned. During interviews, the regional director of clinical services (RDCS #1) confirmed the lack of documentation for the required 12 hours of annual training for the five CNAs. She also mentioned that the facility had undergone new ownership, and annual evaluations had not been conducted for the CNAs. Furthermore, she was unable to obtain the necessary training records from the previous owner. The new company plans to start tracking the CNAs' education moving forward.
Failure to Honor Resident's Right to Refuse Treatment
Penalty
Summary
The facility failed to honor Resident #14's right to refuse treatment, specifically by administering medications without his knowledge and against his wishes. Resident #14, a 77-year-old with a history of aphasia, diabetes, pulmonary embolism, paranoid personality disorder, and dementia, was observed to have medications mixed into his food and beverages without his consent. Despite the resident's increased paranoia and aggression when given pills, the facility continued to disguise medications in his drinks, leading to his refusal to eat and drink once he became suspicious of the practice. The facility's policy on administering medications requires that any refusal or withholding of drugs be documented, but this was not adhered to in Resident #14's case. The resident's care plan included mixing medications into his food due to his paranoia and aggression, but this was done without his knowledge or consent. Multiple notes from physicians and nursing staff indicated that the resident was refusing medications and food once he realized they were being hidden in his drinks, leading to a significant decrease in his meal intake. Interviews with staff, including the LPN, DON, and the nursing home administrator, confirmed that they were aware of the practice of disguising medications and that it was done with the consent of the resident's guardian. However, the facility failed to inform the resident of his right to refuse treatment, and the guardian was not made aware of this right either. The practice continued despite the resident's clear refusal and the negative impact on his trust and willingness to eat and drink.
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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