Citations in Colorado
Comprehensive analysis of citations, statistics, and compliance trends for long-term care facilities in Colorado.
Statistics for Colorado (Last 12 Months)
Financial Impact (Last 12 Months)
Some of the Latest Corrective Actions taken by Facilities in Colorado
- Provided continuous meal-time supervision for the cognitively impaired resident to ensure safe consumption and reduce choking risk (J - F0689 - CO)
- Implemented ongoing safety checks with behavior-log documentation and timely care-plan updates to adjust interventions whenever the resident’s condition changes (J - F0689 - CO)
Failure to Supervise Cognitively Impaired Resident During Meals Leads to Choking Risk
Penalty
Summary
A deficiency occurred when staff failed to provide a safe environment free from accident hazards for a resident with severe cognitive impairment and a history of choking. The resident, who was prescribed a mechanically altered diet and required staff assistance and supervision during meals, was observed eating independently without supervision on multiple occasions. During these times, the resident was able to take large bites, eat inappropriate foods, and take food from other residents' plates, all without staff intervention. The resident's care plan specifically directed staff to assist with controlling the rate of eating, monitor bite sizes, and prevent the resident from stuffing food into his mouth. Despite these interventions being documented, staff did not consistently implement them. Observations showed that the resident was served food items not consistent with the prescribed diet and was not monitored to prevent access to other residents' food. Staff were also observed delivering food and then leaving the resident unsupervised, failing to ensure safe eating practices. Interviews with staff confirmed that the resident had a known tendency to grab food from others and put inappropriate items in his mouth, and that supervision was required during meals. However, staff were not always aware of previous choking incidents, and meal observations confirmed that the required supervision and care-planned interventions were not provided. This lack of supervision and failure to follow the care plan placed the resident at continued risk for further choking incidents.
Removal Plan
- Serve R77 food per the physician's ordered diet of a mechanical soft diet.
- The Certified Nurse Aide (CNA) and/or nurse will provide R77 with supervision during intake to ensure he is eating safely.
- Place R77 on safety checks due to his behavior of taking other residents' food that is not within his prescribed diet texture.
- Address any additional safety concerns or behaviors, document in the behavior log, and update the care plan with appropriate interventions.
- Review and update the care plan and interventions with every change of condition.
Latest Citations in Colorado
Several residents reported that the menu was too repetitive, with frequent servings of chicken, pork, and mixed vegetables. Review of four weeks of menus confirmed repeated use of the same food items, and staff interviews revealed challenges with food deliveries and lack of clear alternate menu options, resulting in limited variety and unmet resident preferences.
The facility did not conduct a thorough investigation after an incident where one resident threw coffee at another during a dining activity. Despite staff statements indicating the coffee was directed at the other resident, the investigation did not include interviews with all key witnesses, such as an LPN and a pulmonary program coordinator who observed the event. The investigation also failed to document all relevant details and did not follow the facility's abuse policy, resulting in an incomplete assessment of the incident involving two cognitively impaired residents.
Two residents experienced a lack of privacy and dignity during care, with staff entering rooms without knocking or identifying themselves and leaving doors open during personal care. Both residents also faced significant delays in call light response, with documented waits exceeding 20 to 60 minutes and, in some cases, over an hour. Staff interviews confirmed inconsistent practices regarding privacy and call light response, and there was no immediate plan to address these issues.
A facility failed to document and resolve grievances submitted by a resident's representative, including concerns about staff communication and improper wheelchair positioning. Grievance forms lacked documentation of actions taken or communication with the representative, and staff had not been trained on proper positioning. Updated forms were later signed by the resident, but there was no evidence the representative was notified or approved the resolutions.
A resident with multiple diagnoses and limited ROM did not receive appropriate contracture management due to the facility's failure to implement and document a physician's order for a foot drop boot. The care plan lacked documentation for the boot, the order was not scheduled in the MAR/TAR, and staff did not consistently apply the device, resulting in missed preventive measures for the resident's right foot.
A resident who was cognitively intact and required assistance with daily activities did not receive timely dental services to address ill-fitting dentures and exposed dental implants. Although a dental provider recommended referral to a specialty clinic for implant removal and new dentures, there was no documented follow-up or communication to ensure the resident received the necessary care.
Two residents receiving hospice care did not have consistent documentation of hospice provider visits or communication between facility and hospice staff, resulting in missing records of care and unresolved equipment needs. Staff interviews revealed inconsistent practices for documenting hospice visits and challenges in accessing hospice notes, leading to gaps in the residents' medical records.
Housekeeping staff did not follow proper infection control procedures, including failing to disinfect all high-touch areas, not using separate rags for each resident area in double occupancy rooms, and not performing hand hygiene with glove changes. Supervisory staff confirmed these lapses, and the facility's policy requiring these practices was not followed.
A nurse unfamiliar with the unit administered medications intended for another resident to a patient with dementia, epilepsy, and dysphagia, after failing to verify the patient's identity due to missing photo identification in the EMR and absent door nameplate. The patient experienced severe hypotension and required hospitalization. The error was attributed to multiple system failures, including lack of proper resident identification and non-adherence to medication administration protocols.
The facility failed to ensure proper hand hygiene among dietary staff during meal service, with staff observed handling food and meal trays after touching their face and nose without washing hands. Additionally, multiple food items in the kitchen were found unlabeled, undated, or past their use-by dates, contrary to facility policy and food safety regulations.
Failure to Provide Varied and Well-Balanced Diet
Penalty
Summary
The facility failed to provide residents with a nourishing, palatable, and well-balanced diet that met their daily nutritional and special dietary needs, as well as their preferences. Multiple residents reported that the menu was too repetitive, with frequent servings of chicken, pork, and various vegetable blends. Residents expressed dissatisfaction with the lack of variety, particularly in the vegetables offered, noting that mixed vegetables and similar blends appeared on the menu multiple times each week. A review of four weeks of facility menus confirmed the repetition of certain food items, especially chicken, pork, potatoes, rice, and various vegetable blends. Staff interviews revealed that the dietary manager had identified menu variety and food quality as areas needing improvement. The dietary manager also reported challenges with food deliveries, which sometimes prevented her from providing a greater variety of vegetables. Additionally, while residents could request alternate menu items, these options were not clearly listed on the alternate menu, and there was confusion among staff regarding how residents were informed about specific vegetables being served.
Failure to Thoroughly Investigate Alleged Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate an allegation of physical abuse involving two residents. According to the facility's policy, an immediate and comprehensive investigation is required when abuse is suspected or reported, including identifying and interviewing all involved parties and witnesses, and documenting the process. In this incident, one resident with a history of combative behavior threw a cup of coffee in the direction of another resident during a dining room activity. The resident who threw the coffee was immediately removed and placed under one-to-one supervision, and both residents were assessed for harm. The investigation conducted by the facility did not include all relevant witness interviews or documentation. Specifically, the investigation failed to document that the coffee was thrown directly at the other resident, despite statements from staff indicating this occurred. Key witnesses, including an LPN and the pulmonary program coordinator who observed the incident, were not interviewed or their statements were not included in the investigation file. Additionally, staff who were interviewed as part of the investigation were not present during the incident, and the investigation did not capture all available information about the event. The residents involved had significant cognitive impairments and required supervision for activities of daily living. The resident who was the alleged victim was monitored after the incident and showed no signs of pain or discomfort. The facility's documentation and investigation process did not align with its own abuse policy, as it did not ensure all relevant staff were interviewed or that all evidence was collected and documented. The nursing home administrator acknowledged that the investigation was incomplete and that the incident was not clearly identified as abuse versus a behavioral issue.
Failure to Ensure Resident Dignity and Timely Call Light Response
Penalty
Summary
The facility failed to ensure the right to a dignified existence and timely response to call lights for two residents. One resident, a 65-year-old with multiple neurodegenerative conditions and cognitive intactness, was observed without privacy during care, with staff entering his room without knocking or identifying themselves, and leaving his door open during personal care. The resident reported feeling disrespected, with staff speaking to him in an aggressive manner and not waiting for his responses, and his representative confirmed repeated instances of lack of privacy and long waits for assistance. Documentation showed that the call light was inaccessible at times and that response times exceeded 20 minutes in 39.3% of calls, and over 60 minutes in another 39.3% of calls, with one instance where the call light was not answered for over an hour and a half. Another resident, who was dependent on staff for all activities of daily living due to multiple sclerosis and other impairments, also experienced significant delays in call light response. The resident reported feeling that using the call light was pointless due to long wait times, sometimes resulting in being left soiled. The call light system data indicated that staff response time exceeded 30 minutes in 24.4% of calls, with some waits as long as 266 minutes. The resident's representative corroborated these concerns, stating that the resident would call her for help when staff did not respond, and that she had to contact the facility herself to request assistance for the resident. Staff interviews revealed inconsistent practices regarding privacy and call light response. Some CNAs stated they closed doors and provided privacy, while others did not consistently follow these procedures. Staff acknowledged that answering call lights promptly was challenging during certain times, such as meals or shift changes, and that there was a lack of clear direction or support for managing high call light volumes. The DON confirmed that everyone was responsible for answering call lights, but also noted that review of call light response times was not consistently performed, and there was no immediate plan to address the delays.
Failure to Document and Resolve Resident Grievances
Penalty
Summary
The facility failed to maintain a system for documenting grievances and demonstrating prompt actions to resolve them, as required by its own grievance policy. The policy stated that residents or their representatives must be informed of the findings of any grievance investigation and corrective actions within ten working days. However, for one resident, the facility did not document the steps taken to address or resolve grievances submitted by the resident's representative, nor did it show evidence of communication with the representative regarding the outcomes. The resident's representative reported filing several grievances, including concerns about staff communication and the resident's head support in her wheelchair. She stated that she was not informed of any resolutions and was unaware of who was responsible for handling grievances at the facility. Observations confirmed that the resident was poorly positioned in her wheelchair, and staff interviews revealed that the head support was not included in the care plan or Kardex, and staff had not been trained on proper positioning after the grievance was filed. A review of the grievance forms showed that while the concerns were documented, the sections for actions taken and follow-up were left blank. There was no documentation of outreach to the resident's representative or resolution of the grievances. Although updated forms were later provided with signatures and notes indicating resolution, these were signed by the resident rather than the representative who submitted the grievances, and there was no evidence that the representative was notified or approved the resolutions.
Failure to Provide and Document Ordered Foot Drop Boot for Resident with Limited ROM
Penalty
Summary
The facility failed to ensure that a resident with limited range of motion (ROM) received appropriate treatment and services as required by facility policy and physician orders. The resident, who had multiple diagnoses including multiple sclerosis, peripheral vascular disease, and contractures, was dependent on staff for activities of daily living and had documented impairments in both upper and lower extremities. Although the care plan included restorative nursing interventions such as passive ROM and splint or brace assistance, it did not document the use of a foot drop boot for the right lower extremity, despite a physician's order for its use. Observations revealed that the resident had two soft heel boots in her room but was not wearing them, stating that only two staff members knew how to apply them correctly and that improper application by others caused her pain. On multiple occasions, the resident was observed in her wheelchair with only socks on her feet, and the boots remained unused on a chair. When offered the boot by the DON, the resident declined and instead accepted a pillow under her feet for comfort. Record review showed that the physician's order for the foot drop boot was not scheduled with a frequency, resulting in its omission from the MAR and TAR, and there was no documentation of administration or refusal of the boot in the EMR. Staff interviews confirmed that the order was not scheduled and therefore not tracked for administration, and that staff relied on the care plan and physician orders for restorative services. The lack of documentation and implementation of the physician's order for the foot drop boot constituted a failure to provide necessary preventive measures for the resident's right foot.
Failure to Arrange Timely Dental Services for Resident Needing Denture Replacement
Penalty
Summary
The facility failed to ensure timely dental services for one resident who required removal of permanent dental implants in order to be fitted with new lower dentures. The resident, who was cognitively intact and required assistance with daily activities, reported that her lower snap-in dentures did not fit properly and that her upper dentures were loose, making it difficult for her to chew. Observations confirmed that the resident had two screws implanted in her lower gums and had to frequently adjust her upper dentures. The care plan documented the resident as edentulous and included general interventions for dental care, but did not include any follow-up or plan to address the issues with her lower dentures or to replace the snap-in dentures. A dental provider's progress note indicated that the resident's upper and lower dentures were several years old, that she no longer wore the lower denture due to discomfort from exposed dental implants, and that she wanted the implants removed and new dentures made. The plan was to refer her to a specialty dental clinic for implant removal. However, a review of the electronic medical record did not reveal any documentation of communication with the specialty clinic or with the resident's representative to coordinate care for her dentures. Staff interviews confirmed that, although a referral was intended, there was no evidence of timely follow-up or documentation to ensure the resident received the necessary dental services.
Failure to Ensure Communication and Documentation of Hospice Services
Penalty
Summary
The facility failed to ensure that hospice services provided to two residents met professional standards and principles, specifically in the areas of communication and documentation between the facility and the hospice provider. The facility did not establish a consistent process for documenting communication with the hospice agency, nor did it ensure that hospice staff notes were easily accessible to facility staff. For both residents, there was no documentation in the electronic medical record of hospice provider visits over a period of several weeks, despite care plans indicating regular hospice nurse and CNA visits. One resident, under the age of 65 with advanced Huntington's disease and other significant diagnoses, was noted to have severe cognitive impairment and was receiving hospice services. The resident's representative expressed frustration with the lack of communication regarding the replacement of a broken Broda chair, which had been unresolved for several weeks. Although a hospice nurse was observed interacting with the resident's representative, there was no documentation of this visit in the facility's records. Additionally, there was no documentation confirming the delivery of a new chair, despite care plan interventions and interdisciplinary notes indicating hospice was to provide one. Another resident, over the age of 65 with multiple chronic conditions and cognitive impairment, was also receiving hospice services. The care plan called for regular hospice nurse and CNA visits, but the facility's records did not contain documentation of any hospice provider visits for over a month. Staff interviews revealed inconsistent practices regarding hospice staff check-ins and documentation, with hospice staff sometimes unable to access the designated binder for notes and not consistently leaving progress notes. Facility leadership acknowledged that hospice notes were sent every two weeks but were not always available in the residents' electronic medical records, further contributing to the lack of accessible and consistent documentation.
Failure to Maintain Effective Infection Control in Housekeeping Practices
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program on one of two units, as evidenced by improper cleaning and disinfection practices by housekeeping staff. Observations revealed that a housekeeper did not follow correct cleaning techniques, such as failing to disinfect high-touch areas like bed remotes, call lights, and light switches, and not using separate clean rags for each side of a double occupancy room. The housekeeper also cleaned the toilet from bottom to top instead of the required top to bottom (clean to dirty) method, and did not consistently perform hand hygiene after glove removal and before donning new gloves. Interviews with the housekeeper and supervisory staff confirmed gaps in knowledge and practice. The housekeeper was unaware of the need to perform hand hygiene with every glove change and did not identify all required high-touch areas for disinfection. Supervisory staff, including the housekeeping supervisor, infection preventionist, and director of nursing, all acknowledged that the correct procedures were not followed, including the use of separate rags for each resident area, proper cleaning sequence for toilets, and the need for hand hygiene with glove changes. The facility's own policy required cleaning all high-touch personal use items with disinfectant and performing hand hygiene after glove removal, which was not adhered to during the observed cleaning process. These failures in cleaning technique, use of supplies, and hand hygiene contributed to the deficiency in the infection prevention and control program.
Significant Medication Error Due to Resident Misidentification
Penalty
Summary
A significant medication error occurred when a nurse administered medications intended for another resident to an 83-year-old resident with dementia, epilepsy, and dysphagia. The nurse, who was unfamiliar with the unit and the residents, failed to properly identify the resident before administering Lisinopril, Metformin, Seroquel, and Ramelteon—none of which were prescribed for the resident. The nurse did not confirm the resident’s identity using a photo in the electronic medication record (EMR) or a name on the door, as both were missing for this resident. The nurse addressed the resident by another resident’s name, and the resident’s representative did not correct her, leading to the administration of the wrong medications. Following the administration, the resident experienced severe hypotension and tachycardia, requiring transfer to the hospital for intravenous fluids and monitoring. The incident report and subsequent investigation revealed that the nurse realized the error only after returning to the medication cart. The nurse had not worked on the resident’s hall previously and relied on a report sheet that listed the wrong room number. The lack of proper resident identification systems, such as missing photos in the EMR and absent door nameplates, contributed to the error. It was also noted that 17 residents in the facility either did not have a photo in the EMR or a name on their door at the time of the incident. Interviews with staff confirmed that the nurse did not follow the facility’s medication administration policy, which requires verification of the resident’s identity using a photo and adherence to the six rights of medication administration. The nurse had previously made another medication error earlier in the month, which involved administering the wrong dose of a different medication. The facility’s investigation concluded that multiple system failures, including inadequate resident identification and failure to follow established procedures, led to the significant medication error and subsequent hospitalization of the resident.
Failure to Maintain Sanitary Food Handling and Proper Food Labeling
Penalty
Summary
The facility failed to maintain sanitary food handling practices in the main kitchen, specifically regarding employee hand hygiene during meal service. Observations revealed that a dietary aide repeatedly engaged in activities such as blowing his nose, touching his face, and scratching his neck without washing his hands before resuming food handling tasks. These actions included assembling meal trays, handling silverware, placing desserts on trays, and preparing drinks, all without performing required hand hygiene in between tasks. Staff interviews confirmed that hand hygiene training was provided, but the observed practices did not align with facility policy or professional standards. Additionally, the facility did not ensure that food items requiring time and temperature control were properly labeled, dated, or disposed of in a timely manner. During a kitchen inspection, multiple food items in both the walk-in and reach-in refrigerators were found to be unlabeled and undated, including shredded cheese, cheese in a metal pan, green chili past its use-by date, turkey pastrami with an outdated label, buttermilk past its best-by date, and raw chicken breasts. Several containers with different foods were also found without any labeling or dating. Staff interviews indicated that undated food items should be discarded, and that kitchen staff were responsible for checking product dates, but these procedures were not consistently followed. The deficiencies were identified through direct observation and staff interviews, with reference to both state food regulations and the facility's own policies. The issues centered on improper hand hygiene during food service and inadequate labeling and dating of food items, both of which are required for safe food handling and storage.
Explore Popular Searches
