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)
Latest Citations in Colorado
Kitchen staff failed to properly clean food thermometers before and after use, instead using an incorrect method involving alcohol wipes and their packaging, which did not meet professional standards or facility policy. Both the cook and dietary manager demonstrated and confirmed this improper cleaning technique during interviews.
The facility did not procure food from approved or satisfactory sources and failed to store, prepare, distribute, and serve food according to professional standards.
Staff did not follow menu extensions or recipes during meal preparation, resulting in residents receiving incorrect portion sizes and food items. A resident on a pureed diet was served items not specified in the menu, and residents on regular diets received only half of the required sandwich portion. The dietary manager admitted to not using recipes and noted a lack of training among dietary aides regarding proper portion sizes.
Surveyors observed that food and drink served to residents were not palatable, attractive, or at a safe and appetizing temperature, resulting in a deficiency.
Two residents with cognitive and physical impairments were subjected to physical abuse by another resident with a history of behavioral disturbances. In both cases, the assailant resident physically grabbed the victims, with staff intervening immediately. The incidents were substantiated through staff and resident interviews and record review, confirming that the facility did not prevent the abuse as required by policy.
A resident who was unable to perform activities of daily living did not receive the necessary care and assistance from staff, resulting in unmet needs.
A deficiency occurred when a resident did not receive treatment and care in accordance with physician orders and their documented preferences and goals, resulting in care that was not individualized as required.
A deficiency was cited for not ensuring that an area was free from accident hazards and for failing to provide adequate supervision to prevent accidents. The environment did not meet safety standards, and supervision was insufficient to prevent incidents.
The facility did not ensure an area was free from accident hazards and failed to provide adequate supervision to prevent accidents, as observed by surveyors.
A plan to meet a resident's most immediate needs was not created or implemented within 48 hours of admission, as required. Surveyors found no documentation or evidence that this process occurred for a newly admitted resident.
Improper Cleaning of Food Thermometers in Kitchen
Penalty
Summary
The facility failed to ensure that kitchen staff properly cleaned food thermometers before and after use, resulting in a deficiency related to food safety and sanitation. During observation of a lunch meal service, the cook was seen cleaning the thermometer by poking it through the middle of an alcohol wipe and its packaging, then running the wipe and packaging up and down the probe. This method was repeated multiple times for different food items, including beans, pureed quesadillas, and sour cream. The alcohol wipe was not fully opened, and the packaging was in contact with the thermometer probe during cleaning, which does not meet professional standards or the facility's own policy for cleaning food-contact equipment. Interviews with the cook and the dietary manager revealed that both staff members had been taught to clean thermometers in this improper manner, using the alcohol wipe and its packaging rather than opening the wipe and cleaning the probe without the packaging touching it. The dietary manager demonstrated the same incorrect technique during the interview. The facility's policy and state regulations require that food-contact surfaces and utensils, including thermometers, be cleaned to sight and touch, and that thermometers be cleaned, rinsed, sanitized, and air-dried before and after use. These requirements were not followed, as observed and confirmed through staff interviews.
Failure to Follow Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from sources that are approved or considered satisfactory and did not store, prepare, distribute, and serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating that the facility did not meet regulatory requirements for food safety and handling. No additional details about specific residents, staff, or events are provided in the report.
Failure to Follow Menu Extensions and Recipes for Resident Meals
Penalty
Summary
The facility failed to ensure that recipes and menu extensions were followed to meet residents' nutritional needs during meal preparation and service. Observations during a dinner meal revealed that residents on regular diets were served only half of a baked Italian sub sandwich instead of the two halves specified in the menu extensions. Additionally, a resident prescribed a pureed diet was served pureed barley soup and a pureed hamburger patty, rather than the required pureed Italian grinder sub and pureed potato salad. The menu extensions also indicated that a pureed brownie should have been served for dessert, but the resident received a pureed chocolate chip cookie and ice cream instead. Record review confirmed that the menu extensions detailed specific portion sizes and food items for both regular and pureed diets, which were not adhered to during meal service. Staff interviews revealed that the dietary manager did not use or follow recipes, was unable to locate them in the dining manager RD program, and acknowledged that dietary aides were not properly trained on portion sizes. The nursing home administrator confirmed that recipes should be followed and recognized the potential concerns related to not doing so, including issues with allergies, safety, and nutritional values.
Failure to Provide Palatable and Properly Tempered Food and Drink
Penalty
Summary
The facility failed to ensure that food and drink provided to residents was palatable, attractive, and served at a safe and appetizing temperature. Surveyors observed that the food and beverages did not meet these standards during their review. The deficiency was identified based on direct observation of the meals served to residents.
Failure to Protect Residents from Physical Abuse by Another Resident
Penalty
Summary
The facility failed to protect two residents from physical abuse by another resident, resulting in substantiated incidents of abuse. In the first incident, a resident with a history of cognitive impairment and behavioral symptoms, including aggression and confusion, entered another resident's room without permission and physically grabbed her by the hair. This event was witnessed by staff, who intervened immediately. The victim, who also had moderate cognitive impairment and required some assistance with activities of daily living, did not recall the incident in detail and reported no injury, but staff and the facility's investigation confirmed the physical contact occurred. In a separate incident the following day, the same resident with behavioral disturbances approached another resident near the nurses' station and grabbed her arm. This incident was directly observed by a CNA, who intervened to separate the residents. The victim in this case had significant physical and cognitive impairments, including hemiplegia and dependence on staff for most activities of daily living. She reported no pain or fear as a result of the incident and continued her routine without issue. Both incidents were substantiated by the facility's internal investigations, which included staff and resident interviews, record reviews, and direct observations. The reports indicated that the assailant resident had a documented history of behavioral symptoms and was known to respond to external stimuli with physical contact. The facility's policies required immediate response and increased supervision in such cases, but the incidents occurred nonetheless, resulting in physical abuse of two residents.
Failure to Assist Residents with Activities of Daily Living
Penalty
Summary
A deficiency was identified when care and assistance were not provided to perform activities of daily living (ADLs) for residents who were unable to do so themselves. The report notes that residents requiring help with ADLs did not receive the necessary support from staff, resulting in unmet care needs. No further details about specific residents, their medical history, or the exact circumstances of the deficiency are provided in the report.
Failure to Provide Care According to Orders and Resident Preferences
Penalty
Summary
A deficiency was identified when treatment and care were not provided in accordance with physician orders, as well as the resident's preferences and goals. The report notes a failure to ensure that care was individualized and aligned with the documented directives and wishes of the resident, as required by regulation.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
A deficiency was identified due to the failure to ensure that a nursing home area was free from accident hazards and that adequate supervision was provided to prevent accidents. The report notes that the environment did not meet safety standards, which could lead to accidents, and that supervision measures in place were insufficient to prevent such incidents. No specific details about individual residents, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Maintain Safe Environment and Adequate Supervision
Penalty
Summary
The facility failed to ensure that an area was free from accident hazards and did not provide adequate supervision to prevent accidents. This deficiency was identified based on observations and findings by surveyors, indicating that the environment posed risks for accidents and that supervision measures in place were insufficient to prevent such incidents. No specific details about the residents involved, their medical history, or their condition at the time of the deficiency are provided in the report.
Failure to Develop and Implement Immediate Needs Plan Within 48 Hours of Admission
Penalty
Summary
A plan to address a resident's most immediate needs within 48 hours of admission was not created or implemented. This deficiency was identified based on the absence of documentation or evidence that such a plan was developed and put into place for newly admitted residents. The lack of timely planning for immediate needs upon admission was observed during the survey.
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.
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