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
A resident with dementia, epilepsy, emphysema, and a history of repeated falls was care planned and ordered for multiple fall-prevention interventions, including a low-profile fall mat, hipsters, a scrum cap, traction strips, a low bed, and call light and personal items within reach. Over several months, the resident experienced multiple falls, including unwitnessed events and one resulting in a closed head injury with documented hematomas and a later subdural hematoma. Surveyors observed that the resident was often in bed without a fall mat or call light within reach, the bathroom lacked traction strips, and the fall mat was placed by the wrong bed. Staff interviews showed inconsistent awareness of the resident’s fall risk and inability to locate ordered hipsters and scrum cap, which were later found in the resident’s old room more than a week after a permanent room move, demonstrating that planned fall interventions were not consistently implemented.
Surveyors identified that the facility’s infection prevention and control program was not effectively implemented, as evidenced by a housekeeper using the same disinfectant wipe on multiple bedside surfaces, not allowing required disinfectant dwell times, failing to clean high-touch areas, contaminating mop water with soiled gloves after toilet cleaning, and not following a clean-to-dirty sequence when cleaning toilets and sinks. The housekeeper also moved between rooms and changed gloves without performing hand hygiene. In addition, an IP providing suprapubic catheter care did not change gloves and perform hand hygiene immediately after removing a soiled dressing and discarded a used Foley catheter bag without placing it in a red biohazard bag, contrary to facility expectations and professional standards.
Surveyors found that the facility failed to keep resident water temperatures within safe limits and did not ensure proper transfer assistance for a high‑risk resident. Multiple resident room sinks were measured with hot water above 120°F despite a policy limiting temperatures to prevent scalding, and monitoring focused on a small sample of rooms and shower areas. CNAs primarily checked water by touch, and thermometers were not consistently available in shower rooms. Separately, a resident with cauda equina syndrome, right‑sided hemiplegia, and significant weakness, who was care‑planned for a gait belt and two‑person assist for transfers, was transferred by a single CNA who was unaware of the updated two‑person requirement, resulting in the resident’s legs giving out and an assisted fall to the floor.
Two residents sharing a room were involved in an unwitnessed altercation when a cognitively intact younger resident with schizoaffective disorder, hallucinations, and a documented history of resident-to-resident altercations reported to a CNA that he had punched his roommate in the head multiple times while the roommate was lying in bed. The aggressor’s care plans identified risks for physical and verbal aggression, internal stimuli, and auditory hallucinations, and staff interviews confirmed he was easily agitated and had previously punched another roommate. The victim, an older resident with dementia, intracranial injury, PTSD, and moderate cognitive impairment, reported being hit in the head while sleeping but denied pain or fear when assessed. Despite the known behavioral history and risk factors of the aggressor, he remained in a shared room, and staff, including nursing, social services, and the NHA, acknowledged delays and uncertainty around room changes and behavior management interventions, resulting in a failure to keep the victim free from physical abuse.
A deficiency occurred when staff did not promptly and thoroughly investigate an alleged sexual abuse incident between two cognitively impaired residents. A CNA heard a resident yelling and found a male resident standing over her bed with his hands on her chest and abdomen over her clothing and bedding, but the abuse investigation was not initiated immediately and the event was not initially treated as sexual abuse. The alleged victim and alleged perpetrator were interviewed many hours later, by which time neither could recall the incident. Video review showed the male resident entering and exiting the room but did not establish how long he was inside before staff intervened. Witness statements lacked detail about the nature of the touching, the residents’ demeanor, and what the yelling resident was saying, and a nearby resident’s report of prolonged yelling and staff discussing touching and groping was not fully captured in the initial documentation. There was also no documentation of behavior monitoring or staff interventions for the yelling that evening, despite prior notes of distressing behaviors, and staff interviews showed inconsistent understanding of reporting and investigation expectations.
The facility failed to prevent resident-to-resident physical abuse when two cognitively impaired residents with known behavioral issues were seated together in the dining room. One resident, who frequently reached for others’ desserts, took the dessert of another resident who was known by staff to be territorial over belongings and food and to become aggressive in such situations. In response, the territorial resident slammed his hands on the table, hit the other resident in the chest, and verbally insulted him. Staff interviews confirmed prior knowledge of both residents’ behaviors, and records showed that the dessert-seeking behavior was not included in the care plan, despite the residents’ dementia, behavioral histories, and need for close supervision.
Surveyors found that medication and treatment carts were repeatedly left unlocked and unattended, including one treatment cart near the front entrance containing wound care supplies and prescription medications. On another occasion, an RN left a medication cart unlocked in a common area with a prefilled insulin syringe and multiple labeled medication cups containing different residents’ medications stacked on top of each other, including one cup with an unknown medication. Staff later confirmed that carts were expected to remain locked when not in use and that prepouring medications was not permitted, but these practices were not followed.
An LPN performed wound care for a resident without following basic infection control practices, including failing to perform hand hygiene before accessing the treatment cart, handling wound care supplies, and changing gloves. The LPN placed supplies and wound care scissors on an unsanitized bedside table, removed a soiled dressing from an open wound, then used the same contaminated gloves to open a sterile saline bottle and set it on the unclean surface. After removing the soiled gloves, the LPN again skipped hand hygiene before donning clean gloves, used saline and gauze to clean the open wound, and then used unsanitized scissors from the soiled table to cut antimicrobial dressing that was applied directly to the wound, and later to cut Velcro from an ace bandage applied over the resident’s arm and brace.
The facility failed to maintain an effective pest control program, resulting in ongoing mouse activity in multiple resident rooms and hallways. A resident’s representative reported repeated sightings of mice and mouse droppings in a resident’s dresser, clothing, and bed, and personally cleaned and laundered the affected items after submitting multiple grievances. The NHA delayed action after the initial grievance and arranged for a pest control contractor that implemented a trapping plan limited to one unit, despite staff and residents on other units reporting frequent mouse sightings. A pest control specialist confirmed a delay between contract signing and trap placement and restricted the initial mitigation to one side of the building, while residents and staff described mice being caught in bathrooms, rooms, dirty clothes bins, and running in hallways on other units, and a live mouse was directly observed under a resident’s bed during the survey.
Surveyors found that the facility failed to maintain sanitary conditions in the main kitchen and to properly store and label food. Walls near food prep areas were splattered and unclean, dishwasher racks had embedded black residue and buildup, and "clean" pans and bins were stacked wet on the drying rack. Food debris and heavy grease were present around the stove, uncovered grease-filled coffee tins were stored under a kitchen sink, and dust and debris had accumulated along pipes, baseboards, and behind the ice machine. In food storage areas, a spoiled bag of cabbage and expired chocolate milk were found, contrary to professional standards and the facility’s own policies for cleaning, dating, and labeling food.
Failure to Consistently Implement Fall-Prevention Interventions for a High Fall-Risk Resident
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to maintain a resident environment free from accident hazards and to provide adequate supervision and consistent implementation of fall-prevention interventions for one high fall-risk resident. The facility’s own Falls and Fall Risk, Managing Policy required staff to identify and implement resident-specific interventions, adjust them if falls recurred, and monitor/document responses. Resident #10, an individual over age 65 with emphysema, dementia, paranoid personality disorder, epilepsy, and a history of repeated falls, was assessed as having moderate cognitive impairment and needing staff supervision for toileting, dressing, and ambulation. The comprehensive care plan, initiated and updated over several months, identified the resident as at risk for falls with and without injury and listed multiple interventions, including call light and personal items within reach, traction strips and reminder signs, bed in low position, room relocation closer to the nurses’ station, hipsters, a low-profile fall mat, and offering a scrum cap when out of bed. Despite these identified risks and planned interventions, the resident sustained eight falls within a three‑month period, including several unwitnessed or unexplained falls and a significant fall resulting in a closed head injury. Documentation showed falls on multiple dates, including events where the resident was found on the floor near his wheelchair, bed, or in the bathroom, and one witnessed fall when he turned too fast and lost balance. On one occasion, a nurse documented being informed after the fact that the resident had fallen on a previous shift without a corresponding report or injury documentation at the time of the event. Emergency room records from one fall documented a closed head injury with periorbital and parietal scalp hematomas, and a later physician note referenced MRI findings of a subdural hematoma, while the facility reported the resident remained neurologically stable. During on-site observations, surveyors found that key fall-prevention interventions were not consistently in place for this resident. On multiple occasions, the resident was observed lying in bed in a different bed position (bed A) than his assigned bed (bed B) without a fall mat in place and without the call light within reach, contrary to the care plan and physician orders. The resident’s bathroom lacked traction strips despite this being a listed intervention. Staff interviews revealed inconsistent awareness and implementation of fall precautions: one CNA stated the resident was not a fall risk and was unaware of his fall history, could not locate his hipsters, and believed the bed did not need to be low. An LPN, who acknowledged the resident was a high fall risk, confirmed that the fall mat was placed by the wrong bed side and that the resident’s hipsters and scrum cap, along with other personal belongings, remained in the resident’s old room more than a week after a permanent room move. The DON confirmed that fall interventions should be used at all times and that staff were expected to use the care plan, Kardex, and intervention binders to guide resident safety, but the resident’s interventions and belongings had not been properly transferred or consistently applied.
Inadequate Environmental Cleaning and Hand Hygiene in Infection Control Practices
Penalty
Summary
The deficiency involves the facility’s failure to maintain an effective infection prevention and control program on two of three units, specifically in housekeeping practices and hand hygiene during resident care. Professional references cited in the report emphasize the importance of cleaning and disinfecting high-touch surfaces, following proper cleaning sequences from cleaner to dirtier areas, and adhering to disinfectant contact (dwell) times to prevent healthcare-associated infections. Facility policies on cleaning and disinfecting resident rooms and on hand hygiene require regular cleaning of environmental surfaces, appropriate selection and use of disinfectants, changing soiled cleaning materials, and performing hand hygiene at key moments, including before and after resident contact and after glove removal. During observations of housekeeping practices, a housekeeper was seen cleaning a double-occupancy room using a single Clorox hydrogen peroxide disinfectant wipe on surfaces for both sides of the room, contrary to hygienic practice and without allowing the surfaces to remain wet for the manufacturer-required one-minute dwell time. The housekeeper sprayed the toilet with Spic and Span disinfectant and then used a toilet brush and a red rag to wipe the toilet rim, seat, and lid in a sequence that did not proceed from the cleanest to the dirtiest areas. Without changing gloves or performing hand hygiene after cleaning the toilet, the housekeeper then reached into the mop bucket twice to wet mop pads, thereby contaminating the cleaning solution, and proceeded to mop the bathroom and resident room. The housekeeper did not clean high-touch areas such as call lights, light switches, bed controls, or the resident sink area, and did not perform hand hygiene between rooms before donning new gloves. In a triple-occupancy room, the same housekeeper again used Spic and Span to spray the toilet and collected trash, then used two Clorox hydrogen peroxide wipes to clean bedside tables and nightstands for two beds, leaving one bed’s nightstand and bedside table uncleaned and not maintaining the required dwell time, as the surfaces dried in about 30 seconds. The housekeeper used Spic and Span and a single rag to clean the sink area and mirror, wiping the mirror first and then the sink handles, bowl, and countertop, again not following a clean-to-dirty sequence. After scrubbing the toilet bowl with a toilet brush, the housekeeper touched the bathroom light switch, items on the cleaning cart, and then placed toilet paper in the bathroom while still wearing soiled gloves used for toilet cleaning. Although gloves were later changed, hand hygiene was not performed between glove changes. The report also documents a failure to perform appropriate hand hygiene during wound and catheter-related care by the facility’s infection preventionist (IP). While providing suprapubic catheter care to a resident, the IP performed initial hand hygiene, donned PPE, removed the resident’s adult disposable brief, removed the old drain sponge, and cleansed and dried the suprapubic area using multiple clean washcloths before placing a new drain sponge and reattaching the brief. After removing PPE and washing her hands, the IP donned gloves and handled the resident’s garbage bag, used PPE, and an old Foley catheter bag to take them to the garbage disposal area. The IP did not change gloves and perform hand hygiene immediately after removing the soiled drain sponge, and the old Foley catheter bag, which was contaminated with bodily fluids, was not placed into a red biohazard bag. In interviews, the IP acknowledged that gloves should be changed after removing a dirty dressing, and the DON confirmed that the correct procedure would include removing the old dressing, removing gloves, washing hands, donning clean gloves, and discarding a dirty Foley catheter bag in a red biohazard bag.
Unsafe Hot Water Temperatures and Improper Transfer Leading to Resident Fall
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident water temperatures within safe bathing limits and to ensure appropriate transfer assistance, resulting in unsafe environmental conditions and a resident fall. The facility’s written Water Temperatures policy required tap water to be kept within a range that prevents scalding, with water heaters set to no more than 120°F and periodic tap water checks documented in a safety log. Despite this, surveyors measured hot water temperatures in multiple resident room sinks that exceeded 120°F, including readings of 133°F, 125.2°F, 126.9°F, 126.7°F, and 124.7°F. The facility’s own monitoring logs showed weekly checks in shower rooms and a small sample of resident rooms, with typical shower temperatures documented between 113°F and 117°F, and some readings below 100°F, indicating inconsistent temperature control. During the survey, the maintenance director reported that he checked each floor’s water temperatures weekly in shower rooms and one to two resident rooms per floor, aiming to keep temperatures below 120°F. He described his method of running showers for five minutes and using the same temperature probe each week. However, when he rechecked temperatures with surveyors present, several resident room sinks again showed hot water at or above the 120°F threshold, including 126.8°F, 123.8°F, 122°F, 123.8°F, and 120.2°F. Staff interviews revealed that CNAs relied primarily on testing water with their hands and resident feedback, and thermometers were not consistently available in shower rooms. CNAs believed maintenance checked temperatures more frequently than the logs reflected, and there were reports of prior concerns about inconsistent hot water during showers. The deficiency also includes a failure in fall management related to a resident with significant neurological and mobility impairments. Resident #2, an older adult with cauda equina syndrome, right-sided hemiplegia and hemiparesis following a stroke, a colostomy, and bladder cancer, was cognitively intact but dependent on staff for toileting and chair-to-bed transfers. The resident had an identified risk for falls due to impaired mobility, weakness, pain, and multiple neurologic conditions, and her care plan included an intervention for staff education on the use of a gait belt and two-person assist for transfers because of severe weakness from cauda equina syndrome. On the date of the incident, the resident sustained a witnessed fall during a morning transfer when her legs gave out and she slid from the edge of the bed to the floor. The incident report did not identify which CNA was involved, but records showed CNA #5 was working with the resident that day. Further review and interviews established that CNA #5 attempted to transfer the resident from bed to wheelchair alone, using a gait belt and with the resident wearing non-slip socks. CNA #5 reported that the resident appeared wobbly and weak, and that she tried to sit the resident back on the bed before assisting her to the ground. CNA #5 stated that the resident usually required one-person assistance for transfers and was not aware that the resident had become a two-person assist. The DON later confirmed that the new intervention designating the resident as a two-person transfer had not been transcribed onto the CNA task list, which resulted in CNA #5 not knowing the resident’s updated transfer status at the time of the fall. This breakdown in communication and task transcription, combined with the resident’s known severe weakness and fall risk, led to the resident being transferred without the required level of assistance and experiencing a fall. Overall, the deficiency centers on two main areas: environmental safety related to hot water control and clinical safety related to fall prevention. In the first area, the facility did not consistently maintain hot water temperatures within the safe range specified in its own policy, and monitoring practices did not prevent multiple resident room sinks from reaching temperatures above 120°F. In the second area, the facility did not ensure that updated fall-prevention interventions—specifically the requirement for two-person assistance for a high-risk resident’s transfers—were effectively communicated and implemented at the CNA level, resulting in a one-person transfer and a subsequent fall.
Failure to Protect Resident From Physical Abuse by Roommate With Known Aggressive Behaviors
Penalty
Summary
The deficiency involves the facility’s failure to protect one resident from physical abuse by another resident during an unwitnessed altercation in a shared room. The facility’s abuse prevention policy states that residents have the right to be free from abuse, including physical abuse, and that they must be protected from harm. On the date of the incident, a resident with schizoaffective disorder left his room and reported to a CNA that he had hit his roommate in the head multiple times because voices told him to do so. The altercation was not witnessed by staff, and the facility’s own investigation confirmed that the assault occurred based on the statements of both residents. The resident who committed the assault was younger than 65 and had documented diagnoses including unspecified schizoaffective disorder, unspecified affective mood disorder, and hallucinations, with a history of behavioral symptoms such as physical and verbal aggression. His MDS showed he was cognitively intact and independent in mobility, and his care plans documented targeted behaviors including internal stimuli, auditory hallucinations, delusions, and aggression. The behavior and schizoaffective disorder care plans also documented that he had been recently involved in two separate resident-to-resident altercations, and staff interviews confirmed he had a history of such altercations, including punching a prior roommate. Despite this known history and identified risk for aggressive behavior toward peers, he remained in a shared room where he was able to physically assault his roommate while the roommate was in bed. The victim of the assault was over 65 with diagnoses including intracranial injury, dementia, post-traumatic stress disorder, and major depressive disorder, and had moderate cognitive impairment per his MDS. He required varying levels of assistance with ADLs and had a trauma-informed care plan identifying him as at risk for decreased psychosocial well-being and emotional distress. On the day of the incident, nursing documentation recorded that the assailant admitted to hitting this resident two to three times in the head while he was sleeping. When assessed, the victim denied pain, loss of consciousness, and fear, and stated his roommate had “just went crazy.” Staff interviews indicated that the assailant was known to be easily agitated and had a history of resident-to-resident altercations, and that a room change for him had been delayed. The combination of the assailant’s known aggressive behaviors, his documented history of altercations, and the continued placement in a shared room led to the failure to keep the victim free from physical abuse. Staff interviews further showed gaps in awareness and implementation of behavior management interventions. A CNA reported that the assailant had been involved in a prior altercation two to three weeks earlier, also self-reported by the resident, and that the victim was only moved to a different room after the current altercation. An RN stated that the resident’s triggers included hearing voices and that care plan updates were important for safety, but she was unsure why there was a delay in changing the assailant’s room. The social services director acknowledged the resident’s history of altercations and stated that previous root causes were related to auditory hallucinations, and that a room change was delayed due to another resident occupying the room and the need for a five-day room change notification. The NHA was unable to state what specific interventions were in place to manage the resident’s anger-related outbursts after the altercation. These circumstances, combined with the known behavioral history and risk factors, resulted in the facility’s failure to ensure that the victim was protected from physical abuse by his roommate. The facility’s investigation concluded that the altercation was substantiated, with both residents confirming the incident. Documentation indicated that the incident did not cause injury or psychosocial stress according to the facility’s assessment, but the core deficiency remained that a resident with known aggressive behaviors and hallucinations was able to physically assault his roommate in their shared room. The facility’s own records and staff interviews demonstrate that the assailant’s behavioral risks and prior altercations were known, yet he remained in a situation where he could and did inflict physical abuse on another resident, contrary to the facility’s abuse prevention policy and the residents’ right to be free from abuse.
Delayed and Incomplete Investigation of Alleged Resident-to-Resident Sexual Abuse
Penalty
Summary
The deficiency centers on the facility’s failure to promptly and thoroughly investigate an allegation of sexual abuse between two residents with severe cognitive impairment, and to adequately document resident monitoring and behaviors surrounding the event. On the evening in question, a CNA heard one resident yelling from her room and entered to find a male resident standing over her bed with his hands on her chest and abdomen area, over her clothing and bedding. Initially, the CNA reported uncertainty about whether the male resident had actually touched the female resident, later clarifying that he had placed his hands on her chest and abdomen. Despite this, the facility did not immediately initiate an abuse investigation at the time of the incident, and the event was not initially considered sexual abuse. The investigation and documentation were delayed and incomplete. The alleged victim was not interviewed until approximately 12 hours after the incident, at which time she did not remember anyone coming into her room or touching her. The alleged perpetrator was not interviewed until about 14 hours after the incident and similarly did not recall entering another resident’s room or hearing anyone calling for help. Both residents had severely impaired cognition, and the delay meant they were unable to provide details of the incident. The facility’s review of hallway video surveillance documented the male resident entering and exiting the female resident’s room and the CNA’s response, but did not establish the exact time he entered the room or how long he remained there before staff intervened. The facility’s investigation also lacked sufficient detail in witness statements and failed to fully explore key information. The CNA’s written statement did not describe the type of touch, the demeanor of either resident, or what the yelling resident was saying. There was no explanation documented for the change in the CNA’s account from the resident’s hands “hovering” to actually touching the other resident. Another resident in a nearby room reported hearing the female resident yelling for help in Spanish for about 10–20 minutes before staff responded, and later overheard staff discussing that a male resident had been in her room touching and groping her; however, this level of detail was not captured in the initial witness statement or incorporated into the investigation. Additionally, there was no documented effort to determine the root cause of the yelling, no documentation of staff monitoring or interventions for the yelling on the evening of the incident, and no timely examination of the alleged victim for injuries that night. Record review further showed that the yelling resident had documented distressing behaviors the day before, including calling out for help, becoming upset when staff attempted to assist, and pinching staff, with a physician notified and new orders initiated. However, there was no documentation of continued behavior monitoring or of her calling out for help on the evening of the alleged abuse, nor of staff actions to monitor and intervene at that time. Staff interviews revealed inconsistent understanding of reporting and investigation expectations, with one CNA stating that after breaking up a resident-to-resident abuse situation and notifying nursing, there was “nothing else to report.” Administrative staff could not demonstrate that the investigator obtained detailed information from the CNA about the exact location and nature of the touching or what the yelling resident was saying, and there was no documentation that later assessments or theories about the male resident’s intent were incorporated into the formal investigation. These omissions and delays in investigation, interviewing, and documentation constitute the core of the cited deficiency.
Failure to Prevent Resident-to-Resident Physical Abuse in Dining Room
Penalty
Summary
The deficiency involves the facility’s failure to provide adequate supervision and intervention to prevent physical abuse between residents, resulting in one cognitively impaired resident physically striking another during a meal. The facility’s abuse, neglect, and exploitation policy requires deployment of trained and qualified staff in sufficient numbers who know residents’ care needs and behavioral symptoms, and mandates prevention of all types of abuse. Despite this, staff interviews and the facility’s own investigation showed that staff were aware of one resident’s frequent behavior of reaching for and taking other residents’ desserts, and another resident’s territorial behavior and history of becoming aggressive when his belongings or food were disturbed. On the date of the incident, both residents, each with severe cognitive impairment and behavioral histories, were seated together at the same dining table. During the meal, the cognitively impaired resident with a history of grabbing desserts reached out and took the other resident’s dessert. In response, the territorial resident slammed his hands on the table, hit the dessert-taking resident in the chest, and called him names. A CNA witnessed the event and confirmed that the altercation occurred immediately after the dessert was taken. The facility’s investigation documented that both residents had severe cognitive impairment with behaviors and concluded that physical abuse had occurred. Record review showed that the victim resident had diagnoses including cognitive, social, or emotional deficit following cerebral infarction, mood disorder due to a physiological condition, generalized muscle weakness, and lower leg contractures, and was totally cognitively impaired with a BIMS score of 0, requiring maximum assistance with all ADLs. His care plan addressed impaired cognitive function and communication strategies but did not document his behavior of reaching for other residents’ desserts. The assailant resident had dementia with psychotic, mood, and anxiety components, cognitive impairment with a BIMS score of 5, and a care plan noting confusion, delusional thought processes, and a suspected trauma history contributing to possessiveness of space and reactive responses. Staff interviews confirmed that this resident was territorial over belongings, became aggressive if someone took his food, and had a history of verbal threats and attempts to hit or grab when close to others. The NHA acknowledged that the victim’s dessert-seeking behavior was not care planned and that the two residents, given their known behaviors, should not have been seated together, leading to the abusive incident.
Unlocked Carts and Unattended Prepoured Medications Left in Common Area
Penalty
Summary
The deficiency involves the facility’s failure to ensure that medications and biologicals were properly stored, secured, and labeled in accordance with accepted professional standards. Over multiple days, a treatment cart located near the front entrance was observed unlocked and unmonitored by nursing staff for extended periods. The contents of this treatment cart included wound care supplies and prescription medications, yet it remained accessible when no nurse was present. The facility was unable to provide a medication storage policy when requested during the survey. On another occasion, a medication cart was observed unlocked and unattended by the assigned RN. On top of this cart, surveyors observed a prefilled insulin syringe and several paper medication cups labeled with different residents’ names, each containing medications. These cups were stacked so that the bottom of one cup was in contact with another resident’s medications, and there was also a plastic medication cup containing an unknown medication at the top of the stack. These medications were left on the cart in a common area without the medication nurse in sight, and the RN later stated she had left the cart to go into the supply room. Staff interviews confirmed that both treatment and medication carts were expected to be locked when not being accessed and that prepouring medications was not allowed, but these expectations were not followed in the observed instances.
Failure to Follow Hand Hygiene and Aseptic Technique During Wound Care
Penalty
Summary
The deficiency involves the facility’s failure to follow proper infection prevention and control practices during wound care for a resident. During an observed wound care procedure, an LPN did not perform hand hygiene before opening the treatment cart, touching wound care supplies, or bringing those supplies and the physician’s wound care order into the resident’s room. The LPN placed wound care supplies and wound care scissors on the resident’s bedside table without sanitizing the table surface or the scissors. The LPN then donned gloves without prior hand hygiene and removed the resident’s soiled wound dressing, which had yellow discharge. With the same soiled gloves, the LPN opened a bottle of sterile saline and set it on the unclean bedside table, again without performing hand hygiene. After handling the saline bottle, the LPN removed the soiled gloves but did not perform hand hygiene before reaching into a box of clean gloves and donning a new pair. The LPN then poured saline on gauze to clean the resident’s open wound and picked up the unsanitized scissors from the soiled bedside table to cut antimicrobial dressing material, which was placed directly onto the open wound. The LPN did not sanitize the scissors before using them to prepare the dressing. The LPN continued the wound care by applying ointment, a foam-covered bandage, an ace wrap, and a hard plastic brace, and then used the same unsanitized scissors to cut off Velcro from another ace bandage applied over the brace and the resident’s arm. These actions occurred despite CDC guidance that failure to perform appropriate hand hygiene is a leading cause of health-care-associated infections and spread of multiresistant organisms.
Failure to Maintain Effective Pest Control Across All Units
Penalty
Summary
The facility failed to maintain an effective pest control program to keep resident rooms free from mice on two of three units. The facility’s pest control policy required an environment free of pests, frequent contracted treatments, allowance for additional visits when problems were detected, and prompt reporting of pest control problems by staff. Despite this, a grievance submitted at the end of December documented mouse feces in a resident’s dresser drawers and on the resident’s clothes and bed, with the resident’s representative personally cleaning the drawers and taking clothes home to wash. The representative reported seeing mice frequently in the resident’s room and stated that there were no traps in the room as of a few days prior to the interview, and that management had provided little to no response despite multiple grievances. The NHA acknowledged receiving the written grievance about mice several days after it was filed and did not initiate housekeeping inspection of the affected unit until nearly a week after the grievance date. The NHA reported that the pest control company had previously been visiting only once per month and that an additional extermination contract was signed later, after the grievance, with the pest control company assessing the building and determining that mice were present only on one of three units. The pest control specialist confirmed that although the contract for extra work was signed, there was about a one‑week delay before traps were actually set, and that the initial mitigation plan and trap placement were limited to a single unit (rooms four through 30) on one side of the building. The specialist also stated that he had identified likely entry points near heater and air conditioner units but had not yet communicated these locations to the NHA. Multiple residents and staff reported ongoing mouse activity outside the unit initially targeted by the pest control plan. One resident reported a mouse caught in her bathroom and another reported a mouse caught in her room, both on a different unit than the one included in the initial mitigation plan, and stated that mice remained a problem throughout the facility despite frequent complaints. During an interview with one of these residents, a live mouse was observed under the resident’s bed, stuck on a glue board and squealing, and the NHA removed it from the room. Additional staff interviews revealed that a housekeeper had found a live mouse in a dirty clothes bin on that same hallway the previous week, a CNA had found and discarded a mouse in the same resident’s room, and an RN reported seeing mice a couple of times per week on her unit, with each sighting entered into the computer system for maintenance. Other residents reported often seeing several mice running up and down the hallway at night and “a lot of mice” in the hallway, including many mice seen just the prior week, demonstrating that mice activity was occurring on more than one unit while the facility’s pest control efforts remained limited and delayed.
Unsanitary Kitchen Conditions and Improper Food Storage
Penalty
Summary
Surveyors identified a deficiency in the facility’s failure to store, prepare, distribute, and serve food under sanitary conditions for all residents receiving meals from the main kitchen. During an initial kitchen tour, surveyors observed multiple sanitation issues in the food preparation area, including walls throughout the kitchen, behind the handwashing station, and around the refrigerator with dime-sized brown and yellow streaks and splatters. The dishwasher plate racks were heavily soiled with black embedded residue that could not be wiped or scraped off, and several racks had gummy blackish buildup of unknown matter in the drainage crevices. The drying rack contained multiple food storage bins and pans stacked on top of each other, trapping moisture between the stacked items on the clean drying rack, contrary to requirements for proper air-drying. Additional observations showed food debris and heavy grease accumulation around the range stove and burner brackets, as well as several coffee tins containing grease left uncovered and stored under a kitchen sink in the food preparation area. Debris and small piles of dust had accumulated along ceiling pipes, along baseboards, and on the sides and behind the ice machine. These conditions conflicted with professional standards and the facility’s own kitchen cleaning policy, which required cleaning before, during, and after food preparation, and mandated that each user properly clean and sanitize the kitchen after their shift and ensure floors were swept and cleaned at the end of the shift. Surveyors also found failures related to proper labeling and storage of perishable foods. In the dry storage and refrigerated food areas, they observed a bag of cabbage with browning and pooling liquid inside the bag, indicating spoilage, and chocolate milk stored in the refrigerator that was labeled with an expiration date that had already passed. These findings were inconsistent with state retail food regulations and the facility’s food storage policy, which required all products to be dated when received and when opened, adherence to use-by or expiration dates, and labeling of foods removed from their original containers with the common name of the food.
Some of the Latest Corrective Actions taken by Facilities in Colorado
- Educated all nursing and dining staff on therapeutic (mechanically altered) diets, diet-order transcription/communication processes, and baseline care plan documentation, and required training completion before staff worked (J - F0805 - CO)
- Educated dietary staff on therapeutic (mechanically altered) diet textures per IDDSI guidelines and required training completion before staff worked (J - F0805 - CO)
- Educated nursing staff on reading tray cards to correctly identify altered-texture diets (J - F0805 - CO)
- Established a process for new staff to receive the same diet-texture and tray-identification training before working in the kitchen or serving residents food, snacks, or beverages (J - F0805 - CO)
Failure to Provide Physician-Ordered Dysphagia Diet Texture Resulting in Harm
Penalty
Summary
The deficiency involves the facility’s failure to ensure a resident received food in the correct texture as ordered by the physician. The resident was admitted with multiple significant diagnoses, including Barrett’s esophagus, Zenker’s diverticulum, dysphagia, GERD, dementia, and a recent history of pneumonia and acute respiratory failure. Hospital records prior to admission documented ongoing oral and suspected pharyngeal dysphagia with overt signs of laryngeal penetration and aspiration on thin liquids and regular solids, and the hospital SLP recommended a dysphagia level 6 (soft and bite-sized) diet with thin liquids, along with specific swallowing precautions. The hospital discharge summary documented that the resident was discharged on a dysphagia diet due to dysphagia being the discharging diagnosis. Upon admission, the facility did not transcribe the physician-ordered dysphagia level 6 diet into the resident’s medical record and did not complete or transmit the required diet form from nursing to dietary. The baseline care plan instead documented a regular texture diet with thin liquids and instructions for the resident to eat two bites and then drink water, which conflicted with the hospital discharge documentation and SLP recommendations. There was no physician order for diet texture in the facility record, indicating the ordered dysphagia diet was not entered. The DON later confirmed that the admitting nurse did not verify and transcribe the diet order and that the nursing department did not complete the diet form needed to communicate the diet to dietary. As a result of these omissions, the resident was served regular texture meals rather than the ordered dysphagia level 6 soft and bite-sized diet. The dietary manager reported that, from admission until after breakfast the following day, the resident received regular texture meals, including pork loin for dinner and eggs with sausage links for breakfast, with the meat only cut up but not altered to a soft, fork-depressible consistency. After the diet order was eventually communicated to dietary, the resident was still served an egg salad sandwich on whole bread with crust and a bag of potato chips for dinner, which did not meet IDDSI level 6 criteria and was not considered appropriate for the resident based on the hospital records and SLP interview. The resident’s representative observed the resident consuming this boxed meal and later reported that the resident appeared to have worsened, with coughing, pain on swallowing, and difficulty breathing, leading to transfer back to the hospital, where an upper GI endoscopy revealed a bleeding Zenker’s diverticulum with a large opening and impacted food requiring surgical removal. Staff interviews further described the breakdown in processes that led to the deficiency. The RD explained that the usual process required nursing to complete a diet form for new admissions and provide it to dietary so the diet could be entered into the tray ticket system, but this was not done for this resident. The dietary manager confirmed that no formal diet form was received, that a text message thread used on the admission day was not a formal communication system, and that she assumed certain items, such as an egg salad sandwich and thin potato chips, were dysphagia-appropriate. The SLP clarified that dysphagia level 6 soft and bite-sized foods must be chopped into 1.5 cm pieces, be soft enough to be fully flattened with a fork, and that regular texture meats, whole bread with crust, and potato chips were not appropriate for this resident given his diagnoses and swallowing difficulties. The DON acknowledged that the facility did not follow its established admission and diet communication processes and confirmed that the resident should have been provided a dysphagia level 6 soft and bite-sized diet upon admission but instead received regular texture meals and later an inappropriate sandwich and chips.
Removal Plan
- The facility conducted an audit to identify other residents who may be receiving the incorrect diet texture by reviewing physician orders and dietary tickets; no other issues were identified.
- The DON or designee provided education to all nursing and dining staff on therapeutic (mechanically altered) diets, the admission process for diet order transcription to the medical record, communication of diet to the dietary department, and accurate documentation in the baseline care plan; staff will not be permitted to work until trained.
- The SLP provided education to dietary staff on therapeutic (mechanically altered) diet textures per IDDSI guidelines; education will continue until all dietary staff have been educated prior to working.
- The DON provided education to nursing staff on how to read the resident's tray card and properly identify correct altered textured diets; education will continue until all staff are sufficiently trained.
- All new staff will receive the same training prior to working in the kitchen or serving residents food, snacks, or beverages.
- The DON reviewed all identified residents with altered diet texture care plans and updated them to reflect each resident's specific dietary interventions and needs.
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