HEALTHCARE RESORT OF COLORADO SPRINGS, THE
For profit - Limited Liability company
97 Beds
THE ENSIGN GROUP
Data: November 2025
1 Immediate Jeopardy citation
Trust Grade
38/100
#105 of 208 in CO
Photo by The Healthcare Resort of Colorado Springs
Photo by The Healthcare Resort of Colorado Springs
Photo by The Healthcare Resort of Colorado Springs
1 / 5 photos
Last Inspection: June 2025
Inspected within the last 6 months. Data reflects current conditions.
Overview
Healthcare Resort of Colorado Springs has received a Trust Grade of F, indicating significant concerns about the facility’s quality of care. It ranks #105 out of 208 nursing homes in Colorado, placing it in the bottom half of all facilities in the state, and #11 out of 20 in El Paso County, meaning there are only a few local options that are better. The trend is stable, with nine issues noted in both 2023 and 2025, suggesting persistent problems. Staffing is a relative strength, earning a 4 out of 5 stars, but with a turnover rate of 49%, which matches the state average. However, the facility has incurred $79,098 in fines, which is higher than 91% of Colorado facilities, indicating repeated compliance issues. Specific incidents include a critical finding where a resident was not provided adequate supervision for transferring, creating a risk for falls, and concerns about food safety practices, such as improperly thawing meat and not following hygiene protocols during meal preparation. Additionally, the facility failed to respect resident choices about dining, which can affect overall satisfaction and autonomy. While there are strengths in staffing, these concerning findings highlight significant weaknesses that families should consider carefully.
- Trust Score
- F
- In Colorado
- #105/208
- Safety Record
- High Risk
- Inspections
- Holding Steady
- Staff Stability ⚠ Watch
- 49% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ⚠ Watch
- $79,098 in fines. Higher than 91% of Colorado facilities. Major compliance failures.
- Skilled Nurses ✓ Good
- Each resident gets 56 minutes of Registered Nurse (RN) attention daily — more than average for Colorado. RNs are trained to catch health problems early.
- Violations ⚠ Watch
- 21 deficiencies on record. Higher than average. Multiple issues found across inspections.
38/100
Top 50%
Review needed
9 → 9 violations
★★★☆☆
3.0
Overall Rating
★★★★☆
4.0
Staff Levels
★★★★★
5.0
Care Quality
★★☆☆☆
2.0
Inspection Score
↔
Stable
2023: 9 issues
2025: 9 issues
The Good
-
4-Star Staffing Rating · Above-average nurse staffing levels
-
5-Star Quality Measures · Strong clinical quality outcomes
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, quality measures, fire safety.
The Bad
3-Star Overall Rating
Near Colorado average (3.1)
Meets federal standards, typical of most facilities
Staff Turnover: 49%
Near Colorado avg (46%)
Higher turnover may affect care consistency
Federal Fines: $79,098
Well above median ($33,413)
Moderate penalties - review what triggered them
Chain: THE ENSIGN GROUP
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 21 deficiencies on record
1 life-threatening
Jun 2025
9 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
ADL Care
(Tag F0677)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activi...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services and assistance for bathing for two (#144 and #146) of three residents reviewed for ADLs out of 39 sample residents.
Specifically, the facility failed to:
-Provide bathing for Resident #144 to maintain the resident's personal hygiene; and,
-Provide the necessary shower assistance for Resident #146, according to the resident's care plan.
Findings include:
I. Facility policy and procedure
The Activities of Daily Living/Maintain Abilities policy and procedure, reviewed December of 2024, was provided by the director of nursing (DON) on 6/26/25 at 9:09 a.m. It read in pertinent part, It is the policy of this facility that residents are given the appropriate treatment and services to maintain or improve his/her abilities. Residents who are unable to carry out activities of daily living (ADL) will receive necessary services or support from staff to maintain. ADL documentation will be maintained in the electronic medical record (EMR) under tasks, care plan, assessments, and therapy documentation. ADLs will be care planned to reflect the residents' specific needs.
II. Resident #144
A. Resident status
Resident #144, age less than 65, was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included quadriplegia, C5-C7 (cervical vertebrae) complete (paralysis of all a person's limbs and body from the neck down), muscle wasting and atrophy and pressure ulcer of left buttocks unstageable.
The 6/6/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. He was dependent on staff assistance for toileting hygiene, upper and lower body dressing, rolling, sitting to lying and lying to sitting, chair to bed transfers and toilet transfers. The resident was non ambulatory and was dependent on the use of a manual highback wheelchair.
The MDS indicated the resident required substantial/maximal assistance with shower/bathing, however shower/bathing transfers were not attempted during the assessment look back period.
B. Resident interview and observations
Resident #144 was interviewed on 6/23/25 at 3:46 p.m. Resident #144 was seated in an electric wheelchair. The resident had facial stubble on his face. Resident #144 said he did not get very many showers. Resident #144 said he thought it was because the facility did not have a shower chair that would work for him because he needed a high back shower chair with side support.
Observation of Resident #144's bathroom during the interview revealed the resident had a fold down shower bench in the shower. Resident #144 said he had a shower chair at home that his wife might be able to bring into the facility for him to use, but he said that would be difficult.
On 6/25/25 at 11:03 a.m. the spa shower rooms on C-Hall and A-Hall were observed. The shower room on C-Hall was being utilized by the facility as the activities office with desks inside and activities supplies stored inside the room.
The A-Hall shower room was being used as another office space with a desk and other medical equipment and supplies stored inside.
C. Record review
Resident #144's ADL self-care performance deficit care plan, initiated 6/6/25, revealed the resident had self-care performance deficits related to showers/bathing due to quadriplegia. Interventions included providing the resident with substantial/maximal assistance for bathing.
Review of Resident #144's shower preference sheet revealed the resident was to receive a bed bath, twice weekly.
The visual/bedside Kardex (a tool utilized by staff to provide consistent care for residents) report, dated 6/25/25, revealed Resident #144 needed substantial/maximal assistance with bathing and preferred bed baths on Tuesday/Friday evenings.
-However, Resident #144 said he had a shower chair that he utilized at home (see resident interview above).
Resident #144's bathing task records were reviewed from 6/5/25 (admission) to 6/25/25. The record revealed the resident was scheduled to bathe on Tuesday/Friday evenings and preferred bed baths.
-The bathing task records revealed no documentation to indicate Resident #144 had received a bath or a shower from 6/5/25 to 6/25/25 (a period of 20 days).
III. Resident #146
A. Resident status
Resident #146, age greater than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included fracture of right femur neck (hip), fall and difficulty in walking.
The 6/20/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required supervision or touching assistance with upper and lower body dressing, personal hygiene, bed mobility, transfers, walking with a walker and shower/bathing.
B. Resident interview and observation
Resident #146 was interviewed on 6/23/25 at 2:54 p.m. Resident #146 said she had to ask twice for a shower because the staff never offered her a shower. Resident #146 said on the third day she was at the facility she asked for a shower and the CNA said yes and got her a towel and then left the room. Resident #146 said she did the shower herself totally unsupervised by a staff member and then got herself dressed. Resident #146 said she was surprised the staff left her to take the shower by herself because she had come to the facility for care after a fall with a hip fracture at home and the staff had told her since admission that she should always ring her bell for assistance for walking into the bathroom using her walker.
Resident #146 said the staff did not go over a bathing plan with her when she first admitted but she preferred a shower twice per week, and wanted the showers to be offered to her on her shower days.
Resident #146 pointed at the instructions written on her white board in her room which said weight bear as tolerated, two wheeled walker, walk resident to the bathroom. Resident #146 said one CNA told her to take her shower and then she would be back, but the resident said the CNA never came back.
C. Record review
Resident #146's ADL self-care performance deficit care plan, initiated 6/15/25, revealed the resident had self-care performance deficits related to right hip pain, right femur/hip fracture, fall and difficulty in walking. Bathing interventions revealed the resident required supervision or touching assistance with bathing.
Review of Resident #146's shower preference sheet revealed Resident #146 preferred a shower from female staff only on Tuesdays and Fridays during the day time.
The visual/bedside Kardex report, dated 6/24/25, revealed Resident #146 needed supervision or touching assistance with bathing and her bathing preference was Tuesday/Friday day shift.
Resident #146's bathing task records were reviewed from 6/14/25 (admission) to 6/24/25. The record revealed the resident was scheduled to bathe Tuesday/Fridays day shift.
The bathing task records indicated Resident #146 had received three showers from 6/14/25 to 6/24/25.
-However, the amount of assistance documented in the resident's bathing records revealed the staff only provided setup assistance, not the required supervision or touching assistance with bathing the resident was supposed to receive, according to the resident's care plan and Kardex (see above).
IV. Staff interviews
CNA #7 was interviewed on 6/25/25 at 11:19 a.m. CNA #7 said she worked at the facility as needed (PRN). CNA #7 said she knew how much assistance a resident required for ADLs by looking at the paper report sheet at the nurses' station because sometimes physical therapy had not done their evaluation yet. CNA #7 said there also was a white board in each of the residents' rooms that had notes about the assistance each resident needed. CNA #7 said the CNAs were responsible for completing the residents showers and after giving the showers she would document the shower in the resident's EMR in the task section. CNA #7 said the CNAs would ask the residents their shower preferences upon admission and fill out the resident's preference sheet.
CNA #7 said she had not tried a shower or bath with Resident #144 but he probably required a hoyer lift or he got a bed bath. CNA #7 said if a resident could not sit steadily on the fold down shower bench in their rooms then they would give the resident a bed bath. CNA #7 said residents only had the shower bench available for showers because the spa rooms were not available for bathing use.
CNA #7 said Resident #146 was just set up assistance for showers and she would let the CNAs know when she wanted a shower.
-However, according to the care plan, the resident required supervision or touching assistance with showers (see record review above).
CNA #6 was interviewed on 6/25/25 at 11:29 a.m. CNA #6 said she had worked at the facility fulltime for four years. CNA #6 said she knew how much assistance a resident needed with ADLs by looking at the Kardex in the computer and there was a communication board in the resident's room. CNA #6 said the CNAs completed the showers and documented them in the shower task section of the resident's EMR. CNA #6 said the spa rooms were offices so they only used the showers in the residents' rooms. CNA #6 said the CNAs filled out the residents' shower preference sheets when they were admitted to the facility.
CNA #6 said that Resident #144 wanted an evening shower and he required a hoyer lift into the shower chair or he could have a bed bath. CNA #6 said she would chart Resident #144's showers/bed baths in the EMR however she had not personally given him any showers or baths.
CNA #6 said she had given Resident #146 a shower and she required set up assistance. CNA #6 said she had given Resident #146 a shower three or four times and she only required a set up.
-However, according to the care plan, the resident required supervision or touching assistance with showers (see record review above).
Registered nurse (RN) #1 was interviewed on 6/25/25 at 11:39 a.m. RN #1 said the CNAs knew how much assistance a resident needs for ADLs by looking at the Kardex in the EMR. RN #1 said there was also a daily report sheet at the nurses' station that the CNAs had access to and the nurses would pass information regarding the residents down to the CNAs. RN #1 said she additionally used the white boards in the residents' rooms for communication and the white boards were updated daily. RN #1 said the shower preferences were obtained by the CNAs during the initial assessment of residents upon admission and put in the residents' hard paper charts. RN #1 said the CNAs completed the showers in the residents' own bathrooms because the spa bathrooms were not available for use. She said the CNAs charted in the residents' EMRs.
RN #1 looked at the printed report sheet for Resident #144 and said the facility did have an appropriate shower chair for him but she was pretty sure he got a bed bath. RN #1 said Resident #144 would require maximal assistance with a hoyer lift using a shower chair or he would have maximal assistance with a bed bath.
RN #1 said she was not sure how much assistance Resident #146 required because she did not usually work in that hall. RN #1 looked at the printed report sheet on the nurses' station and said Resident #146 required stand by assistance.
-However, per the resident and CNA documentation, staff was not providing the resident with stand by assistance for showers (see above).
The DON was interviewed on 6/25/25 at 1:44 p.m. The DON said the CNAs documented the resident showers in the residents' EMR task section. The DON said the CNAs knew how much assistance to provide to a resident by the report from the hospital and the therapy evaluation and it would be written on the white board in the resident's room. The DON said the nurses also helped determine resident assistance levels by taking into consideration the resident's precautions and whether they needed a walker, wheelchair or a mechanical lift. The DON said the information regarding how much assistance a resident required additionally was documented on the Kardex and it was generated from the initial assessment of the resident and the baseline care plan. The DON said the CNAs should follow the assistance levels listed on the Kardex and the care plan and that it was important to do so for safety.
The DON viewed the EMR task section for Resident #144 and said the record did not indicate that any baths/showers had been given to him. The DON said she was surprised and did not see how that could be correct because his baths were scheduled. The DON said she had started a facility wide shower audit (during the survey) because she knew showers were an issue. The DON said she was not sure if the issue with residents not getting showers was a lack of care or a lack of documentation. The DON said if the facility had the shower chair staff would not have to give residents bed baths.
The DON said the Kardex and care plan for Resident #146 revealed the resident required supervision or touch assistance for showers. The DON reviewed the resident's EMR bathing task documentation which indicated that the CNAs had been providing set up assistance only for Resident #146's showers. The DON said the CNAs should be providing supervision to the resident because leaving Resident #146 alone during a shower could result in an injury for the resident. The DON said she needed to fine tune the system a little more and was going to meet with the DOR and the MDS team and look at a better system to communicate resident assistance levels with the CNAs.
The director of rehabilitation (DOR) was interviewed on 6/25/25 at 4:05 p.m. The DOR said the facility had a shower chair but she was not sure how many they had.
After an extensive look around the facility the DOR found an appropriate shower chair for Resident #144 and the DOR said she would bring it to Resident #144.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0679
(Tag F0679)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#76) of three residents reviewed for act...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure one (#76) of three residents reviewed for activities out of 39 sample residents received an ongoing program of activities designed to meet the needs and interests, and promote physical, medical and psychosocial well-being.
Specifically, the facility failed to ensure group were available for Resident #76 on the weekends per her preference.
Findings include:
I. Facility policy and procedure
The Activities policy and procedure, revised December 2024, was received from the director of nursing (DON) on 6/26/25 at 1:29 p.m. It revealed in pertinent part, It is the policy of this facility to ensure that residents have the right to choose the types of activities and social events in which they wish to participate.
Residents are encouraged to choose the types of activities and social events in which they prefer to participate in.
Daily activities, including those on weekends and holidays, are provided, as well as scheduled religious and social activities. However, residents are free to choose whether or not they wish to attend any activity or other scheduled event(s).
II. Resident #76
A. Resident status
Resident #76, age less than 65, was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included fracture of the left lower leg, hypertension (high blood pressure), depression and hypothyroidism (abnormal thyroid function).
The 5/14/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required moderate staff assistance with dressing, toileting, and transfers. She was independent with eating and personal hygiene.
The MDS assessment revealed it was very important for her to do things with groups of people.
B. Resident interview
Resident #76 was interviewed on 6/24/25 at 9:21 a.m. She said there were no activities on the weekends that had group interactions. Resident #76 said she had to have her husband bring in a compact disc (CD) player from home as it was too quiet on weekends with nothing to do.
Resident #76 said she preferred to do activities with other people to socialize and she was not getting much socialization from others on weekends. Resident #76 said other than the staff coming to her room for therapy or other needs, and if her husband came to visit she was in her room. Resident #76 said she felt isolated in her room.
Resident #76 said she did have an activities calendar in her room. The calendar indicated there was coffee and news on the weekend and she said no one attended it if they had it. Resident #76 said the other activities were listed as independent activities and she had to collect the supplies from the cabinet on her own.
C. Record review
The activities comprehensive care plan, revised 5/12/25, revealed Resident #76 enjoyed being with a group of people. It was very important to Resident #76 to do her favorite activities such as bingo, bible study, socializing, arts and crafts.
On 6/26/25 at 9:29 a.m. the DON provided a copy of the facility June 2025 monthly activity calendar. It revealed the following activities for all Sundays for June 2025:
-9:30 a.m. non denominational church;
-10:30 front desk newspaper and coffee; and,
-Coloring contest in dining room (independent activity)
It revealed the following activities for all Saturdays for June 2025:
-10:00 a.m. Individual bible study;
-2:00 p.m. Main dining room brain teaser on activity cabinet; and,
-3:00 p.m. Journaling (individual activity).
III. Staff interviews
The activities director (AD) was interviewed on 6/26/25 at 10:54 a.m. She said she was the only activities staff member. She said she worked Monday through Friday. The AD said they had two group activities every day during the week.
The AD said on Sundays the activity schedule had a non-denominational church service in the multipurpose room where services were streamed in. The AD said coffee and news was completed by the receptionist or the manager on duty for the weekend. The AD said the last scheduled activity on Sunday was a coloring contest, an individual activity where residents could obtain materials from the cabinet in the main dining room.
The AD said on Saturdays residents were able to do independent Bible study, brain teasers on the activity cabinet and journaling. The AD said these were all individual activities.
The AD said beside coffee and news and church all activities on the weekend were considered independent.
The social services consultant (SSC) was interviewed on 6/26/25 at 11:00 a.m. The SSC said the manager on duty should be assisting with activities on the weekend. The SSC said she would review the manager on duty check list to see if it was on their schedule to help with.
The receptionist was interviewed on 6/26/25 at 11:15 a.m. She said she was responsible for answering the phone, managing packages/mail and assisting visitors. The receptionist said she did not assist with activities.
IV. Facility follow up
On 2/26/25 at 2:19 p.m. the SSC provided the manager on duty check list that had been modified (during the survey) to show the manager on duty was to assist with weekend activities.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide necessary respiratory care and services cons...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to provide necessary respiratory care and services consistent with professional standards of practice and the comprehensive person-centered care plan for two (#60 and #74) of three residents reviewed for respiratory care out of 39 sample residents.
Specifically, the facility failed to ensure that Resident #60 and Resident #74 received oxygen therapy in accordance with their physician's orders.
Findings include:
I. Facility policy and procedure
The Oxygen Administration, Storage, and Handling policy, revised December 2024, was provided by the director of nursing (DON) on 6/26/25 at 9:28 a.m. It read in pertinent part, The purpose of this policy is to educate staff on the safety guidelines and usage requirements for medical gases and their cylinders.
Upon orientation and annually thereafter, all staff shall be trained on the following: Oxygen therapy should be administered by the licensed nurse as ordered by the physician or as a nursing measure and as an emergency measure until the order can be obtained, proper use of oxygen tanks in the facility, and proper handling of oxygen tanks in the facility.
II. Resident #60
A. Resident status
Resident #60, age greater than 65, was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia, hyperlipidemia, anxiety disorder and depression.
The 5/3/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required set-up assistance with eating, moderate assistance with personal hygiene, maximum assistance with transfers, and toileting.
The assessment revealed the resident was receiving oxygen therapy.
B. Observations
On 6/23/25 at 10:56 a.m. Resident #60's nasal cannula (tubing device that supplies oxygen through the nose) was in her nose, connected to a room oxygen concentrator with a setting of 5 liters per minute (LPM) of oxygen.
On 6/24/25 at 3:15 p.m. Resident #60 was sitting in her recliner in her room. The nasal cannula was in the resident's nose and the oxygen concentrator was on and set at 5 LPM of oxygen.
On 6/25/25 at 10:34 a.m. Resident #60 was sitting in a recliner in her room. The resident was connected to the oxygen concentrator via a nasal cannula in her nose, and the concentrator was set at 5 LPM of oxygen.
C. Resident interview
Resident #60 was interviewed on 6/24/25 at 3:16 p.m. Resident #60 said she used oxygen continuously at all times. She said she was on 4 LPM of oxygen but she did not know what oxygen setting her oxygen concentrator was currently set on.
D. Record review
The oxygen therapy care plan, initiated 4/30/24 and revised 5/4/24, revealed Resident #60 required oxygen related to ineffective gas exchange, coronary artery disease, and COPD. Interventions included providing oxygen therapy as ordered by the physician, monitoring for difficulty breathing, oxygen settings via nasal cannula up to 4 LPM continuously to keep oxygen saturations (level of oxygen in the blood) at or above 90 percent (%).
-A review of Resident #60's electronic medical record (EMR) revealed no documentation to indicate how many LPM of oxygen the resident was receiving.
Review of Resident #60's June 2025 CPO revealed a physician's order for oxygen up to 4 LPM via nasal cannula continuously to keep the resident's oxygen saturation levels at or above 90%, ordered on 4/17/25.
-However, observations on 6/23/25, 6/24/25 and 6/25/25 revealed Resident #60 was receiving 5 LPM of oxygen, not 4 LPM as was ordered by the physician (see observations above).
III. Resident #74
A. Resident status
Resident #74, age greater than 65, was admitted on [DATE]. According to the June 2025 CPO, diagnoses included COPD, acute and chronic respiratory failure with hypoxia (deficiency for oxygen reaching the brain), anxiety, depression, muscle weakness and acute systolic heart failure.
The 5/7/25 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 10 out of 15. She required maximum assistance from staff with personal hygiene, and was dependent on staff assistance for mobility, transfers and toileting.
The assessment revealed the resident was receiving oxygen therapy.
B. Observations
On 6/23/25 at 11:05 a.m. Resident #74 was lying in her bed watching a television show with an oxygen mask attached to her nose. The oxygen concentrator was on and attached to the oxygen mask. The resident's oxygen concentrator was set to 6 LPM of oxygen.
On 6/24/25 at 3:25 p.m. Resident #74 was in bed with her eyes closed and her oxygen mask on. The oxygen concentrator was set at 6 LPM of oxygen.
On 6/25/25 at 10:45 a.m. Resident #74 was awake, lying in bed with her oxygen mask on and her oxygen concentrator was set at 6 LPM of oxygen.
C. Resident interview
Resident #74 was interviewed on 6/25/25 at 10:46 a.m. Resident #74 said she required oxygen at all times due to her diagnosis of COPD. She said her oxygen order was for 5 LPM of oxygen and she believed that was what the oxygen concentrator was set on. Resident #74 said the staff checked her oxygen saturation levels in the morning.
D. Record review
The oxygen therapy care plan, initiated 5/1/25, revealed Resident #74 had oxygen therapy related to ineffective gas exchange and COPD. Interventions included providing oxygen therapy as ordered by the physician, head of bed to be elevated (semi-Fowler's to Fowler's position or resident out of bed upright in a chair during episodes of difficulty breathing, and monitoring for signs and symptoms of acute respiratory insufficiency. The care plan oxygen settings documented to apply oxygen via high flow nasal cannula (HFNC) up to 10 LPM. Care plan revised on 5/5/25.
-However, a review of the physician's order revealed Resident #74 had a physician's order for up to 5 LPM of oxygen continuously to keep oxygen saturations at or above 90%, order date 5/18/25.
A review of the resident's EMR revealed Resident #74's oxygen saturation levels ranged between 91% to 99%.
IV. Staff interviews
Certified nurse aide (CNA) #1 was interviewed on 6/25/25 at 12:00 p.m. CNA #1 said the unit nurse would
communicate a change of the resident's oxygen liter flow to the CNAs for monitoring purposes. She said CNAs were not permitted to change the oxygen liter flow of residents' oxygen concentrators. CNA #1 said she did not check Resident #60's oxygen concentrator when getting the resident up in the morning (6/25/25). She said she forgot to and would try to remember the next time.
Licensed practical nurse (LPN) #2 was interviewed on 6/25/25 at 11:54 a.m. LPN #2 said Resident #60's physician's order indicated the resident was to receive up to 4 LPM of oxygen , and Resident #74 physician's order indicated the resident was to receive up to 5 LPM flow of oxygen. The LPN confirmed that Resident #60 and #74 were both on an incorrect LPM of oxygen. LPN #2 said she did not check the liter flows of oxygen for Resident #60 or Resident #74 during her morning rounds. LPN #2said it was important to follow the physician's order because oxygen was considered a form of medication.
The DON was interviewed on 6/25/25 at 2:14 p.m. The DON said a physician's order was to be followed because oxygen was a form of medication. She said it was the facility's policy for staff to ensure all oxygen orders were followed. The DON said only nurses were able to change the liter flow of oxygen if necessary and informed the physician of changes in times of emergencies. The DON said receiving too much or too little oxygen could result in medical complications for residents. She said she would immediately conduct facility-wide oxygen audits and provide education to all nursing staff to ensure all residents' oxygen physician's orders were followed appropriately.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews, the facility failed to ensure the medication error rate was less than five percent (%).
Specifically, the facility had a medication error rate of 7.14%, which was two errors out of 28 opportunities for error.
Findings include
I. Professional reference
According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), E.[NAME], St. Louis Missouri, pp. 606-607. Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment.
Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights:
1. The right medication
2. The right dose
3. The right patient
4. The right route
5. The right time
6. The right documentation
7. The right indication.
According to the Voltaren gel package insert, retrieved on 6/30/25, from https://www.accessdata.fda.gov/drugsatfda_docs/label/2009/022122s006lbl.pdf, The proper amount of Voltaren Gel should be measured using the dosing card supplied in the drug product carton. The dosing card is made of polypropylene, like the tube cap containing Voltaren Gel, but without the white colorant.
The dosing card should be used for each application of a drug product. The gel should be applied within the oblong area of the dosing card up to the 2 gram (g) or 4 gram line (2 g for each elbow, wrist, or hand, and 4 g for each knee, ankle, or foot). The dosing card containing Voltaren Gel can be used to apply the gel. The hands should then be used to gently rub the gel into the skin. After using the dosing card, hold with fingertips, rinse, and dry.
II. Facility policy and procedure
The Medication Administration policy and procedure, revised December of 2024, was received from the director of nursing (DON) on 6/26/25 at 1:29 p.m. It revealed in pertinent part It is the policy of this facility that medications shall be administered as prescribed by the attending physician.
Medications must be administered in accordance with the written orders of the attending physician. All current drugs and dosage schedules must be recorded on the resident's medication administration record (MAR).
III. Observations and staff interviews
On 6/24/25 at 9:01 a.m. licensed practical nurse (LPN) #3 was preparing and administering medications to Resident #194. LPN #3 dispensed a 7.5 milligram (mg) tablet of meloxicam (non-steroidal anti-inflammatory).
The physician's order read Meloxicam 7.5 mg tablet, give 0.5 tablet by mouth one time a day for osteoarthritis. Cut the pill in half for a 3.75 mg dose.
LPN #3 was prompted to review the medication she had dispensed prior to medications being administered to Resident #194.
LPN #3 then identified she should have cut the meloxicam tablet in half to acquire the correct dose ordered. LPN #3 took the tablet and cut it in half using a tablet cutter. LPN #3 said the correct dose of a medication was part of the rights of medication administration.
-LPN #3 failed to correctly dispense the correct dose of meloxicam without prompting.
On 6/24/25 at 3:27 p.m. certified nurse aide with medication aide authority (CNA-Med) #1 was preparing medications for Resident #47. CNA-Med #1 dispensed Voltaren gel directly from the tube into a 30 milliliter (ml) medication cup.
The physician's order read Voltaren External Gel 1 %, apply 2 grams (gm) to shoulders topically four times a day for pain ordered on 6/13/25.
Observation of the medication cup revealed the medication filled the medication cup to just below the 2.5 ml line, which was the smallest measurement on the cup.
CNA-Med #1 said 2 ml was equal to 2 gm.
CNA-Med #1 said she dispensed less than 2.5 ml based on observation of medication in the cup so it was the correct amount per the order.
CNA-Med #1 said the Voltaren gel was a house stock item and was used for multiple residents, which was why she dispensed it into the medication cup.
CNA-Med #1 said she was not sure of the manufacturer's dispensing methods (see professional reference above) to ensure proper dose was administered.
CNA-Med #1 dispensed the Voltaren gel using the manufacturer's dispensing card to the two gram mark and placed it into a new medication cup.
The two medication cups were observed side by side. The medication with the correct dose had less medication in the cup compared to the medication cup that was incorrectly dispensed.
-CNA-Med #1 failed to accurately dispense the Voltaren gel according to manufacturer's guidelines and physician's order.
III. Additional staff interviews
The DON was interviewed on 6/24/25 at 4:10 p.m. She said anyone who was administering medications were to follow the seven rights of medication administration; right patient, medication, dose, time, route, documentation and diagnosis.
The DON said the rights were important to ensure residents were getting the correct medication ordered by the physician and to prevent medication errors.
The DON said Voltaren gel needed to be dispensed onto a strip to measure out the correct dose. The DON said the facility provided paper strips for Voltaren gel to be dispensed onto for the nurses to utilize for individual resident use.
The pharmacist was interviewed on 6/26/25 at 1:00 p.m. She said meloxicam was a non steroidal anti-inflammatory drug that could cause an increase of a gastrointestinal bleeding if too much was given.
The pharmacist said Voltaren gel should be measured using the dosing card that came in each box to ensure the correct dose was administered. The pharmacist stated that too much Voltaren gel could cause an increase in gastrointestinal bleeding.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Laboratory Services
(Tag F0770)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure physician ordered laboratory services were provided in a ti...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, the facility failed to ensure physician ordered laboratory services were provided in a timely manner for one (#12) of two residents reviewed for laboratory services out of 39 sample residents.
Specifically, the facility failed to ensure timely follow-up for Resident #12's urine sample, which was sent to the laboratory (lab) without being labeled with the resident's identifying information.
Findings include:
I. Facility policy and procedure
The Laboratory Services and Reporting policy and procedure, revised December 2024, was provided by the director of nursing (DON) on 6/26/25 at 1:37 p.m. It read in pertinent part, The facility must provide or obtain laboratory services to meet the needs of its residents.
The facility is responsible for the timeliness of the [laboratory] services.
II. Resident #12
A. Resident status
Resident #12, age [AGE], was admitted on [DATE]. According to the June 2025 computerized physician orders (CPO), diagnoses included diabetes, chronic obstructive pulmonary disease (COPD) and benign prostatic hyperplasia (non-cancerous enlargement of the prostate gland) without lower urinary tract symptoms.
The 5/15/25 minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The assessment documented the resident was dependent for toileting hygiene and independent for most other activities of daily living (ADL).
The assessment documented the resident was occasionally incontinent of both bowel and bladder.
B. Record review
The incontinence care plan, revised 9/25/24, revealed Resident #12 was occasionally incontinent of bladder and always incontinent of bowel. Pertinent interventions included assisting with toileting as needed, checking as required for incontinence and monitoring/documenting any signs or symptoms of a urinary tract infection (UTI).
Review of Resident #12's June 2025 CPO revealed the following physician's orders:
Urinalysis with culture and sensitivity, if indicated, for dysuria, ordered 6/19/25 at 4:17 p.m.
Ciprofloxacin (antibiotic medication) 500 milligram (mg) tablets, give one tablet by mouth every 12 hours for UTI for five days, ordered 6/25/25 at 11:40 a.m.
A progress note, dated 6/20/25 at 8:47 a.m., revealed Resident #12 complained of burning with urination. Resident #12's urine was yellow and cloudy and the nursing staff were unable to tell if the urine had a foul odor. An order for a urinalysis was noted from Resident #12's physician.
Review of Resident #12's June 2025 treatment administration record (TAR) revealed the urinalysis with culture if indicated was marked as completed on 6/20/25 at 1:57 p.m.
A lab result report, dated 6/21/25 at 1:17 a.m., revealed the facility's outside laboratory received a urine sample from the facility for Resident #12 on 6/21/25 at 1:03 a.m. The report documented the urine sample was collected from Resident #12 on 6/20/25 at 9:46 a.m. with a physician's order for a urinalysis with culture and sensitivity. The report documented the urine sample was not labeled with Resident #12's information. The report did not indicate that the urine sample had been run for a urinalysis with culture and sensitivity
A progress note, dated 6/20/25 at 3:57 p.m., revealed Resident #12 requested oxycodone (pain medication) for pain related to a UTI.
A progress note, dated 6/23/25 at 4:14 p.m., revealed Resident #12 requested oxycodone for bladder and penis pain.
A progress note, dated 6/24/25 at 6:33 a.m., revealed Resident #12 requested oxycodone for bladder and penis pain.
A progress note, dated 6/24/25 at 5:04 p.m., revealed Resident #12 requested Tylenol Extra Strength (pain medication) for bladder and penis pain.
A progress note, dated 6/24/25 at 5:05 p.m., revealed Resident #12 requested oxycodone for bladder and penis pain.
A change in condition note, dated 6/25/25 at 10:32 a.m., revealed Resident #12 had a change in condition due to dysuria (pain or discomfort during urination), cloudy urine and urinary frequency. Resident #12's physician and representative were notified of the resident's change in condition at that time.
An infection surveillance assessment, dated 6/25/25 at 12:31 p.m., revealed Resident #12 had an onset of symptoms including acute dysuria, cloudy urine and increased urinary frequency on 6/24/25. The assessment documented Resident #12's physician was notified on 6/24/25 and a urinalysis was ordered at that time. The urinalysis results returned on 6/25/25 and revealed multiple out of range findings. The culture and sensitivity report results were still pending. The resident's physician was contacted and ordered antibiotic therapy for Resident #12 for a UTI. Not all criteria were met for antibiotic usage, but the order was clarified with the physician who said to continue with the order for antibiotic therapy.
-However, Resident #12's UTI symptom onset was documented earlier in the progress notes (on 6/20/25), and a urinalysis was initially ordered on 6/19/25 and documented as obtained on 6/20/25 (see physician's orders and progress note above).
-Review of the progress notes did not reveal documentation to indicate the reason that a second urinalysis was ordered on 6/24/25 or that an initial urinalysis had already been collected on 6/20/25.
-Additionally, review of the June 2025 CPO did not reveal a physician's order for the urinalysis ordered on 6/24/25 or the reason a second urinalysis needed to be obtained.
A weekly nursing note, dated 6/25/25 at 2:38 p.m., revealed Resident #12 had a urinalysis with culture and sensitivity pending. Resident #12 had a physician's order for ciprofloxacin 500 mg tablets with instructions to give one tablet by mouth every 12 hours for five days for a UTI.
A progress note, dated 6/26/25 at 7:05 a.m., revealed Resident #12 was receiving an antibiotic for a UTI. Resident #12 reported mild discomfort with voiding. Fluids were encouraged throughout the night and Resident #12 did not have a fever.
A lab result report, dated 6/26/25 at 8:55 a.m., revealed Resident #12's urinalysis results had returned with several abnormalities and colonizing bacteria from the internal and external genitalia and no further testing was performed. The urine sample was collected from Resident #12 on 6/24/25 at 1:04 p.m. and was received by the laboratory on 6/25/25 at 4:24 a.m.
A change in condition form, undated, revealed Resident #12 had a change in condition with dysuria, cloudy urine and urinary frequency beginning on 6/19/25. The form documented Resident #12 did not have any pain. The form documented Resident #12's symptoms had stayed the same since the change was first noted.
-However, multiple progress notes between 6/20/25 and 6/24/25 documented Resident #12 requested pain medication related to bladder and penis pain (see above).
-Review of Resident #12's electronic medical record (EMR) failed to reveal documentation to indicate the facility followed up with the lab or the physician regarding Resident #12's urinalysis prior to 6/24/25, four days after the resident's initial urinalysis was received by the lab without a label with the resident's identifying information and five days after the resident initially began complaining of UTI symptoms.
III. Staff interviews
Licensed practical nurse (LPN) #1 was interviewed on 6/25/25 at 9:33 a.m. LPN #1 said Resident #12 did not have any urinary issues she was aware of and was mostly continent. LPN #1 said Resident #12's order for antibiotics had not been confirmed yet and was received this morning (6/25/25). LPN #1 said Resident #12 had not started the antibiotic yet. LPN #1 said Resident #12's urinalysis sample was collected on 6/24/25. LPN #1 said the usual turnaround for a urinalysis was about 24 to 48 hours. LPN #1 said after 72 hours, the lab would request the facility recollect the sample.
LPN #1 reviewed Resident #12's EMR and found the fax from the lab on 6/21/25. LPN #1 said there was a urine sample collected on 6/20/25. LPN #1 said she was not sure what happened during the time between the sample being collected on 6/20/25 and the sample being recollected on 6/24/25.
LPN #1 called Resident #12's physician to confirm the physician's order for the antibiotic at 9:52 a.m. (on 6/25/25) LPN #1 told the physician if a urine sample was collected from the resident on a Friday it would not be picked up until Monday. LPN #1 told the physician Resident #12 had only reported dysuria.
-However, a urine sample was collected on 6/20/25 (a Friday) and received by the outside laboratory on 6/21/25 (a Saturday).
LPN #1 was interviewed a second time on 6/25/25 at 4:13 p.m. LPN #1 said she spoke with Resident #12's physician and he wanted to start antibiotics as soon as possible. LPN #1 said she initiated a change of condition for Resident #12 and administered his first dose of antibiotic. LPN #1 said Resident #1 had multiple urinary symptoms including dysuria and urinary frequency. LPN #1 said Resident #12 reported he was having shooting pain in his legs from the UTI and had pain medication orders already.
LPN #1 said it was important to get lab results back as soon as possible so they could start treatment if needed. LPN #1 said she had spoken with the DON who told her some of Resident #12's urine samples were contaminated so the facility had to recollect the urine sample.
The assistant director of nursing (ADON) was interviewed on 6/25/25 at 9:57 a.m. The ADON said she spoke with Resident #12 and he reported the facility collected two urine samples. The ADON said Resident #12 first gave a urine sample on 6/20/25 and another one on 6/24/25. The ADON said the urine sample recollection occurred because the urine sample collected on 6/20/25 had sat too long before being tested.
The DON, the ADON and the regional clinical resource (RCR) were interviewed together on 6/26/25 at 11:30 a.m. The DON said it was impossible to get an uncontaminated free catch urine sample from Resident #12 due to his anatomy, so part of the issue was the urine samples being contaminated. The DON said Resident #12 had mild discomfort noted in his EMR. The DON said she spoke with the ADON and the ADON said the original sample was contaminated. The DON said Resident #12 went out of the facility often during the day. The DON said Resident #12 would frequently go out of the facility and that was the only reason she could think of for the delay between the first urine sample being collected on 6/20/25 and the second one collected on 6/24/25.
The RCR asked the DON and the ADON if anyone from the facility had contacted the lab to follow-up on the fax received by the facility on 6/21/25, however neither the DON nor the ADON verbalized a response.
The DON and the RCR were interviewed together again on 6/26/25 at 12:57 p.m. The RCR said Resident #12's first urine sample (from 6/20/25) was contaminated, but Resident #12 kept signing out of the facility so they had to attempt to recollect the sample multiple times. The RCR said there was no documentation in the resident's medical record of any other attempts to recollect the resident's urine sample.
The RCR said whenever the facility received a fax from the outside lab they typically gave it to the facility's lab technician.
The DON said she did not know if anyone from the facility contacted the lab after the fax on 6/20/25 regarding the unlabeled urine sample for Resident #12 was sent to them. The DON said she did not know if there was a set timeframe for when the facility needed to respond to a fax from the lab.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0849
(Tag F0849)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** IV. Resident #60
A. Resident status
Resident #60, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diag...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** IV. Resident #60
A. Resident status
Resident #60, age greater than 65, was admitted on [DATE]. According to the [DATE] CPO, diagnoses included chronic obstructive pulmonary disease (COPD), acute and chronic respiratory failure with hypoxia, hyperlipidemia, anxiety disorder and depression.
The [DATE] MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She required set-up assistance with eating, moderate assistance with personal hygiene, maximum assistance with transfers, and toileting. The resident was receiving oxygen therapy.
The assessment indicated the resident was not receiving hospice services.
B. Record review
Review of the [DATE] CPO revealed Resident #60 was admitted to hospice services related to her diagnosis of COPD on [DATE].
-Review of Resident #60's comprehensive care plan, revised on [DATE], revealed the care plan did not indicate the resident was receiving hospice services. The care plan did not include a delineation of care between the facility and the hospice company.
C. Staff interviews
CNA #1 was interviewed on [DATE] at 12:23 p.m. CNA #1 said she knew Resident #60 was receiving hospice care. She said when a resident received hospice services, a care plan should be implemented. CNA #1 said when a resident was on hospice services, there was typically a hospice binder. She said she did not know where the hospice binder for Resident #60 was located.
CNA #1 said she provided basic care for Resident #60, such as repositioning, turning the resident, assisted with transfers out of bed, and basic hygiene. She said the hospice staff came in frequently, but she did not remember the days the hospice team came in to visit the resident.
LPN #2 was interviewed on [DATE] at 12:35 p.m. LPN #2 said anytime a resident was placed on hospice care, a care plan should be implemented. She said when a resident was admitted to hospice services, she initiated a care plan revision. She said the minimum data set coordinator (MDSC) also updated the care plan. She said she did not know what Resident #60's goals were for care and treatment at the end of life. She said she was not aware that a care plan was not initiated for Resident #60 and did not know why.
The regional clinical resource (RCR) was interviewed on [DATE] at 11:48 a.m. The RCR said a hospice care plan should have been developed detailing what care the facility would provide and the role of hospice. She said the facility staff should have been educated on their role and also on where to find information related to hospice care. The RCR said the resident's care plan was not updated when she was admitted to hospice services. She said she would ensure the care plan was updated.
The DON was interviewed on [DATE] at 2:14 p.m. The DON said Resident #60 had been on hospice care since [DATE] and should have had a hospice care plan implemented. She said the resident should have a hospice-initiated care plan and a facility-initiated care plan. She said she knew Resident #60 was receiving hospice services. She said she did not know that a care plan for the resident's hospice services was not implemented, and it was an issue that she was looking forward to establishing a better communication link with outside agencies to improve the services the facility provides. She said the MDSC and nursing staff were responsible for updating the care plans. The DON said she would ensure the resident's care plan was updated immediately.
MDSC #1 and MDSC #2 were interviewed together on [DATE] at 12:12 p.m. MDSC #1 said they were responsible for updating the comprehensive care plans when there was a significant change of condition of a resident. She said she would look at the physician's orders and go by them to determine what needed to be updated on the residents' care plan.
MDSC #1 and MDSC #2 said they knew Resident #60 was placed on hospice services from their morning team meeting and should have followed up with the hospice service to determine their role and update the resident's care plan. They said they would ensure the updates were completed immediately.
Based on record review and interviews, the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for two (#24 and #60) of two residents reviewed for hospice services out of 39 sample residents.
Specifically, the facility failed to:
-Ensure the hospice agency notes regarding Resident #24's care were easily accessible to the facility staff in an attempt to effectively coordinate care with the hospice agency; and,
-Ensure the comprehensive care plan for Resident #60 was updated in a timely manner for a resident who was admitted to hospice services.
Findings include:
I. Facility policy and procedure
The End of Life Care policy and procedure, revised [DATE], was received from the director of nursing (DON) on [DATE] at 1:29 p.m. It read in pertinent part, On admission of a resident with a terminal diagnosis, or when a change in diagnosis or prognosis indicates a terminal condition, a palliative care assessment will be conducted by the interdisciplinary team.
A care plan will be developed based on the individualized assessments, the desires of the resident/surrogate decision-maker, and the physician's orders.
Hospice services will be offered as appropriate and as ordered by the physician. These services will be integrated into the overall individualized, interdisciplinary care plan. Collaboration with hospice will include processes for orienting staff to facility policies and procedures which may include documentation and record-keeping requirements.
The MDS (minimum data set assessment) will be updated per regulations. Significant change in status assessments may be deferred once identification of end-stage disease status is made unless the significant change is unrelated to the terminal illness.
II. Facility-Hospice contract
The contract between the facility and the hospice services company, dated [DATE] was provided by the DON on [DATE] at 8:51 a.m. It read in pertinent part, Facility shall provide orientation on the policies and procedures of the facility including record-keeping requirements to hospice staff furnishing care to hospice patients.
The hospice and facility agree to develop a plan of communication for each hospice patient and further agree as required by state or federal regulations, to enter all necessary information into the patients' medical chart.
III. Resident #24
A. Resident status
Resident #24, age greater than 65, was admitted on [DATE] and expired on [DATE]. According to the [DATE] computerized physician orders (CPO), diagnoses included sepsis, dementia and polyneuropathy.
The [DATE] minimum data set (MDS) assessment documented the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. The resident was dependent on staff for most activities of daily living (ADL).
The MDS assessment documented the resident was not receiving hospice services.
-However, record review revealed the resident admitted to hospice services on [DATE] (see record review below).
B. Record review
The [DATE] CPO revealed a physician's order for Resident #24 indicating the resident was admitted to hospice services on [DATE] due to his diagnosis of senile degeneration of the brain.
The hospice care plan, revised [DATE], revealed Resident #24 was admitted to hospice due to a terminal prognosis from senile degeneration of the brain. Pertinent interventions included having hospice certified nurse aides (CNAs) and registered nurses (RNs) come in twice per week and the hospice chaplain come in as needed, and to work cooperatively with Resident #24's hospice team to ensure his spiritual, emotional, intellectual, physical and social needs were met.
A hospice notebook was provided by licensed practical nurse (LPN) #5 on [DATE] at 1:20 p.m. Review of the notebook revealed a hospice staff sign-in page with one visit from the hospice social worker, dated [DATE].
-However, the notebook did not reveal any documentation from the hospice nursing staff regarding their visits and the care they provided.
A progress note, dated [DATE] at 2:58 p.m., revealed hospice staff were at the facility to admit Resident #24.
A progress note, dated [DATE] at 9:15 a.m., revealed Resident #24 did not want to take his prescribed morphine (pain medication) as it caused him to itch. Resident #24's hospice nurse had discussed getting an order for hydroxyzine (anti-itch medication) for itching the week prior. The facility had not received a prescription at that time. Resident #24 also requested an order for naproxen (pain medication). The facility staff member called Resident #24's on-call provider regarding morphine and naproxen.
A progress note, dated [DATE] at 9:50 a.m., revealed Resident #24 requested morphine for pain after a hospice staff member gave him a bed bath.
-Review of Resident #24's electronic medical record (EMR) failed to reveal any other progress notes from the hospice services provider.
C. Staff interviews
CNA #2 was interviewed on [DATE] at 2:26 p.m. CNA #2 said the hospice nurses and CNAs came in to visit Resident #24 twice per week. CNA #2 said the hospice staff bathed Resident #24 and attended to more acute issues like adjusting his wedge positioning pillows. CNA #2 said the hospice staff verbally briefed the nurse on the unit or the CNAs of what care they provided Resident #24 as they were leaving. CNA #2 said there was not any written documentation of what care the hospice staff provided Resident #24 during their visits.
LPN #5 was interviewed on [DATE] at 3:21 p.m. LPN #5 said the hospice CNAs had visited and bathed Resident #24 that morning ([DATE]) and his nurse had come in the day prior. LPN #5 said a hospice staff member visited Resident #24 every other day. LPN #5 said the hospice staff told the facility's nursing staff what care they provided at the end of their visit. LPN #5 said she signed documents for the hospice staff confirming the care they provided at each visit, and that the hospice staff kept documentation of what care they provided.
-However, documentation of what care was provided by the hospice staff for Resident #24 was not in the resident's EMR (see record review above).
LPN #1 was interviewed on [DATE] at 9:13 a.m. LPN #1 said any documentation by the hospice CNAs or nurses would be kept in Resident #24's hospice binder. LPN #1 reviewed Resident #24's hospice binder and said the hospice nursing staff signed in on the sign-in sheet. LPN #1 said she knew the hospice staff had visited Resident #24 more than what was recorded on the sign-in sheet (see record review above). LPN #1 said the hospice nursing staff gave a verbal report of what care they provided Resident #24 before they left, and the nurse on duty needed to document any showers that were given in the resident's EMR so the next nursing shift would know.
CNA #3 was interviewed on [DATE] at 2:38 p.m. CNA #3 said the hospice staff bathed Resident #24, washed his hair and shaved his face as needed. CNA #3 said she thought the hospice staff kept their own documentation and told the facility nurse what care they provided Resident #24, but the facility staff charted any baths the resident received in his EMR.
The executive director (ED) of the hospice provider was interviewed on [DATE] at 4:58 p.m. The ED said Resident #24 received two visits from a hospice CNA and one visit from a hospice nurse each week. The ED said a hospice chaplain and a social worker visited Resident #24 once per month. The ED said she had spoken with the nurse who worked with Resident #24, and was told the nurse checked in verbally with one of the facility nurses or the facility social worker before leaving. The ED said there were no forms or documents filled out for the facility that she was aware of. The ED said the facility's processes of communication were a grey area.
The DON was interviewed on [DATE] at 11:30 a.m. The DON said she had looked through her emails to see if she had received any documentation or communication from the hospice provider but could not find any. The DON said she had recently talked with a liaison from the hospice provider about how to improve communication. The DON said there was verbal communication between the hospice nursing staff and the facility nursing staff, and new orders were added to Resident #24's hospice binder. The DON said in the past they had a process where the hospice company would email any notes to the facility's medical records department who would then upload the documents to the resident's EMR. The DON said the hospice notes were needed to implement interdisciplinary care for the residents.
-However, review of Resident #24's EMR and hospice binder did not contain any hospice visits or any documentation aside from the hospice social worker visit (see record review above).
The assistant director of nursing (ADON) was interviewed on [DATE] at 11:52 a.m. The ADON said she had noticed the previous Friday ([DATE]) that the facility was having communication issues with their hospice providers. The ADON said she met with the hospice provider earlier that day to improve their communication. The ADON said the hospice providers were not signing in when they came to the facility. The ADON said the facility currently had verbal communication between the hospice providers and the facility nursing staff. The ADON said she would prefer to have all of the care information written in the resident's medical record so the facility could track whether the residents'showers were being given, if any orders had changed, or to see if the resident had any changes in health.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected multiple residents
Based on record review and interviews, the facility failed to honor resident choices for residents residing on three of four units of the facility.
Specifically, the facility failed to ensure resident...
Read full inspector narrative →
Based on record review and interviews, the facility failed to honor resident choices for residents residing on three of four units of the facility.
Specifically, the facility failed to ensure residents could choose to eat in the dining room at dinner time and on the weekends.
Findings include:
I. Facility policy and procedure
The Promoting/Maintaining Resident Self-Determinations policy and procedure, revised December 2024, was provided by the director of nursing (DON) on 6/26/25 at 1:29 p.m. It read in pertinent part, Each resident has the right to make choices about aspects of his or her life in the facility that are significant to the resident.
Each resident has the right to interact with members of the community and participate in
community activities both inside and outside of the facility.
The facility will accommodate the resident preferences to the extent possible.
II. Resident interviews and observations
On 6/23/25 at 4:30 p.m. Resident #60 was sitting next to a round table close to the north hall nursing station, accompanied by an unidentified resident. Resident #60 said she was waiting for a staff member to bring her dinner. Resident #60 said she preferred going down to the dining room for meals, but the dining room was only open for breakfast and lunch. She said the dining room was closed for dinner on weekdays and on the weekends. Resident #60 said the dining room had always been closed for dinner and wished that the facility would consider opening it for the resident since she enjoyed dining there with her peers.
Resident #17 was interviewed on 6/24/25 at 5:18 p.m. Resident #17 said she did not know the dining room was open again. Resident #17 said the dining room had been closed for a long time. Resident #17 said she did not know if any of the facility staff had ever invited her to the dining room.
Resident #76 was interviewed on 6/24/25 at 9:16 a.m. Resident #76 said she liked to eat in the dining room. Resident #76 said she wished the dining room was open for dinner, but that it was closed during dinner and for all meals on the weekend. Resident #76 said the facility staff members told her they were trying to get approval to have the dining room open for dinner and on the weekends. Resident #76 said she had to eat in her room otherwise. Resident #76 said she preferred to be in the dining room to help her socialize, enjoy the company of other people and get her food faster. Resident #76 said she did not have fun eating in her room alone. Resident #76 said at home she had her husband to sit and eat with.
III. Observations
On 6/23/25 at 12:02 p.m. two unidentified residents were talking in the dining room during the lunch meal service. One resident told the other that dinner was only served in the residents' rooms. The resident told the other resident only breakfast and lunch were served in the dining room.
On 6/24/25 at 4:46 p.m. Resident #76 was not in the main dining room for dinner. Resident #76 was sitting in her room sitting in her wheelchair. Resident #76 said she was waiting for her dinner.
On 6/24/25 at 4:48 p.m., during the scheduled dinner service, no residents were present in the dining room.
On 6/25/25 at 4:05 p.m. Resident #66's representative came out of her room and to the nurse's station. Resident #66's representative told licensed practical nurse (LPN) #4 that he would like to take Resident #66 to the dining room for dinner. LPN #4 said the dining room was not open because there was no one available to supervise them. Resident #66's representative went back to the resident's room with a disappointed look on his face.
On 6/25/25 at 5:15 p.m. an unidentified resident and her representatives walked into the dining room. One of the resident's representatives told the other representative they could eat in the dining room at breakfast and lunch, but it was closed for dinner and on the weekends.
IV. Record review
A facility all-staff inservice, dated 3/10/25 at 2:15 p.m., was provided by the regional dietary consultant (RDC) on 6/26/25 at 1:38 p.m. It revealed staff were educated on the main dining room being reopened. The inservice documented the dining room would be reopened on 3/11/25. The inservice documented the facility certified nurse aides (CNA) would be primarily responsible with helping residents get to the dining room and would be present in the dining room during meals.
An undated flyer was provided by the RDC on 6/26/25 at 1:38 p.m. It revealed the dining room was reopened on 3/10/25. Meal times were listed and included dinner starting at 4:30 p.m.
An undated performance improvement plan was provided by the RDC on 6/26/25 at 11:42 a.m. It revealed the dining room and meal times were an identified concern. The plan documented dining was slow to resume after the COVID-19 pandemic and the facility was working on opening the dining room. The plan documented there were concerns that not all facility staff members were aware of the open-dining processes. Corrective actions included a soft opening of the dining room, completed 3/11/25, a grand opening of the dining room in April 2025 and education with staff on the dining room processes, completed 3/11/25. Additional corrective actions completed during the survey process included reeducation to staff on the open, completed 6/25/25 (during the survey process), and reeducation and announcing to residents to advise them of the open dining and meal times, completed 6/26/25 (during the survey process).
V. Staff interviews
CNA #3 was interviewed on 6/25/25 at 2:38 p.m. CNA #3 said the nursing staff invited the residents to go to the dining room for breakfast and lunch. CNA #3 said the facility's restorative aide did restorative dining and monitored the dining room for breakfast and lunch. CNA #3 said the CNAs also helped in the dining room as needed. CNA #3 said the restorative aide left work after lunch, so the facility did not have dinner in their main dining room. CNA #3 said the residents at the facility wanted to eat in the dining room for dinner but they did not have the staff to do so. CNA #3 said if residents wanted to eat in the dining room for dinner, the nursing staff brought them to the tables near the nurse's stations to eat.
LPN #1 was interviewed on 6/25/25 at 4:13 p.m. LPN #1 said the nursing and facility staff invited residents to eat in the dining room. LPN #1 said residents only went to the dining room for breakfast and lunch but did not go to the dining room for dinner. LPN #1 said she did not know if any of the residents wanted to go to the dining room for dinner, as she had not asked any of them if they wanted to eat in the dining room at dinner time.
The dietary manager (DM) and the RDC were interviewed together on 6/26/25 at 9:54 a.m. The DM said the facility's restorative aide went around the facility and asked residents if they wanted to eat in the dining room. The RDC and the DM said residents should have been invited to the dining room at dinner time. The RDC said she heard a staff member say the dining room was not open at dinner so she provided them with education.
The RDC said the facility did a grand reopening of their dining room in March 2025 and had been doing reeducation with the facility staff since then.
The DM said the dining room was also open on the weekends. The RDC said she thought more education needed to be done with the facility staff.
The RDC was interviewed a second time on 6/26/25 at 2:02 p.m. The RDC said the admission binder had a page with the meal times and noted it said each meal was available in the dining room or in the resident's room. The RDC said the facility staff went around that day (6/26/25) to each of the long-term residents to educate them that the dining room was open, as it had been a while since they received their admission binder. The RDC said she knew the process of the facility reopening their dining room had been slow-going. The RDC said the facility had tried to reopen the dining room, had a COVID-19 outbreak, opened the dining room again and had a norovirus outbreak.
CNA #5 was interviewed on 6/26/25 at 11:19 a.m. CNA #5 said the facility recently had a resident council meeting to discuss meal times and remind residents to go to the dining room. CNA #5 said she knew with certainty the dining room was open for breakfast and lunch. CNA #5 said she was not sure if the dining room was open for dinner on the weekends because she did not work that shift.
The DON, the assistant director of nursing (ADON) and the regional clinical resource (RCR) were interviewed together on 6/26/25 at 11:52 a.m. The ADON said the main dining room was open for all meals every day of the week. The DON and the RCR said the dining room was open each meal every day of the week. The ADON said the facility had been trying to do education on it being open with both the facility staff and the residents. The ADON said the facility did a grand reopening of the dining room. The ADON said there may have been some miscommunication at some point with the staff and residents, so they had been doing education to promote residents going to the dining room.
The nursing home administrator (NHA) was interviewed on 6/26/25 at 2:00 p.m. The NHA said the facility's last norovirus (gastrointestinal virus) outbreak was three months prior (March 2025) and the main dining room was reopened after that. The NHA said the facility had a grand reopening for their main dining room and discussed the dining room being open during their all-staff meeting on 3/11/25. The NHA said the dining room was open during breakfast and lunch now, but there was no dining in the dining room on the weekends.
VI. Facility follow-up
The RDC sent an email with additional information on 6/27/25 at 1:40 p.m. (after the survey). The RDC said the facility had open dining in the dining room and each unit in the facility had tables for residents to dine. The RDC said residents were able to eat dinner and socialize at tables in each unit's dining area. The RDC said the main dining room had been back and forth on being opened due to different outbreaks, but the dining locations on each unit had been consistently open.
-However, observations, resident interviews and staff interviews revealed the dining room was not consistently open during dinner and on the weekends for dining (see observations and interviews above).
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards in two of four medications carts and one of one vaccine storage refrigerators.
Specifically, the facility failed to:
-Ensure vaccinations were not stored in dormitory style refrigerator;
-Ensure expired vaccines were removed from refrigerators;
-Ensure Tubersol (used to test for tuberculosis) vials were dated upon opening;
-Ensure medication carts were clean from loose pills; and,
-Ensure medications were stored according to route.
Findings include:
I. Professional reference
According to the Vaccine Storage and Handling Tool-kit, dated 3/29/24, retrieved on 6/30/25, from https://www.cdc.gov/vaccines/hcp/downloads/storage-handling-toolkit.pdf, it revealed in pertinent part, Do not store any vaccine in a dormitory-style or bar-style combined refrigerator/freezer unit under any circumstances. These units have a single exterior door and an evaporator plate/cooling coil, usually located in an icemaker/freezer compartment. These units pose a significant risk of freezing vaccines even when used for temporary storage.
According to the Tuberculin Purified Protein Derivative Tubersol package insert, retrieved on 6/30/25 from https://www.fda.gov/media/74866/download It revealed in pertinent part A vial of Tubersol which has been entered and in use for 30 days should be discarded.
II. Facility policy and procedure
The Storage of Medications policy and procedure, dated 10/1/23, was received from the director of nursing (DON) on 6/26/25 at 1:29 p.m. It revealed in pertinent part Medications and biologicals were stored safely, securely, and properly, following manufacturer's recommendations or those of the supplier. The medication supply was accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications.
All medications dispensed by the pharmacy were stored in the container with the pharmacy label. Orally administered medications were kept separate from externally used medications and treatments such as suppositories, ointments, creams, vaginal products. Eye medications were stored separately per facility policy. Except for those requiring refrigeration or freezing, medications intended for internal use were stored in a medication cart or other designated area.
Outdated, contaminated, or deteriorated medications and those in containers that were cracked, soiled, or without secure closures were immediately removed from inventory, disposed of according to procedures for medication disposal.
Medication storage areas were kept clean, well-lit, and free of clutter and extreme temperatures and humidity. Medication storage conditions were monitored on a monthly basis by the consultant pharmacist and corrective action taken if problems were identified. Refrigerated medications were kept in closed and labeled containers, with internal and external medications separated and separate from fruit juices, applesauce, and other foods used in administering medications.
Other foods such as employee lunches and activity department refreshments were not stored in this refrigerator.
Medications requiring refrigeration were kept in a refrigerator at temperatures between 36 degrees fahrenheit (F) and 46 F were refrigerated unless otherwise directed on the label.
The facility should maintain a temperature log in the storage area to record temperatures at least once a day. The facility should check the refrigerator or freezer in which vaccines were stored, at least two times a day, per CDC (Centers for Disease Control and Prevention) guidelines.
III. Vaccine storage
A. Observations
On 6/26/25 at 10:38 a.m. the vaccine refrigerator was observed with the infection preventionist (IP) and the DON. There was no thermometer in the refrigerator upon opening.
The vaccine fridge constrained the following:
-Two COVID-19 vaccine comirnaty that expired on 4/17/25;
-Two vials of Prevnar 20 0.5 milliliter (ml) that expired in February 2025;
-Four boxes (10 vials each) totaling 40 doses of Influenza Vaccine FLUAD (Influenza Vaccine, Adjuvanted) which expired on 4/19/25;
-One vial of Tubersol with no open date; and,
-Three boxes (ten vials each) of Afluria flu vaccine totalling 30 doses.
-The facility failed to monitor temperatures of vaccines stored and failed to remove expired medications timely.
The vaccine refrigerator was also observed to be a dormitory style refrigerator (see professional reference above).
-The facility failed to store vaccines in a refrigerator approved for vaccine storage.
B. Staff interviews
The DON and the IP were interviewed on 6/26/25 at approximately 10:40 a.m. during observation of the vaccine refrigerator. She said temperature monitoring was important to ensure vaccines were kept at appropriate temperatures. The IP said storage was important to help ensure the effectiveness of a vaccine. The IP was unaware that vaccines were not to be stored in a dormitory style refrigerator.
The IP said the Tubersol should have been dated upon opening to ensure it was not used past the use by date once opening. The IP said she was unaware how many days it was good for once the vial of Tubersol was opened.
The DON said she was unaware the IP stored vaccines in her office. The DON said she was unaware vaccines could not be stored in a dormitory style refrigerator. The DON said they would get a thermometer placed in the refrigerator immediately. The DON took all expired vaccines and the open Tubersol with her for disposal.
IV. Medication cart
A. Observations
On 6/25/25 at 4:47 pm the Granada medication cart was observed with licensed practical nurse (LPN) #1. The medication cart had three boxes of Estradiol vaginal cream 0.1 (milligram/ per gram (mg/gm) stored in the same compartment as inhalers and nasal sprays. There were three tubes of clobetasol propriate (used to treat skin irritations) 0.05% cream stored next to inhalers and nasal sprays.
-The facility failed to ensure creams were not stored with inhalers/nasal sprays.
The Granada cart also had six tablets and two capsules loose within the medication drawers.
-The facility failed to keep the medication cart clean.
On 6/25/25 at 5:10 p.m. the Oasis medication cart was observed with LPN #2. The cart had two open Aspercream cream 4 % lidocaine (topical pain relief) patches open in the box (no longer in original manufactured foil packaging).
-The facility failed to ensure medications were kept in original packaging.
B. Staff interviews
LPN #1 was interviewed on 6/25/25 at 4:47 p.m. during observations of the [NAME] medication cart. She said medications should be stored according to their route to prevent contamination of medications or the exposure of one route to another route a medication was not used for. LPN #1 said it was the responsibility of all staff administering medications to keep the medication cart clean.
LPN #2 was interviewed on 6/25/25 at 5:10 p.m. during observation of the Oasis medication cart. She said medications were to be stored in the original packaging till ready to administer. LPN #2 said the Aspercream 4% lidocaine patches were no longer in their original packaging and they should have been disposed of when not used.
V. Additional staff interviews
The pharmacist was interviewed on 6/26/25 at 1:00 p.m. She said vaccines should be stored in a refrigerator between 37 to 47 degrees F and temperature monitoring should occur 1 one to two times a day. The pharmacist said expired medications or vaccines should be removed as soon as possible to prevent administration of an expired medication.
The pharmacist said medications should be stored according to the route of administration to ensure there was no cross contamination and to prevent medication from being administered incorrectly.
The pharmacist said all medications should be stored in original packaging to ensure effectiveness. The pharmacist said Aspercream patches were sticky and if not stored
properly would be less effective in sticking to the resident and it would affect the delivery of medication.
The pharmacist said vials should be dated when open as medications were only good for so many days once opened. The pharmacist said using a medication passed its best use by date decreases the effectiveness of the medication.
CONCERN
(F)
Potential for Harm - no one hurt, but risky conditions existed
Food Safety
(Tag F0812)
Could have caused harm · This affected most or all residents
Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen.
Specifically, the facility f...
Read full inspector narrative →
Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen.
Specifically, the facility failed to:
-Thaw meat in a safe manner; and,
-Ensure jewelry was not worn during food preparation and meal service.
Findings include:
I. Failed to thaw meat in a safe manner
A. Professional reference
The Colorado Retail Food Establishment Regulations, effective 3/16/24, were retrieved on 6/30/25. It read in pertinent part, Time/temperature control for safety food shall be thawed completely submerged under running water with sufficient water velocity to agitate and float off loose particles in an overflow. (3-501.13)
B. Facility policy and procedure
The Safe Thawing Practices policy and procedure, revised September 2017, was received from the regional dietary consultant (RDC) on 6/26/25 at 11:42 a.m. It read in pertinent part, Thaw items in clean water. When water is running, it should be running fast enough to agitate any loose particles.
C. Observations
During a continuous observation of the lunch meal service on 6/25/25, beginning at 10:13 a.m. and ending at 12:48 p.m. the following was observed:
At 10:15 a.m. three bags of raw frozen chicken cutlets were submerged in water in the kitchen sink. The faucet was not on and the bags of chicken were not under running water. All of the chicken cutlets were in their original plastic packaging.
At 10:57 a.m. the dietary manager (DM) turned the sink faucet on and adjusted the flow of water and the drain opening.
At 11:08 a.m. the three bags of chicken cutlets were in the kitchen sink and the water in the sink had completely drained. A slow trickle of water came out of the sink faucet and hit one corner of one of the bags of cutlets.
At 11:18 a.m. the DM turned the sink faucet so the water flowed faster and pressed on the bags of chicken several times.
At 11:23 a.m. the sink was filled with water but the bags of chicken cutlets were not completely submerged by the water. The faucet had a steady flow of water flowing onto one of the bags of chicken. The top side of each of the bags (approximately eight inches by 11 inches of surface area) of chicken cutlets was not covered by water.
At 11:26 a.m. the kitchen sink was overflowing with water and spilling onto the floor. Dietary aide (DA) #1 adjusted the sink drain.
At 11:45 a.m. the three bags of chicken cutlets were sitting completely submerged in water in the sink. No water was running from the faucet.
At 11:47 a.m. the RDC turned on the faucet for the sink containing the chicken cutlets.
At 11:50 a.m. the RDC told the DM they may need to thaw the chicken cutlets in a different manner. The DM told the RDC the chicken cutlets were for dinner that night. The DM removed the bags of chicken cutlets from the sink, placed them into a plastic bin and placed them in the walk-in refrigerator.
D. Staff interviews
The RDC and the DM were interviewed together on 6/26/25 at 9:54 a.m. The DM said when meat was thawing in the sink it should be under running water. The RDC said meat thawed in the sink could be in its original packaging under running water. The RDC said the chicken cutlets were in the walk-in cooler but were frozen solid, so the dietary staff placed it under running water. The RDC said someone had shut the water off, so she turned it back on. The RDC said the dietary staff ideally did not thaw meat in the sink, but she provided education on thawing practices for the dietary staff. The RDC said meat thawed in the sink did not need to be completely submerged in water but needed to maintain a constant water flow.
II. Failure to ensure jewelry was not worn during food preparation and service
A. Professional reference
The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 6/30/25. It read in pertinent part, Except for a plain ring such as a wedding band, while preparing food, food employees may not wear jewelry including medical information jewelry on their arms and hands. (2-303.11)
B. Facility policy and procedure
The Sanitary Standards Dietary Personnel policy and procedure, revised July 2016, was received by the RDC on 6/26/25 at 11:42 a.m. It read in pertinent part, Dietary personnel are not permitted to wear costume jewelry, large dangling earrings or rings with stones while on duty. Jewelry may include a wristwatch, wedding band, and post earrings.
B. Observations
During a continuous observation of the lunch meal service on 6/25/25, beginning at 10:13 a.m. and ending at 12:48 p.m. the following was observed:
At 10:13 a.m. cook (CK) #1 was wearing a watch and a fashion dangly chain bracelet on his left wrist, a plain band ring on his right index finger and a plain band ring on his left ring finger.
At 11:34 a.m. CK #1 began plating meals for the lunch service. CK #1 was still wearing the items of jewelry above.
At 12:08 p.m. CK #1 used hand sanitizer to perform hand hygiene. While rubbing his hands with the sanitizer, CK #1's ring fell off of his index finger and onto the tray line near one of the steam table bins of food. CK #1 picked the ring up and placed it into his pocket before continuing to plate food.
C. Staff interviews
The RDC and the DM were interviewed together on 6/26/25 at 9:54 a.m. The DM said the dietary staff should not wear any jewelry aside from a small wedding band. The RDC said a wedding band was appropriate to wear, and a watch was fine. The RDC said the dietary staff tried to avoid wearing excess jewelry while on duty. The RDC said she and the DM both saw CK #1 was wearing a bracelet during lunch service the day prior. The RDC said CK #1's bracelet did not come off and was not able to be removed. The RDC said she provided education on the topic of jewelry with the dietary staff the day prior (6/25/25). The DM said he and the RDC were going to get together to figure out what education to give CK #1 since his bracelet could not be removed.
Nov 2023
9 deficiencies
1 IJ (1 affecting multiple)
CRITICAL
(K)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Immediate Jeopardy (IJ) - the most serious Medicare violation
Free from Abuse/Neglect
(Tag F0600)
Someone could have died · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C. Resident #8, age [AGE], was admitted to the facility on [DATE]. According to the November 2023 CPO, her diagnoses included st...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** C. Resident #8, age [AGE], was admitted to the facility on [DATE]. According to the November 2023 CPO, her diagnoses included stroke, left-sided paralysis, lupus, embolism (blood clot) left leg, kidney disease, anxiety, and depression.
The 9/21/23 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. She required set-up assistance with eating and supervision with showering and transferring from the bed.
The MDS identified the resident had no behavioral symptoms. However, the resident had a behavior care plan, initiated 2/15/2001, that identified Resident #8 could have the potential for physical and verbal aggression towards others and interventions included (in part) to approach in a calm manner, anticipate and meet the resident's needs, encourage the resident to express feelings appropriately, and explain all procedures/cares.
1. Resident interviews
Resident #8 was interviewed on 11/1/23 at 2:17 p.m. She said CNA #1 told her that he had to take care of her no matter how disgusting she was. Resident #8 said she reported this information to a frequent facility visitor.
Resident #8 was interviewed again on 11/6/23 at 10:05 a.m.
-She said she was scared that there might be repercussions for her saying things to the frequent facility visitor about CNA #1, as she knew the CNA had friends at the facility. She said the nurses might take his side and it might come back to her. Resident #8 said the NHA had told her everything had been resolved.
-She said CNA #1 was always a bully; he often slammed the door and he would knock so loudly on the door that other residents thought he was knocking on their doors. She said he sometimes would not talk to her at all (ignored her) when he was supposed to be caring for her, yet he was talking very loudly in the hallway. Resident #8 said if CNA #1 was working, she was anxious that he might come in and say something to her. She said, I felt like I did something wrong. It had been a relief not to hear his loud voice over the unit. (CNA #1 was terminated on 10/27/23.) She said she could not understand how anyone like that was working in healthcare.
Resident #8 was interviewed again on 11/7/23 at 10:00 a.m.
-She said at one point, CNA #1 suddenly stopped speaking to her. She said that he brought food trays into the room, and slammed them down on the table, and then slammed the door shut. Resident #8 said CNA #1 was hostile toward her and he told her once that she was full of it. She said if she pressed her call light, he would walk into the room, be abrupt, and sternly said yes. The resident said she was not comfortable with him caring for her again, but I thought I could suck it up.
-She said that sometimes she did not press her call light if he was the only one that she knew would answer because she was afraid of the way he would treat her. Resident #8 said staff members had told her that CNA #1 had a bad attitude and there were other witnesses that she was not willing to identify because she was afraid of repercussions.
2. Facility response to CNA #1 behaviors - failures in response
a. On 11/2/23 at 4:00 p.m. the human resources director (HRD) provided staffing records for CNA #1. A Counseling/Disciplinary Notice of written warning for CNA #1 was reviewed, which was completed by the director of nursing (DON) and dated 10/4/23. It read in pertinent part:
Reasons why counseling/disciplinary action is necessary: On multiple occasions staff and residents have raised concern in regards to your attitude and negativity on the unit. This includes rude interactions, frustrated comments and generalized negative statements in front of staff and residents.
Corrective action: Re-education to staff member on facility standards in regards to professional interactions with patients, family and staff. The expectation is that these actions will be corrected immediately.
There was no further documentation on the counseling/disciplinary form whether there was distress on the part of the residents who raised concerns.
b. On 11/6/23 at 5:40 p.m., the NHA provided an email received from a frequent facility visitor on 10/23/23. The email read, in pertinent part:
CNA #1 was verbally abusive to her (Resident #8). Every day for the past month CNA #1 has had a bad attitude. In one instance, the resident was leaving for an appointment soon and was wondering if she would be able to eat before she had to go. She asked CNA #1 if her food was there yet and he stated, we are not withholding food no matter how disgusting you are to us. Now he slams her food tray down and will leave without saying a word.
b. On 11/2/23 at approximately 10:00 a.m., the NHA provided the abuse investigation documents triggered by the frequent visitor's email regarding Resident #8 and the final report of an investigation which was submitted to the state on 10/28/23. There were ten resident and ten staff interviews included in the investigation which documented no concerns from staff or residents about CNA #1. The facility did not substantiate the allegation of verbal abuse.
c. On 11/2/23 at 4:00 p.m., the human resource director (HRD) provided a Counseling/Disciplinary notice that indicated CNA #1 was terminated on 10/27/23. The reason for the termination was that multiple grievances had been reported related to customer service concerns and attitude, and had included interviews with staff and residents.
3. Failures in facility response
(1) Untimely response
An interview with the frequent visitor (see below) revealed they had witnessed CNA #1's behavior toward Resident #8 in late July 2023, and had discussed the staff's behavior generally with the NHA in August 2023. However, in the facility responses set forth above, there was no evidence the facility considered the CNA's behavior potentially abusive. Further, there was no evidence corrective action was taken until 10/4/23 and then on 10/28/23 to investigate, as potential abuse, the issues raised by the visitor to protect Resident #8, as well as other residents, from his behavior.
The frequent visitor was interviewed on 11/7/23 at 10:28 a.m. She said she first heard about CNA #1 being rude and treating Resident #8 poorly on 7/11/23, however, the resident did not want to file a formal grievance due to fear of retaliation. She said she visited the resident again on 7/27/23 and was in the room when CNA #1 brought a tray of food to the resident. The frequent visitor said she requested CNA #1 wait a minute to confirm the food was what the resident had requested. She said CNA #1 said I don't have time for that, and he dropped the tray on the side table and left without removing the lid off the food. She said the resident did not want to file a formal grievance due to fear of retaliation, but the frequent visitor was a witness to CNA #1's behavior. The frequent visitor said she met with the NHA in August 2023 and she discussed the issues of rude staff. She said the NHA said he thought he knew who she was talking about.
The frequent visitor said the resident ultimately permitted her to report the abuse to the facility administration on 10/23/23.
(2) Incomplete investigation
The investigation included interviews with ten staff and ten residents, all of whom said they had no concerns about CNA #1. However, the investigation failed to include the history of disciplinary action and other grievances involving CNA #1, even though the 10/27/23 termination of the CNA (see above) indicated CNA #1 had triggered multiple grievances related to customer service concerns from staff and residents. The investigation reported an interview with the resident who stated she was comfortable having the CNA care for her, but see above; interviews with Resident #8 indicated she was concerned about retaliation.
Further, a review of the facility abuse investigation completed on 10/28/23 revealed no evidence it led to changes in the facility abuse procedures to ensure that abusive incidents would be properly identified, promptly and thoroughly reviewed and analyzed, and changes implemented to prevent future incidents of abuse.
D. Resident #4, age [AGE], was admitted on [DATE]. According to the November 2023 CPO, her diagnoses included kidney disease, heart disease, vascular dementia, epilepsy, and major depressive disorder.
The 7/25/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15. She required set-up assistance with eating and supervision with showering and transferring from the bed.
The MDS identified the resident had no behavioral symptoms. However, the resident had a behavior care plan, initiated 7/28/2001, that identified Resident #4 could have the potential for behavioral issues related to her anxiety and vascular dementia. Interventions included (in part) to approach in a calm manner, anticipate and meet the resident's needs, encourage the resident to express feelings appropriately, and explain all procedures/cares.
1. Resident interview and observation
Resident #4 was interviewed on 11/7/23 at 3:05 p.m. She started to have tears in her eyes when CNA #1's name was mentioned regarding her care and experience with him. When asked if she could talk further about him, she shook her head no and appeared sad. The resident sighed and appeared relieved when informed that CNA #1 did not work for the facility anymore.
2. Facility response to Resident #4's complaint - failures in response
A grievance/complaint and concern form dated 9/22/23, completed for Resident #4, was provided by the NHA on 11/7/23 at approximately 10:00 a.m. The form described the complaint in pertinent part:
-The resident voiced concerns regarding CNA (#1) and said he was frustrated with her when she did not answer fast enough or do tasks fast enough and said that CNA (#1) was rude in his interactions.
-Follow-up findings on the grievance form, per DON documentation, included re-education for CNA (#1) of customer service expectations on 10/4/23. There was no further documentation on the grievance/complaint and concern form and no indication of whether there was distress on the part of the resident.
This was the second response by the facility that read CNA #1's behavior was considered a customer service issue. (See above response to Resident #253 complaint) There was no evidence that other action was considered or taken by the facility. Specifically, the complaint was not recognized as potential abuse and was not reported or thoroughly investigated. (Cross-reference F609 and F610). Further, there was no evidence of a plan to monitor CNA #1 despite repeated complaints about his interactions with residents.
E. Resident #15, age [AGE], was admitted on [DATE]. According to the November 2023 CPO, her diagnoses included kidney disease, hypothyroidism, chronic obstructive pulmonary (lung) disease, vascular dementia, and anxiety disorder.
The 10/5/23 MDS assessment revealed the resident had moderate cognitive impairment with a BIMS score of 12 out of 15. She required set-up assistance with eating, substantial/maximal assistance with showering, and partial/moderate assistance with transferring from the bed.
The MDS identified the resident had no behavioral symptoms. However, the resident had a behavior care plan, initiated 7/25/2001, that identified Resident #15 could have the potential for paranoia and delusions and interventions included (in part) to approach in a calm manner, anticipate and meet the resident's needs, encourage the resident to express feelings appropriately, and explain all procedures/cares.
1. Interviews
A frequent visitor was interviewed on 11/7/23 at 10:28 a.m. She said three residents reported that CNA # 1 had treated them poorly, and she identified Resident #15 as one of the three residents.
Resident #15 was interviewed on 11/7/23 at 12:45 p.m. She said that CNA #1 screamed at her because she was not fast enough. She said she did not like him because he was mean to her and made her feel like an idiot. She said he would yell You do it now! Resident #15 said CNA #1 picked on her because she could not talk fast enough. She said he would storm out of the room.
2. Facility response to CNA #1's reported behavior - failures in response
A grievance/complaint and concern form dated 9/22/23 was provided by the NHA on 11/7/23 at approximately 10:00 a.m. The form was completed for Resident #15 and described the complaint in pertinent part:
-Resident voiced concerns about a specific CNA (#1) being frustrated when the resident did not answer fast enough or do tasks fast enough and said the CNA (#1) was rude in his interactions. There was no further documentation on the grievance/complaint and concern form and no indication of whether there was distress on the part of the resident.
-Follow-up findings on the grievance form, per DON documentation, included re-education for CNA #1 of customer service expectations on 10/4/23.
See above; although this was yet another grievance regarding CNA #1's interaction with residents, there was no evidence that other action was considered or taken by the facility. Specifically, the complaint was not recognized as potential abuse and was not reported or thoroughly investigated. (Cross-reference F609 and F610). Moreover, there was no evidence of a plan to monitor CNA #1 despite repeated complaints about aggressive interactions with residents.
F. Resident #87, age [AGE], was admitted on [DATE] and discharged on 10/27/23. According to the October 2023 CPO, her diagnoses included intracerebral hemorrhage (bleeding in the brain), paralysis of vocal cords, heart disease, urinary tract infection, and diabetes.
The 10/17/23 MDS assessment revealed the resident was cognitively intact with a BIMS score of 13 out of 15. She required set-up assistance with eating, substantial/maximal assistance with showering, and partial/moderate assistance with transferring from the bed. The MDS assessment identified the resident had no behavioral symptoms.
1. Resident representative interviews
Resident #87's representative was interviewed on 11/7/23 at 11:30 a.m. He said he did not feel comfortable leaving his mom alone in the facility due to CNA #1's behaviors. He said either he or his sister stayed with their mother throughout her stay.
Resident #87's representative was interviewed again on 11/8/23 at 11:46 a.m. He said his mother was frightened by CNA #1's behaviors. He said CNA #1 came into the room late at night knocking very loudly on the door. He said he observed CNA #1 yank the blood pressure cuff off Resident #87's arm with one hand. He said that CNA #1 did not seem to care that her arms were tender and bruised. He said the CNA practically dropped the food trays on the table. He said CNA #1 was intimidating and would turn his back to him and walk away when a question was asked. He said, Someone like that should not be working in a place like this.
2. Facility response to CNA #1's reported behavior - failures in response
A grievance/complaint and concern form dated 10/19/23 was provided by the NHA on 11/7/23 at approximately 10:00 a.m. The form described the complaint in pertinent part: Son expresses that CNA (#1) is not professional. Son stated he knocks loud and doesn't give direction with cares.
The grievance form findings to the concern read in pertinent part: CNA (#1) suspended pending facility investigation for an unrelated incident. CNA (#1) terminated due to customer service issues. The findings were dated 10/20/23, one week before the termination date for CNA #1 which was 10/27/23.
There was no further documentation on the grievance/complaint and concern form and no indication of whether there was distress on the part of the resident.
Further, the findings on the grievance form did not include information about an investigation into the complaint concerning Resident #87 and showed no further follow-up. There was no evidence Resident #87's complaint was considered potential abuse and thoroughly investigated and reported. (Cross-reference F609 and F610).
Finally, there was no evidence it led to changes in the facility abuse procedures to ensure that abusive incidents would be properly identified, promptly and thoroughly reviewed and analyzed, and changes implemented to prevent future incidents of abuse.
G. Staff Interviews
1. The DON was interviewed on 11/2/23 beginning at 3:20 p.m.
Regarding the facility's response to grievances, she said if a grievance was filed about nursing staff, they talk to the resident and re-educate staff on the resident's perception. She said if there were similar grievances for one staff member, the staff member was retrained, and if that was not effective they were terminated.
-She further stated that when a grievance is filed about a staff member being unprofessional, she said she talks to the resident to see about the miscommunication to see if the staff member was in a rush or was too fast. She educates the staff member on the resident's perception and to spend extra time on their care. She said a grievance was considered resolved after she followed up with the resident for a couple of days.
Regarding CNA #1's behavior, she said CNA #1 did not get taken the right way by some patients, and often came across as arrogant. She said he had issues with a few residents who did not perceive him well. The DON said about the abuse investigation involving CNA #1 that was completed on 10/28/23 (see above), additional interviews were completed, and there were no staff or resident concerns. She said CNA #1 was a good and efficient CNA. She said that she did not substantiate abuse, and said CNA #1 had customer service issues.
2. The NHA was interviewed on 11/2/23 at 4:16 p.m. He said CNA #1 was a good CNA who went really sideways in the last six weeks or so.
3. The social services director (SSD) and the regional resource social services (RRSS) were interviewed on 11/6/23, beginning at 4:40 p.m. The SSD said she was the grievance official. She said that she obtained a copy of each grievance and she also files them on behalf of residents. She said certain keywords differentiate grievance from abuse and that she would report abuse to the NHA. The SSD explained that customer service would be when people didn't get along with each other, the perception of each other. She said staff training would include reviewing how important tone and body language were to the residents.
4. The NHA was interviewed again on 11/6/23, beginning at 6:19 p.m.
In response to process questions about grievances/complaints, he said anybody can file a complaint with the facility using the facility grievance forms. He said the forms are reviewed weekly and primarily he or the SSD follow up on them. He said the manager who resolved the grievance usually signed the form.
In response to questions about abuse, he said the facility takes abuse seriously and he investigates claims of abuse personally. He said all staff were trained to let him know immediately of any instances of abuse. He said he gave out his phone number to all staff going through orientation to ensure everyone received it. He said any staff member suspected to be involved in an abuse situation with a resident was to be suspended immediately until an investigation could be completed. He said staff members were sometimes looked at for rushing care but he did not consider that abuse.
In response to questions about CNA #1, he said CNA #1 had a change of attitude over the past four to six weeks and was re-educated. He said the CNA's response to the reeducation was not great and he was concerned that there was a risk CNA #1's behavior could be escalating. He said CNA #1 also had an interpersonal conflict with another staff member, and the employees were assigned to separate units.
-He said he was aware that the DON had re-educated CNA #1 on other occasions, and residents had raised concerns about his negative attitude.
-He said the situation with Resident #253 (see above) was handled by the SSD since it was information captured from a survey after the resident was discharged . He said he did not identify the resident's concerns as abuse-related but more of a customer service issue. He said CNA #1 was never taken off the schedule and an abuse investigation was never completed.
5. Registered nurse (RN) #1 was interviewed on 11/6/23 at 10:47 a.m. She said CNA #1 had a reputation for being intimidating to residents and staff. She said he moved to multiple sections of the facility due to not being able to work civilly with other staff. She said CNA #1 was known for loudly voicing frustrations and concerns which made other staff uncomfortable.
6. RN #2 was interviewed on 11/7/23 at 12:05 p.m. She said that CNA #1 had demonstrated concerning behaviors. She said approximately three months ago an unidentified resident who had a stroke was very upset by the way CNA #1 treated him. RN #2 said CNA #1 became angry with the resident because he could not decide on his food quickly enough. She said the resident did not want the CNA to return to his room, and she asked CNA #1 not to return to the room. She said she went into the room to calm the resident and CNA #1 returned to the room anyway to antagonize the resident and he made the resident more upset. RN #2 said that CNA #1 had been very intimidating to staff also, and she tried to stay off his radar. She said she witnessed CNA #1 frequently antagonizing CNA #3.
7. CNA #3 was interviewed on 11/7/23 at 3:30 p.m. She said several months earlier, CNA #1 was upset that he was called out by the charge nurse for not cleaning rooms properly.
-She said when she arrived at work, CNA #1 put his hand on her arm and sarcastically said she was the only good CNA, and he let her know he thought she (CNA #3) had told on him, and this had gotten him in trouble for not completing work the previous day. She said CNA #1 was always walking in the halls and would laugh at her (in a mocking way) as she passed by. She said CNA #1 had a scary laugh, and he was always taunting and harassing her.
-She said she reported his behavior to the assistant director of nursing (ADON). She said CNA #1 stopped making comments but continued to laugh at her every day. She said she was considering quitting and told other staff. She said she told the staff development coordinator (SDC), and she was told that she had her story and CNA #1 had his story. She felt the SDC blew off her complaint. She said others on the unit witnessed this daily treatment by CNA #1.
-She said she thought CNA #1 looked for vulnerable staff and residents to taunt and harass.
8. The regional resource nurse (RRN) and the regional resource social services (RRSS) were notified on 11/7/23 at 4:38 p.m. of potential abuse involving Resident #4 and #15. The RRN and RRSS said they were going to begin an abuse investigation.
H. Facility follow-up
The NHA was interviewed on 11/7/23 at 10:40 a.m. after being informed of the immediate jeopardy situation. He said that looking back at the incident with Resident #253 and CNA #1, he should have launched an abuse investigation. He said he had no idea the resident was so upset by that interaction. He said the facility's process of reporting abuse allegations and filing grievances had some areas for improvement and he was working with the team to fix the issues.
The NHA was interviewed again on 11/8/23 at 4:52 p.m. He said the grievance/complaint from 10/19/23 regarding Resident #87 was reported to the SSD. He said, based on the training they had just completed, the follow-up noted by the DON on the complaint form was not sufficient or appropriate. He said the concerns stated in the original grievance were not addressed. He said it was not evident whether there had been abuse based on the lack of documentation on the grievance form, and that follow-up with the resident and her son was indicated (but had not been done). The NHA said there was no indication whether there was distress on the part of the resident because it had not been investigated. He said he could not explain why the date of follow-up on the grievance form was before the date CNA #1 was terminated.
Based on record review and interview, the facility failed to create an environment that protected six (#8, #4, #15, #87, #253, and #254) of eight out of 42 sample residents from mental and verbal abuse, contributing to residents experiencing, among other emotions, night terrors, anxiety, fear, and humiliation.
In interviews with Residents #8, #15, and #253, the residents stated certified nurse aide (CNA) #1 slammed and dropped food trays on their tables and slammed their doors shut, mocked them, yelled at them, made them feel like an idiot, and feel anxious, frightened, and humiliated. Resident #4 had tears in her eyes when CNA #1's name was mentioned; when asked if she could talk further about him, she shook her head no and appeared sad.
Although the residents and visitors either spoke with management or filed complaint/concern forms about their interactions with CNA #1 as early as February 2023 and later in August, September, and October, their reports, despite their repetition, were not recognized as potential staff-to-resident abuse, leading to failures in reporting, investigating, and implementing corrective actions to protect and prevent further abuse.
The facility's systemic failure to ensure residents were protected from staff-to-resident abuse created a situation of immediate jeopardy with Residents #234, #8, #15, and #4 sustaining actual serious harm, and the potential for serious harm to other residents residing in the facility.
Cross-reference F609 (reporting of alleged violations), F610 (investigation of alleged violations), and F867 (QAPI).
Findings include:
I. Immediate jeopardy
A. Findings of immediate jeopardy
Based on record review and interviews, the facility failed to create an environment that protected six (#8, #4, #15, #87, #253, and #254) of eight out of 42 sample residents from mental and verbal abuse, contributing to residents experiencing, among other emotions, night terrors, anxiety, fear, and humiliation.
In interviews with Residents #8, #15, and #253, the residents stated certified nurse aide (CNA) #1 slammed and dropped food trays on their tables and slammed their doors shut, mocked them, yelled at them, made them feel like an idiot, and feel anxious, frightened, and humiliated. Resident #4 had tears in her eyes when CNA #1's name was mentioned; when asked if she could talk further about him, she shook her head no and appeared sad.
Although the residents and visitors either spoke with management or filed complaint/concern forms about their interactions with CNA #1 as early as February 2023 and later in August, September, and October, their reports, despite their repetition, were not recognized as staff-to-resident abuse, leading to failures in reporting, investigating, and implementing corrective actions to protect and prevent further staff-to-resident abuse.
The facility's systemic failure to ensure residents were protected from staff-to-resident abuse created a situation of immediate jeopardy with Residents #234, #8, #15, and #4 sustaining actual serious harm, and the potential for serious harm to other residents residing in the facility.
On 11/7/23 at 2:15 p.m., the nursing home administrator (NHA) was notified that the facility's failure to recognize, report, investigate, and protect residents from staff-to-resident verbal and mental abuse created a situation of immediate jeopardy of serious harm that required immediate correction.
B. Interim plan to ensure resident safety
On 11/7/23 at 3:00 p.m., the NHA implemented an interim plan to ensure the safety of all residents until a formal, final plan could be submitted on 11/8/23. CNA #1 was terminated from employment on 10/27/23.
C. Facility plan to remove immediate jeopardy
On 11/8/23 at 5:34 p.m., the facility submitted its final plan to remove immediate jeopardy. The plan read:
1. Clinical Nurse Resource and Social Service Resource conducted education with Administrator, Social Services, director of rehabilitation services (DOR), nursing management, and human resources (HR). The education was completed on 11/6/2023 and was completed with the Director of Nursing upon return from vacation.
The education included: Full grievance process; how to identify instances and allegations of abuse and; the difference between a concern and all forms of abuse. Steps in conducting investigations Immediate safety interventions - including who can suspend staff and when staff should be suspended.
Grievance forms are to be reviewed each business day to ensure that all allegations of abuse have not been triaged as grievances.
The identification of allegations of abuse, types of abuse and appropriate follow up. Taking appropriate actions to protect residents from further alleged abuse. How to determine and document the outcome of investigation and report to the Health Department per the Abuse Policy Reporting Abuse, this included a review of the Elder Justice Act that went over reporting timeframes.
2. The identified IDT (interdisciplinary team) members completed an Abuse competency with the Social Service Resource by 11/7/2023. Once Competency was completed the identified IDT members are able to participate in on going education that will be given to staff members.
Resident #253 was discharged from the facility on 8/26/2023. Facility initiated an abuse investigation on 11/6/2023 and will complete and submit a final report on 11/11/2023. CNA #1 identified was terminated and has not worked at the facility since 10/27/2023.
3. Clinical Resource completed 1:1 education over the phone on 11/7/2023 with floor nurse RN (registered nurse) who Resident #253 talked prior to discharge. This education included ways to identify abuse: all types of abuse; reporting allegations of abuse timely to abuse coordinator and; recognizing signs of mental harm and distress.
In addition, the floor nurse RN was educated again in person on 11/8/2023 by the Administrator. This education included; all forms of abuse; signs and symptoms of psychosocial distress, techniques to prevent abuse; and how to report abuse. Floor Nurse completed the return demonstration test on 11/8/2023.
4. Identification of others: The facility completed a full house audit and interviewed all residents who were able to participate in interviews between 11/6/2023 and 11/7/2023. For residents who were not able to interview, the facility attempted to get in touch with emergency contact or resident representative to review for risk of abuse. The full house audit also included educating residents or their representatives on who to report allegations or concerns (of) abuse to.
There were two residents (for whom) the facility could not reach emergency contacts, for those two residents nurse and social services completed observation for any indicators of psychosocial distress or change in mood. The facility will continue to try to reach emergency contacts for those 2 residents. Facility to report any identified allegations by 11/8/2023.
5. Actions to prevent occurrences/recurrence: Clinical Nurse Resource and Social Service Resource initiated education and return demonstration to all staff; which includes clinical nursing staff, maintenance, dietary, therapy, nursing, administrative, activity, housekeeping, agency staff and anyone providing direct care. This education was initiated on 11/6/2023 and completed on 11/8/23.
This education reviewed the Abuse Policy and the following additional information: The forms of abuse (General Neglect,
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0574
(Tag F0574)
Could have caused harm · This affected multiple residents
Based on observations and interviews, the facility failed to ensure residents received notices in a written description of their legal rights.
Specifically, the facility failed to post a sign with ho...
Read full inspector narrative →
Based on observations and interviews, the facility failed to ensure residents received notices in a written description of their legal rights.
Specifically, the facility failed to post a sign with how to file a complaint to the State Survey Agency.
Findings include:
I. Resident group interview
The group interview was conducted on 11/2/23 at 12:57 p.m. with three residents (#1, #16 and #31) identified by assessment and the facility as interviewable. All three residents said they did not know they could file a complaint with the State Agency and they did not know where the facility posted information in regard to pertinent State Agencies' contact information.
II. Observation and staff interview
On 11/2/23 at 1:15 p.m., an observation was conducted throughout the facility. There were no signs in the front lobby of the building and no signs in each of the four units that contained the State Agency contact information. Each unit had an eight by eleven inch white paper posted next to the nurse's station with contact information for other local and State contact information next to the contact information for the ombudsman.
The director of nursing (DON) was interviewed on 11/2/23 at 1:43 p.m. She was not sure where the sign was posted. She walked to each nurse's station and did not see the sign. She said she would find out where the sign was posted in the building.
On 11/2/23 at 1:49 p.m., the DON showed the white paper was updated with the State Agency contact information. The font of the contact information was small to some and could require assistance.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Abuse Prevention Policies
(Tag F0607)
Could have caused harm · This affected multiple residents
Based on interviews and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse and/or mistreatment of facility residents.
Specifically, the ...
Read full inspector narrative →
Based on interviews and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse and/or mistreatment of facility residents.
Specifically, the facility failed to post a conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency and who the abuse coordinator was for the facility.
Findings include:
I. Professional reference
According to the Elder Justice Act notice, undated, retrieved online 11/14/23 from https://lms.healthcareacademy.com/courses/HCA_Annual/ElderJusticeAct1d/EJA_poster.pdf,
What you need to know: The Elder Justice Act (the Act) is a federal law passed as part of the Patient Protection and Affordable Care Act. Its aim is to combat abuse, neglect and exploitation of elders by promoting the discovery of crimes against residents of long-term care facilities. It does this by requiring that specific individuals report any reasonable suspicion of a crime against anyone who is a resident of or is receiving care from a long-term care facility. Section 1150B of the Social Security Act contains the mandatory notification and reporting requirements. The requirements are in effect now, but currently, there are no regulations specifying how these requirements should be implemented. The Centers for Medicare & Medicaid Services is expected to publish regulations that apply specifically to 1150B responsibilities. In the meantime, the following is what you need to know.
A long-term care facility may not retaliate against an employee for making a report, or for causing a report to be made. This means that a facility may not discharge, demote, suspend, threaten, harass, or deny a promotion or other employment-related benefit to an employee or in any other manner discriminate against an employee in the terms and conditions of employment because of lawful acts done by the employee; or file a complaint or a report against a nurse or other employee with the appropriate State professional disciplinary agency because of lawful acts done by the nurse or employee. An employee may file a complaint with the Secretary of Health and Human Services against a long-term care facility that violates the employee's rights under section 1150B of the SS Act.
-There was no posting of The Elder Justice Act in the facility.
II. Facility policy
The Abuse: Prevention of and Prohibition Against policy and procedure, revised January 2023, was provided by the nursing home administrator (NHA) on 11/1/23 at 11:45 a.m. It read in pertinent part, Prevention: All personnel, residents, visitors, etc. are encouraged to to report incidents and grievances without the fear of retribution. The facility will act to protect and prevent abuse and neglect from occurring within the facility by: supervising staff to identify and correct any inappropriate and unprofessional behaviors. Providing residents and representatives, information on how and to whom they may report incidents and grievances without the fear of retribution; and providing feedback regarding the concerns that have been expressed.
Investigation: All identified events are reported to the administrator immediately. All allegations of abuse, neglect, misappropriation of resident property, and exploitation will be promptly and thoroughly investigated by the administrator of his/her designee.
Reporting: The administrator/designee will contact the law enforcement agency per elder abuse law. The administrator/designee will contact the ombudsman. The administrator/designee will complete the initial report to the Colorado department of public health and environment within 24 hours electronically via the occurrence reporting portal and complete the report within five days from the initial report. Post a conspicuous notice of employee rights, including the right to file a complaint with the state survey agency if they believe the facility has retaliated against an employee or individual who reported a suspected crime and how to file such a complaint.
-There was no posting of the State complaint phone line in the facility.
III. Observations
On 11/8/23 at 4:00 p.m. during a tour of the facility, it was observed the Elder Justice Act information was not posted on four of four resident units, the front desk, the activities office or the social services office. It was observed the Abuse Coordinator information was not posted on four of four units, the NHA office or the front desk.
IV. Interviews
On 11/8/23 at 4:15 p.m. the social services director (SSD) and regional resource social services (RRSS) were interviewed. The SSD said there should be Elder Justice Act postings at every nurse station. She said they should be where the residents could read it.
The RRSS said the Elder Justice Act information should be available for the residents and staff.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Resident #4
1. Cross-reference F600.
Cognitively intact Resident #4 was interviewed on 11/7/23 at 3:05 p.m. She started to ...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Resident #4
1. Cross-reference F600.
Cognitively intact Resident #4 was interviewed on 11/7/23 at 3:05 p.m. She started to have tears in her eyes when CNA #1's name was mentioned regarding her care and experience with him. When asked if she could talk further about him, she shook her head no and appeared sad. The resident sighed and appeared relieved when informed that CNA #1 did not work for the facility anymore.
2. Record review
A grievance/complaint and concern form dated 9/22/23 was provided by the NHA on 11/7/23 at approximately 10:00 a.m. The form was completed for Resident #4 and described the resident's complaint in pertinent part: Resident #4 voiced concerns that a specific certified nurse aide (CNA) was frustrated when the resident did not answer fast enough or do tasks fast enough and CNA (#1) was rude in his interactions.
Follow-up findings documented on the grievance form per the director of nursing (DON) included a notation of re-education for the CNA of customer service expectations on 10/4/23.
-However, the follow-up findings on the grievance form did not include details of any interviews with the resident or staff to determine if the incident should be investigated as abuse (cross-reference F610) and there was no evidence the incident was reported to authorities as an allegation of abuse.
C. Resident #15
1. Cross-reference F600.
Resident #15 was interviewed on 11/7/23 at 12:45 p.m. She said that CNA #1 screamed at her because she was not fast enough. She said she did not like him because he was mean to her and made her feel like an idiot. She said he would yell You do it now! Resident #15 said CNA #1 picked on her because she could not talk fast enough. She said he would storm out of the room.
2. Record review
A grievance/complaint and concern form dated 9/22/23 was provided by the NHA on 11/7/23 at approximately 10:00 a.m. The form was completed for Resident #15 and described the complaint in pertinent part: Resident voiced concerns about specific CNA (#1) being frustrated when the resident did not answer fast enough or do tasks fast enough and the CNA is rude in his interactions.
Follow-up findings per DON documentation on the grievance form included re-education for CNA #1 of customer service expectations on 10/4/23.
-However, the follow-up findings on the grievance form did not identify the CNA, identified by NHA later as CNA #1, and did not include details of any interviews with the resident or staff to determine if the incident should be investigated as abuse (cross-reference F610) and there was no evidence the incident was reported to authorities as an allegation of abuse.
D. Resident #87
1. Cross-reference F600.
The representative for cognitively intact Resident #87 was interviewed on 11/8/23 at 11:46 a.m. He said his mother was frightened by CNA #1's behaviors. He said CNA #1 came into the room late at night knocking very loudly on the door. He said he observed CNA #1 yank the blood pressure cuff off Resident #87's arm with one hand. He said that CNA #1 did not seem to care that her arms were tender and bruised. He said the CNA practically dropped the food trays on the table. He said CNA #1 was intimidating and would turn his back to him and walk away when a question was asked.
2. Record review
A grievance/complaint and concern form dated 10/19/23 was provided by the NHA on
11/7/23 at approximately 10:00 a.m. The form described the complaint in pertinent part:
Son expresses that CNA (#1) is not professional. Son stated he knocks loud and doesn't give directions with cares.
The findings to the concern documented on the grievance form by the DON read in pertinent part: CNA suspended pending facility investigation for an unrelated incident. CNA (#1) terminated due to customer service issues.
-However, the follow-up findings on the grievance form did not identify the CNA, identified by NHA later as CNA #1, and did not include details of any interviews with the resident or staff to determine if the incident should be investigated as abuse (cross-reference F610) and there was no evidence the incident was reported to authorities as an allegation of abuse.
E. Staff interviews
The NHA was interviewed on 11/6/23 at 6:20 p.m. He said the facility's practice was not to put the name of the staff member involved on the grievance/complaint form. He said when they reviewed the complaint at the leadership morning meeting, they did not mention the names of the employees involved. He said the manager who resolved the grievance usually signed the form.
-However, after the past complaints were researched to determine the staff names involved in the allegations, CNA #1 was found to be a staff member involved in at least six complaints.
The NHA said CNA #1 had a change of attitude over the past four to six weeks and was re-educated. He said the CNA's response to the reeducation was not great and he was concerned that there was a risk CNA #1's behavior could be escalating. He said CNA #1 also had an interpersonal conflict with another staff member, and the employees were assigned to separate units. He said he was aware that the DON had re-educated CNA #1 on other occasions, and residents had raised concerns about his negative attitude.
The regional resource nurse (RRN) and the regional resource social services (RRSS) were notified by the surveyor on 11/7/23 at 4:38 p.m. of potential abuse involving Resident #4 and Resident #15. The RRN and RRSS said they were going to begin investigating the residents for potential abuse.
The NHA was interviewed again on 11/8/23 at 4:52 p.m. He said the complaint from 10/19/23 regarding Resident #87 was reported to the SSD. He said, based on the training they had just completed, the follow-up noted by the DON was not sufficient or appropriate. He said the concerns stated in the original grievance were not addressed. He said it was not evident whether there had been abuse, and that follow-up with the resident and her representative was indicated. The NHA said there was no indication whether there was distress on the part of the resident.
Based on interviews and record review, the facility failed to timely report incidents of potential abuse to the proper authorities, including the state survey agency. This involved four residents (#4, #15, #87, #253) out of eight residents reviewed from a total sample of 42 residents.
Specifically, the facility leadership failed to ensure four incidents of potential verbal and/or mental abuse by a staff member, certified nurse aide (CNA) #1, were timely reported to authorities, including the state survey agency.
Cross-reference F600 (abuse) and F610 (investigation of potential abuse)
Findings include:
I. Facility policy and procedure
The Abuse Prevention Program policy and procedure, dated November 2017, was provided by the nursing home administrator (NHA) on 11/8/23 at 11:18 a.m. It read in pertinent part:
All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator or Designated Abuse Coordinator. The Administrator/designee will contact the Law Enforcement Agency per Elder Abuse Law. The Administrator/designee will contact the Ombudsman. The Administrator/designee will complete the initial report to the Colorado Department of Public Health and Environment within 24 hours electronically via the Occurrence Reporting Portal and complete the report within 5 days from the initial report.
The Facility will ensure that all individuals who are involved in the reporting or investigation process are free from retaliation or reprisal. Post a conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency if they believe the facility has retaliated against an employee or individual who reported a suspected crime and how to file such a complaint. The Facility will report to the State Nurse Aide Registry or the appropriate licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service.
II. Incidents of potential staff-to-resident abuse involving CNA #1
A. Resident #253
1. Cross-reference F600.
Cognitively intact Resident #253 was interviewed on 11/6/23 at 10:00 a.m. She said she had experienced several incidents of emotional and verbal abuse by CNA #1 contributing to recurring night terrors, anxiety, crying, and fear, even months after discharge on [DATE]. She said CNA #1 was verbally aggressive on multiple occasions.
She said that on a day around 8/17/23, her breakfast was late so she used her call light. CNA #1 came in and said What do you need now? although that was the first time he had been in her room. She told him her breakfast was late and he said that if she quit calling, then maybe they could get it to her on time. He came back with her breakfast, slamming down her tray, and said, Here's your breakfast and walked out.
She said that later, he brought her lunch in and said, Here your Highness in a condescending tone and walked out. The resident noticed some things were missing from her lunch tray so she used her call light. CNA #1 came in and said, Was it not up to your standard? in a sarcastic tone. He went out and came back and slammed the food on the bedside table, and talking through his teeth and in a very angry voice, said, Don't bother me again.
She said she then said to CNA #1, I would like you to leave my room. CNA #1 did not leave her room, but instead, slammed her door shut, walked toward her, and said to her, I will leave your room whenever the (expletive) I feel like it. She said she thought he might hurt her because he came really close to her and that made her feel hysterical, afraid, and scared and the incident brought back memories of trauma and abuse from her past. She said she told all this information to the NHA, but he dismissed her concerns and said CNA #1 was a good worker and it was probably a misunderstanding.
She said on her day of discharge, 8/26/23, CNA #1 found her in the hallway and said in a threatening way, Just remember I have access to your records. The resident said she felt that the staff member would find where she lived and she was terrified about that.
2. Record review
On 11/2/23 at approximately 10:00 a.m. the nursing home administrator (NHA) provided the facility's response to Resident #253's concerns about her interaction with CNA #1. A comment/concern dated 8/25/23 read the social services director (SSD) wrote Resident #253's concern as Patient voiced concerns regarding (CNA #1) being rude and inconsiderate when providing care to the patient. Stating that it felt like he was demanding her to do things.
CNA #1 received a counseling/disciplinary notice on 8/25/23 for customer service-related corrections.
-However, there was no evidence in the information provided by the NHA that the facility identified Resident #253's allegation as potential staff-to-resident verbal and mental abuse, despite the staff's aggressive verbal and nonverbal conduct toward the resident and reported it to authorities as required.
3. Interview and record review
The NHA was interviewed on 11/6/23 at 6:19 p.m. He said the facility takes abuse seriously. He said the situation with Resident #253 was handled by the SSD since it was information captured from a survey after the resident was discharged . He said he did not identify the resident's concerns as abuse-related but more of a customer service issue. He said CNA #1 was never taken off the schedule and the incident was not reported to authorities.
A review of facility records revealed on 11/6/23 the NHA filed an abuse investigation with the state involving Resident #253 and CNA #1.
On 11/7/23 at 10:40 a.m., the NHA said that looking back at the incident with Resident #253 and CNA #1, he should have launched an abuse investigation. (Cross-reference F610) He said he had no idea the resident was so upset by that interaction. He said the facility's process of reporting abuse allegations and filing grievances had some areas for improvement and was working with the team to fix the issues.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Resident #4
1. Cognitively intact Resident #4 was interviewed on 11/7/23 at 3:05 p.m. She started to have tears in her eyes w...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** B. Resident #4
1. Cognitively intact Resident #4 was interviewed on 11/7/23 at 3:05 p.m. She started to have tears in her eyes when CNA #1's name was mentioned regarding her care and experience with him. When asked if she could talk further about him, she shook her head no and appeared sad. Cross-reference F600 for further details.
2. A grievance/complaint and concern form dated 9/22/23 was provided by the NHA on 11/7/23 at approximately 10:00 a.m. The form was completed for Resident #4 and described the resident's complaint in pertinent part: Resident #4 voiced concerns that a specific certified nurse aide (CNA) was frustrated when the resident did not answer fast enough or do tasks fast enough and CNA (#1) was rude in his interactions.
Follow-up findings documented on the grievance form per the director of nursing (DON) included a notation of re-education for the CNA of customer service expectations on 10/4/23.
The follow-up findings indicated the grievance was not adequately addressed. Specifically, the findings failed to include details of any interviews with the resident or staff to show a comprehensive investigation of the resident's complaint was conducted to determine whether an abuse investigation and a report to authorities were required (cross-reference F609). The follow-up findings did not identify the CNA, who was later identified by the NHA as CNA #1, did not address whether there was distress on the part of the resident, and did not include a plan to monitor CNA #1.
Neither an abuse investigation nor a report to the state authorities was completed for Resident #4's complaint.
C. Resident #15
1. Moderately cognitively impaired Resident #15, interviewed on 11/7/23 at 12:45 p.m., said CNA #1 screamed at her because she was not fast enough. She said she did not like him because he was mean to her and made her feel like an idiot. She said he would yell You do it now! Resident #15 said CNA #1 picked on her because she could not talk fast enough. She said he would storm out of the room. Cross-reference F600 for further details.
2. A grievance/complaint and concern form dated 9/22/23 was provided by the NHA on 11/7/23 at approximately 10:00 a.m. The form was completed for Resident #15 and described the complaint in pertinent part: Resident voiced concerns about specific CNA (#1) being frustrated when the resident did not answer fast enough or do tasks fast enough and the CNA is rude in his interactions. Follow-up findings per DON documentation on the grievance form included re-education for CNA #1 of customer service expectations on 10/4/23.
The follow-up findings indicated the grievance was not adequately addressed. Specifically, the findings failed to include details of any interviews with the resident or staff to show a comprehensive investigation was conducted to determine if an abuse investigation and a report to authorities were required (cross-reference F609). The follow-up findings did not identify the CNA, who was later identified by the NHA as CNA #1, did not address whether there was distress on the part of the resident, and did not include a plan to monitor CNA #1.
Neither an abuse investigation nor a report to the state authorities was completed for Resident #4's complaint.
D. Resident #87
1. Cognitively intact Resident #87's representative was interviewed on 11/8/23 at 11:46 a.m. He said his mother was frightened by CNA #1's behaviors. He said CNA #1 came into the room late at night knocking very loudly on the door. He said he observed CNA #1 yank the blood pressure cuff off Resident #87's arm with one hand. He said that CNA #1 did not seem to care that her arms were tender and bruised. He said the CNA practically dropped the food trays on the table. He said CNA #1 was intimidating and would turn his back to him and walk away when a question was asked.
2. The grievance/complaint and concern form dated 10/19/23 was provided by the NHA on
11/7/23 at approximately 10:00 a.m. The form described a complaint by the resident's representative in pertinent part: Son expresses that CNA (#1) is not professional. Son stated he knocks loud and doesn't give direction with cares.
The findings to the concern documented on the grievance form by the DON read in pertinent part: CNA suspended pending facility investigation for an unrelated incident. CNA (#1) terminated due to customer service issues.
The follow-up findings indicated the grievance was not adequately addressed. Specifically, the findings failed to include details of any interviews with the resident or staff to show a comprehensive investigation was conducted to determine if an abuse investigation and a report to authorities were required (cross-reference F609). The follow-up findings did not identify the CNA, who was later identified by the NHA as CNA #1, and did not address whether there was distress on the part of the resident. Further, there was no explanation for the findings which noted CNA #1's termination was dated 10/20/23, one week before the termination date for CNA #1 (10/27/23).
Neither an abuse investigation nor a report to the state authorities was completed for Resident #4's complaint.
E. Resident #8
1. Cognitively intact Resident #8 was interviewed on 11/1/23 at 2:17 p.m., 11/6/23 at 10:05 a.m. and again on 11/7/23 at 10:00 a.m. Her interviews revealed CNA #1 told her that he had to take care of her no matter how disgusting she was. She said she was scared that there might be repercussions for her saying things about the CNA which she had shared with a frequent facility visitor. Resident #8 said if CNA #1 was working, she was anxious that he might come in and say something to her. She said, I felt like I did something wrong. Cross-reference F600 for further details.
2. On 11/2/23 at approximately 10:00 a.m., the NHA provided documents from an abuse investigation of the incidents involving Resident #8 and the final report the facility had submitted to the state on 10/28/23. There were ten resident and ten staff interviews included in the investigation which documented no concerns from staff or residents about CNA #1. The facility did not substantiate the allegation of verbal abuse.
-However, the investigation failed to include the history of disciplinary action and other grievances involving CNA #1. Further, even though the investigation reported an interview with the resident stating she was comfortable having the CNA care for her, interviews with Resident #8 (cross-reference F600) indicated she was concerned about retaliation.
F. Staff Interviews and facility record review
1. The NHA was interviewed on 11/6/23 at 6:20 p.m. He said the facility's practice was not to put the name of the staff member involved on the grievance/ complaint form. He said when they reviewed the complaint at the leadership morning meeting, they did not mention the names of the employees involved. He said the manager who resolved the grievance usually signed the form.
The NHA said CNA #1 had a change of attitude over the past four to six weeks, and was re-educated. He said the CNA's response to the reeducation was not great and he was concerned that there was a risk CNA #1's behavior could be escalating. He said CNA #1 also had an interpersonal conflict with another staff member, and the employees were assigned to separate units. He said he was aware that the DON had re-educated CNA #1 on other occasions, and residents had raised concerns about his negative attitude.
2. The regional resource nurse (RRN) researched past grievances/complaints on 11/6/23 (as they did not include staff names) to determine which staff were involved in the complaints. CNA #1 was found to be a staff member involved in at least seven of the complaints.
3. The NHA was interviewed on 11/8/23 at 4:52 p.m. He said the complaint from 10/19/23 regarding Resident #87 was reported to the SSD. He said, based on the training they had just completed, the follow-up noted by the DON was not sufficient or appropriate. He said the concerns stated in the original grievance were not addressed. He said it was not evident whether there had been abuse, and that follow-up with the resident and her son were indicated. The NHA said there was no indication whether there was distress on the part of the resident. The NHA acknowledged a thorough investigation of the concern involving Resident #87 was not done for Resident #87.
Based on record review and interviews with residents and staff interviews, the facility failed to ensure incidents of potential abuse involving five residents (#8, #4, #15, #87, and #253) out of a total sample of 42 residents were thoroughly investigated.
Cross-reference F600 (abuse) and F609 (reporting abuse).
Findings include:
I. Facility policy
The Abuse Prevention Program policy and procedure, dated November 2017, was provided by the nursing home administrator (NHA) on 11/8/23 at 11:18 a.m. In part:
All allegations of abuse, neglect, misappropriation of resident property, or exploitation should be reported immediately to the Administrator or Designated Abuse Coordinator. The Administrator/designee will contact the Law Enforcement Agency per Elder Abuse Law. The Administrator/designee will contact the Ombudsman. The Administrator/designee will complete the initial report to the Colorado Department of Public Health and Environment within 24 hours electronically via the Occurrence Reporting Portal and complete the report within 5 days from the initial report.
The Facility will ensure that all individuals who are involved in the reporting or investigation process are free from retaliation or reprisal. Post a conspicuous notice of employee rights, including the right to file a complaint with the State Survey Agency if they believe the facility has retaliated against an employee or individual who reported a suspected crime and how to file such a complaint. The Facility will report to the State Nurse Aide Registry or the appropriate licensing authorities any knowledge it has of any actions by a court of law which would indicate an employee is unfit for service.
II. Incidents known to the facility indicating potential abuse
A. Resident #253
1. Cognitively intact Resident #253 was interviewed on 11/6/23 at 10:00 a.m. She said she had experienced several incidents of emotional and verbal abuse by certified nurse aide (CNA) #1 contributing to recurring night terrors, anxiety, crying, and fear, even months after discharge on [DATE]. She said CNA #1 was verbally aggressive on multiple occasions. Cross-reference F600 for further details.
2. Facility documents included a comment/concern interview by the social service director (SSD) of Resident #253, referencing an incident around 8/17/23. The interview was completed on 8/25/23 and read Resident #253's concern was, Patient voiced concerns regarding (CNA #1) being rude and inconsiderate when providing care to the patient. Stating that it felt like he was demanding her to do things. The comment/concern read CNA #1 received a counseling/disciplinary notice on 8/25/23 for customer service-related corrections.
There was no further information regarding the resident's concerns, including no indication of whether there was distress on the part of the resident.
On 11/2/23 at approximately 10:00 a.m., the nursing home administrator (NHA) provided the facility's abuse investigation documents. There was no evidence in the information provided by the NHA that the facility identified Resident #253's allegation as potential staff-to-resident verbal and mental abuse, despite the staff's aggressive verbal and nonverbal conduct toward the resident.
Likewise, and contrary to regulation and facility policy (see above), there was no evidence the facility conducted a comprehensive investigation of the incident that included an interview with other residents, CNA #1, and other staff members who might have information regarding the alleged incident, or interviews with other residents to whom CNA #1 provided care or services, as well as interviews with staff members having contact with CNA #1.
Further, there was no evidence that the facility took sufficient steps to protect residents from further potential abuse. Although Resident #253's allegation involved potential verbal and mental abuse by staff, the facility failed to monitor CNA #1's interactions with Resident #253 and other residents to ensure the action taken by the facility (counseling/disciplinary notice) was an effective response to his reported behavior.
3. Staff interviews
The NHA was interviewed on 11/6/23 at 6:19 p.m. He said the facility takes abuse seriously and he investigated claims of abuse personally. He said all staff were trained to let him know immediately of any instances of abuse. He said any staff member suspected to be involved in an abuse situation with a resident was to be suspended immediately until an investigation could be completed. He said he did not identify the resident's concerns as abuse-related but more of a customer service issue. He said CNA #1 was never taken off the schedule and an abuse investigation was never completed.
4. Facility follow up
On 11/6/23 the NHA filed an abuse investigation with the state involving resident #253 and CNA #1.
The NHA was interviewed again on 11/7/23 at 10:40 a.m. He said that looking back at the incident with Resident #253 and CNA #1, he should have launched an abuse investigation. He said he had no idea the resident was so upset by that interaction. He said the facility's process of reporting abuse allegations and filing grievances had some areas for improvement and was working with the team to fix the issues.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
QAPI Program
(Tag F0867)
Could have caused harm · This affected multiple residents
Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate...
Read full inspector narrative →
Based on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety.
Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to freedom from abuse, reporting and investigating that rose to the level of immediate jeopardy and caused a pattern of psychosocial harm.
Findings include:
I. Facility policy
The Quality Assurance and Performance Improvement (QAPI) policy and procedure, revised January 2023, was provided by the nursing home administrator (NHA) on 11/1/23 at 11:45 a.m. It read in pertinent part, The purpose of this QAPI plan and processes is to continually assess the facility's performance in all service areas, so that systems and processes achieve the delivery of person-centered care, and which maximizes the individual's highest practicable physical, mental, and social well-being.
Procedure included,
1. Quality assessment and assurance committee;
2. QAPI plan components: The plan will include,
-design and scope,
-governance and leadership,
-feedback, data systems, and monitoring,
-performance improvement projects (PIP's),
-systemic analysis and systemic action.
3. Identification of, and prioritizing of, PIP's through:
-open-door policy for staff reporting of quality problems,
-staff meetings,
-resident council,
-grievances,
-systematic review of facility data, data sources, and comparative data, from market, state, and national sources,
-prioritizing through identification of high-risk, high volume, or problem-prone issues.
4. Education and information sharing;
5. Governance and leadership:
-The governing board and administrator will promote and create a fair and open culture where staff are comfortable identifying quality problems and opportunities.
-The administrator will provide support for staff time, space, and resources to carry out QAPI activities.
-The administrator will share QAPI plans and activities periodically to the governing board.
6. QAPI tools to support performance improvement activities:
The facility may utilize the following established performance improvement tools/processes:
-plan-do-study-act (PDSA cycles).
-The five why's to identify root cause.
-The fishbone.
II. Cross-reference citations
Cross-reference F574: The facility failed to post required notices and contact information with failure to post the state contact information in order for residents and staff to report complaints to the State Agency.
Cross-reference F600: The facility failed to ensure residents were protected from staff to resident verbal and emotional abuse. The facility's failure to protect residents from staff to resident verbal and emotional abuse created an immediate jeopardy situation.
Cross-reference F607: The facility failed to develop and implement abuse policies with failure to post a conspicuous notice of the Elder Justice Act.
Cross-reference F609: The facility failed to report alleged violations of potential verbal and emotional abuse to the State Survey and Certification Agency in accordance with state law.
Cross-reference F610: The facility failed to investigate alleged allegations of verbal and emotional abuse.
III. Staff interviews
The medical director (MD) was interviewed on 11/7/23 at 3:40 p.m. She said she was informed of the immediate jeopardy on 11/7/23. She said she was in the facility four days per week. She said she attended QAPI committee meetings regularly. The MD said she was not aware that abuse was happening and recommended that resident concerns and the grievances process be a more in depth investigation. She said the behavior of some staff members shocked her and made her upset to hear about it.
The NHA was interviewed on 11/8/23 at 5:01 pm. He said the facility had a QAPI committee who consisted of the required members and met monthly. He said the committee looked at things they were tracking like falls, looked at trends and key performance metrics. He said the QAPI meetings had an agenda, the general agenda stayed the same with some details changed each month. He said the committee looked for trends, root causes, fish bone metrics, graphs, charts and dissected charts to understand the trends. He said they did a performance improvement plan (PIP) at least yearly such as working on reducing resident falls.
He said his last QAPI meeting was 10/25/23 but abuse, reporting and investigating were not part of the topic. He said topics come to the QAPI meeting from department heads' concerns and clinical measures.
He said his new plan would be to revise the facility's grievance forms to include questions to do a deeper dive into possible allegations of abuse. He said the main failure in identifying abuse was not asking more probing questions and enough questions into the state of the residents to find out preferences and concerns.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected multiple residents
II. Isolation precautions
A. Professional references
According to the Centers for Disease Control and Prevention (CDC), revised 5/8/23, Recommended Routine Infection Prevention and Control (IPC) Pract...
Read full inspector narrative →
II. Isolation precautions
A. Professional references
According to the Centers for Disease Control and Prevention (CDC), revised 5/8/23, Recommended Routine Infection Prevention and Control (IPC) Practices During the COVID-19 pandemic, retrieved on 11/13/23 from https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html:
If they (N95 masks) are used during the care of patient for which a NIOSH Approved respirator or facemask is indicated for personal protective equipment (PPE), they should be removed and discarded after the patient care encounter and a new one should be donned.
Place a patient with suspected or confirmed SARS-CoV-2 infection in a single-person room. The door should be kept closed.
HCP (Health Care Personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH Approved particulate respirator with N95 filters or higher, gown, gloves, and eye protection (goggles or a face shield that covers the front and sides of the face).
According to the CDC, revised 11/29/22, CDC's Core Infection Prevention and Control Practices for Safe Healthcare Delivery in All Settings, retrieved on 11/13/23 from https://www.cdc.gov/infectioncontrol/guidelines/core-practices/index.html?CDC_AA_refVal=https%3A%2F%2Fwww.cdc.gov%2Fhicpac%2Frecommendations%2Fcore-practices.html:
Remove and discard PPE, other than respirators, upon completing a task before leaving the patient's room or care area. If a respirator is used, it should be removed and discarded after leaving the patient room or care area and closing the door.
Ensure that healthcare personnel have immediate access to and are trained and able to select, put on, remove, and dispose of PPE in a manner that protects themselves, the patient, and others.
B. Facility policy
The Infection Prevention and Control Program policy, revised January 2023, was provided by the regional resource nurse (RRN) on 11/6/23 at 1:12 p.m. It read in pertinent part:
Goals: Decrease the risk of infection to residents and personnel, recognize infection control practices while providing care, identify and correct problems relating to infection control, and ensure compliance with state and federal regulations related to infection control.
C. Observations
On 11/1/23 at 11:52 a.m., an unidentified certified nurse aide (CNA) exited room A133 room (droplet precautions sign on the door), walked out of the room with no personal protective equipment on (removed her N95 mask prior to leaving the room).
-Per the director of nursing interview (see below) staff were to remove their mask after leaving the room.
On 11/2/23 at 11:26 a.m., an unidentified staff exited room A114 (droplet precautions sign on the door) with N95 mask on, did not remove N95 mask after leaving the room.
At 11:32 a.m. room C128, had a droplet precautions sign on the door, the resident was in the room with licensed practical nurse (LPN) #1 and the door to her room was completely open. The door remained open until LPN #1 left the room at 11:39 a.m.
At 1:45 p.m. room A135, had a droplet precautions sign on the door. There were visitors in the room without masks. CNA #2 entered the room with a gown and gloves on. She did not have eye protection or a N95 mask. The door to the room remained open until 2:18 p.m.
At 1:49 p.m. room A133 and room A135 had droplet precautions signs on the doors. The instructions posted on both doors were to wash hands prior to entering and leaving the room, put on a mask when entering the room, put on protective eyewear when entering the room and remove all PPE prior to leaving the room.
At 1:56 p.m. room A133 had a droplet precautions sign on the door, two unidentified CNAs removed N95 masks prior to leaving the room.
-However, the signage for PPE was updated by staff to indicate that their mask should be disposed of outside of the room.
At 4:54 p.m, there was no isolation sign on door of room A135 (the droplet precautions sign had been removed), however, the resident had an active order for contact precautions.
D. Staff interviews
LPN #1 was interviewed on 11/2/23 at 11:39 a.m. She said the resident in room C128 had COVD-19. She said the door was to remain closed at all times.
CNA #2 was interviewed on 11/2/23 at 2:20 p.m. She said that she was not sure what type of isolation room A135 should be on (sign on door was droplet precautions) and did not know if the isolation signage on the door was correct. She said she should have worn a face shield and the door should have remained closed if the resident was in droplet precautions.
CNA #7 was interviewed on 11/0/23 at 2:38 p.m. She said she should wear a gown, gloves, eye protection and N95 mask when entering the room of a resident with droplet precautions. She said that she always removed gown and gloves prior to exiting the room and took off goggles and N95 mask after she left the room. She said the resident's door was to be closed all of the time.
The director of nursing (DON) and RRN were interviewed on 11/2/23 at 3:54 p.m. The DON said room A135 should have been on contact precautions, not droplet precautions as posted on the door. She said the staff should identify the type of isolation needed, then wear appropriate PPE. The DON said staff should change their N95 mask after leaving the room for a resident in droplet isolation. She said the residents' doors should remain closed whenever possible.
E. Facility follow-up
On 11/6/23 at 11:58 a.m., the RRN and infection preventionist (IP) said the facility added PPE to isolation carts and added trash cans outside of droplet isolation rooms to ensure N95 masks were disposed properly. The RRN said that staff had posted the incorrect sequence/disposal of PPE on the resident doors. The RRN said that staff have been educated about correct signage, sequencing and disposal of PPE.
III. Storage of Portable oxygen
A. Observations
On 11/1/23 at 9:17 a.m., portable oxygen tanks were resting on the floor inside the door of room C104, C110 and C125.
At 10:15 a.m., portable oxygen was resting on the floor inside the door of C160 room.
On 11/6/23 at 5:52 p.m., portable oxygen was resting on the floor outside of C133A room.
B. Staff Interviews
The infection preventionist (IP) was interviewed on 11/7/23 at 2:49 p.m. She said respiratory therapy, nurses and certified nurses aids (CNAs) could refill the portable oxygen tanks. The IP said the tanks were taken to the oxygen room to be refilled and they should not be resting on the floor at any time.
Licensed practical nurse (LPN) #2 was interviewed on 11/7/23 at 3:25 p.m. She said both CNAs and nurses fill the residents' portable oxygen tanks. She said she would not expect portable oxygen to be on the floor at any time. She said there was a hanger for staff to use on hooks or on wheelchairs. LPN #2 said she thought staff might have put them on the floor at the change of shift to signal they needed filling.
Based on observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for two out of four units in the facility.
Specifically, the facility failed to:
-Ensure housekeeping staff cleaned high touch areas were cleaned appropriately;
-Ensure housekeeping staff used proper surface disinfectant times;
-Ensure housekeeping staff cleaned from cleaner to dirtier areas;
-Ensure housekeeping staff changed gloves and performed hand hygiene between bathroom and bedroom;
-Ensure housekeeping staff changed mop heads between bathroom and bedroom;
-Ensure housekeeping staff changed cleaning cloths between bathroom and bedroom;
-Provide accurate isolation precautions, including isolation signage, appropriate use of personal protective equipment (PPE) and assure the resident doors remained closed; and,
-Appropriately store resident portable oxygen equipment.
Findings include:
I. Housekeeping failures
A. Professional reference
The Centers for Disease Control (CDC) Environment Cleaning Procedures https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html# retrieved on 11/14/23 read in pertinent part, High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility.
Common high-touch surfaces include:
-bedrails
-IV (intravenous) poles
-sink handles
-bedside tables
-counters
-edges of privacy curtains
-patient monitoring equipment (keyboards, control panels)
-call bells
-door knobs
Proceed From Cleaner To Dirtier
Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include:
-During terminal cleaning, clean low-touch surfaces before high-touch surfaces.
-Clean patient areas (patient zones) before patient toilets.
-Within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone.
-Clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions.
B. Facility policy and procedure
The Infection Control policy and procedure for the Housekeeping Department, revised November 2022, was provided by the regional resource nurse (RRN) on 11/8/23 at 11:18 a.m. The policy read in pertinent part: It is the policy of this facility to require effective environmental sanitation to lessen the hazards of exposure to contaminated air, dust, furnishings, equipment and other fomites.
Frequent cleaning of the facility's interior will aid in physically removing some of the microorganisms which might cause these hazards.
The housekeeping supervisor will work closely with the infection control team to establish and maintain consistent practices and high standards of cleanliness.
C. Disinfectant
The disinfectant in the facility was identified as Spic and Span with a 10 minute surface disinfectant time.
C. Observations and interview
During continuous observation on 11/7/23 at approximately 10:00 a.m. on C hall, housekeeper (HSK) #1 failed to clean door knobs, television remote and call button in room C132. HSK #1 said a surface disinfectant time of one minute for the disinfectant chemicals used to clean the room. HSK #1 used the toilet brush to clean the interior, exterior and the seat of the toilet. The observations were as follows:
HSK #1 used a toilet brush from a bucket to clean the interior, seat and exterior of the toilet, then dried it with a dry cloth not allowing for surface disinfectant time.
HSK#1 failed to clean the handrails in the bathroom.
HSK#1 failed to change gloves and perform hand hygiene between cleaning the bathrooms and bedroom areas.
HSK #1 used a wet cloth from a filled bucket in the cart to wipe the surfaces in the room and then used a dry cloth immediately after to dry the surfaces, not allowing for surface disinfectant times.
HSK#1 failed to clean high touch surfaces/items including the television remote, call button and door knobs.
During observation on 11/7/23 at approximately 10:30 a.m. on A hall in room A146. HKS #2 said the surface disinfectant time to three to four minutes for disinfection, failed to allow surface disinfectant times on high touch surfaces including door knobs, and failed to change the mop head and perform hand hygiene between the bathroom and bedroom. Observations were as follows:
HSK #2 sprayed areas and immediately wiped with a dry cloth not allowing for surface disinfectant time.
HSK #2 failed to clean the call button.
HSK #2 sprayed and immediately wiped the handrails dry in the bathroom, not allowing for surface disinfectant time.
HSK #2 sprayed the sink allowing for approximately 30 seconds before wiping it dry.
After HSK #2 failed to change the mop head and perform hand hygiene after cleaning the bathroom and before mopping the bedroom area.
E. Staff interviews
HSK #1 was interviewed on 11/7/23 at 10:00 a.m. HSK #1 said there was a one minute disinfectant time for the disinfectant in the regular rooms and 10 minute time for isolation rooms. She said high touch areas were walkers, tables, wheelchairs, guest chairs and bathrooms.
-The HSK failed to say the resident call buttons, handrails and door knobs were high touch areas.
HSK #2 was interviewed on 11/7/23 at 10:30 a.m. HSK #1 said they clean the knobs every day. She said the disinfectant spray had a three to four minute disinfectant time. She said high touch areas were tables, radio, television and the room phone.
-The HSK failed to say the resident call buttons and bathroom handrails were high touch areas.
The housekeeping supervisor (HSKS), the maintenance supervisor (MTS) and corporate safety consultant (CSC) were interviewed on 11/7/23 at 12:12 p.m. The HSKS said the process for cleaning resident rooms depended on if the resident was in the room or not. She said there were two methods of applying the disinfectant: it could be sprayed on or cloths could be soaked in a solution with the disinfectant. She said the disinfectant had a 10 minute surface disinfectant time. She said the housekeeper should spray or wipe the bathroom first and leave it so the solution would have time to sit. She said they should then clean the bedroom area. She said the housekeepers should not use a dry cloth after using the wet cloth, the solution should be allowed to dry naturally. She said high touch items included resident door handles, remotes, call light buttons, bathroom rails, wheelchairs, walkers, tables and drawer handles. She said the housekeepers should use one mop for the bathroom and one for the bedroom. She said it was the same with the cloths, one for the bathroom and one for the bedroom area. She said the housekeepers should not use the same mop head or the same cloth to clean the entire resident room. She said the housekeepers should change gloves between the bathroom and the bedroom. She said everything should be wiped down.
The infection preventionist (IP) was interviewed on 11/7/23 at 12:28 p.m. She said if the housekeeping staff did not change the mop head or cloths they would take germs from the bathroom into the bedroom, which could spread bacteria or viruses. She said the facility followed the recommendations on the disinfectant container. She said the recommendation on the container should be adhered to kill bacteria. She said the surface disinfectant times were listed on the bottle. She said during orientation the facility taught the staff where to find the disinfectant times.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Room Equipment
(Tag F0908)
Could have caused harm · This affected multiple residents
Based on observation and interviews, the facility failed to ensure essential equipment was in proper working order.
Specifically, the facility failed to ensure the pellet base heating elements were in...
Read full inspector narrative →
Based on observation and interviews, the facility failed to ensure essential equipment was in proper working order.
Specifically, the facility failed to ensure the pellet base heating elements were in safe condition.
Findings include:
I. Facility policy and procedure
The Equipment Maintenance and Repairs policy and procedure, revised January 2018, was provided by the regional registered dietitian (RRD) on 11/9/23 at 1:36 p.m. It read in pertinent part, Equipment will be maintained in working order. Equipment not in working order will be repaired/replaced.
Small equipment (blenders, toasters, microwaves) will be maintained in a safe, clean, and operable manner. Dietary staff and the dietary director will remove any equipment that is broken or not in working order. Equipment will be repaired or replaced.
Smallwares (bowls, cups, cutting boards, utensils, dishware) will be maintained in a safe, clean and operable manner. Smallwares will be removed from rotation when considered unfit for use and replaced as needed.
II. Observations
During continuous observation on 11/02/23 at 10:46 a.m. during the lunch meal preparation, there were several round, gray, pellet heating elements that accompanied the serving plates for meals that had large, between 0.5 inches and 4 inches, chips out of the edges.
At approximately 12:40 p.m. the test tray heating element had two large chips on either side of the element. The chips were approximately 0.5 inches and 2.5 inches.
On 11/6/23 at approximately 12:00 p.m. during the lunch meal it was observed that three of four opened plates had chipped heating elements. The two inch chipped portion of the heating element felt rough and slightly sharp to the touch on an emptied service tray.
On 11/7/23 at 3:02 p.m. during an interview with the dietary director (DD) after the lunch meal it was observed that there were approximately one dozen leftover plates over the steam table. The DD stacked seven heating elements which all had various sized chips, between one inch and four inches in them. The elements had between one and two chips each. The DD found an element with two chips, one was two and a half inches and the second was four inches and the DD threw it in the trash.
III. Interview
The DD was interviewed on 11/7/23 at 3:02 p.m. The DD said it was possible for a resident to get hurt on one of the heating elements because they could be sharp. She said the chipped elements were an ongoing problem. She said the heating element with two chips, that she had thrown away, should not have been in circulation and it should have been thrown away. She said the facility had ordered new elements but she was unsure when they would arrive.
MINOR
(C)
Minor Issue - procedural, no safety impact
Deficiency F0577
(Tag F0577)
Minor procedural issue · This affected most or all residents
Based on observations and interviews, the facility failed to ensure the residents had access to the results of the facility's most recent survey conducted by Federal or State surveyors over the past t...
Read full inspector narrative →
Based on observations and interviews, the facility failed to ensure the residents had access to the results of the facility's most recent survey conducted by Federal or State surveyors over the past three years of survey, to include survey findings and any plan of correction, in a place readily accessible to to residents, family members and legal representatives of residents.
Specifically, the facility failed to make survey results accessible.
Findings include:
I. Facililty policy
The Availability of Survey Results policy, revised November 2023, was provided by the regional resource nurse (RRN) on 11/8/23 at 11:18 a.m. It read in pertinent part: Place readily accessible is a place where individuals wishing to examine survey results do not have to ask to see them.
II. Resident group interview
The group interview was conducted on 11/2/23 at 12:57 p.m. with three residents (#1, #16 and #31) identified by assessment and the facility as interviewable. All three residents said they did know the location of the results from previous annual and complaint survey findings.
III. Observations and staff interviews
On 11/2/23 at 1:15 p.m., an observation was conducted throughout the facility. The survey findings book was not visible or easily accessible.
The director of nursing (DON) was interviewed on 11/2/23 at 1:43 p.m. She was not sure where the survey findings book was located. She went with a surveyor to the front lobby and asked the receptionist if she knew where the survey findings book was located. The receptionist located the survey findings book. It was in a magazine holder behind the receptionist. The desk was over five feet and someone in a wheelchair would not be able to access the survey findings book without asking for assistance. At that time, it was observed there was a sign on the wall next to the receptionist L shaped desk that said the survey findings book was available on the receptionist's desk. The sign was blocked by a stand alone hand sanitizer dispenser.
On 11/8/23 at 12:00 p.m., the survey findings book was in the same location. The RRN was notified.
By 11/8/23 at 1:30 p.m., the survey findings book was moved to a location that was readily accessible which was next to the receptionist desk.
Jul 2022
3 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy review, the facility failed to provide wound care as ordered by the...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy review, the facility failed to provide wound care as ordered by the physician for 1 (Resident #36) of 1 resident reviewed for treatments.
Findings included:
A review of the facility's policy and procedure titled, Dressing Changes, revised December 2021, revealed, POLICY: The purpose of this procedure is to provide guidelines for the application of dry, clean dressings. Facility will apply treatments as orders [sic] by prescribing physician.
A review of the admission Record for Resident #36 revealed the facility admitted the resident with diagnoses of displaced trimalleolar fracture of left lower leg, subsequent encounter for closed fracture with routine healing, unspecified fall, subsequent encounter, and encounter for other orthopedic aftercare.
A review of the care plan, dated 06/21/2022, revealed Resident #36 had actual impairment to skin integrity related to an abrasion on the left knee that was present on admission, with an intervention to follow facility protocols for treatment of the injury.
A review of the 5-day Minimum Data Set (MDS), dated [DATE], indicated Resident #36 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The MDS further indicated the resident had surgical wound(s) present.
A review of the Order Summary Report revealed a physician's order, dated 07/22/2022, to cleanse the resident's left shin wound with wound cleanser, pat dry, apply medi-honey to the wound bed, and secure with a foam dressing every night.
During an observation on 07/25/2022 at 10:53 AM, Resident #36 was sitting in their room. A dressing was observed on the resident's lower left shin, dated 07/22/2022. Resident #36 revealed the dressing was covering a surgical wound where the rod was removed from their leg. Resident #36 indicated the dressing was to be changed daily but had not been changed since 07/22/2022.
During an observation on 07/26/2022 at 8:28 AM, Resident #36 was lying in bed, and the dressing to the resident's left shin was dated 07/22/2022. Resident #36 reported staff were busy at night and the dressing was not getting changed.
During an interview on 07/26/2022 at 8:31 AM, Licensed Practical Nurse (LPN) #1 revealed the charge nurses were responsible for providing wound care to the residents.
During an observation on 07/26/2022 at 8:36 AM, LPN #1 removed the dressing from Resident #36's left chin and revealed the dressing had a date of 07/22/2022.
During a telephone interview on 07/26/2022 at 2:37 PM, Registered Nurse (RN) #1 revealed she had failed to perform the dressing change to Resident #36's left shin. RN #1 revealed the physician's order should have been followed.
During an interview with the Director of Nursing (DON) on 07/27/2022 at 9:14 AM, the DON revealed wound care should be performed per physician orders and as scheduled. The DON revealed the expectation of the staff was to complete treatments timely and as prescribed by the physician.
During an interview on 07/27/2022 at 9:18 AM, the Administrator revealed it was expected for staff to follow the order and perform wound care daily if it was ordered daily.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy review, the facility failed to ensure a medication error rate of le...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, record review, and policy review, the facility failed to ensure a medication error rate of less than 5% for 2 (Resident #28 and Resident #67) of 4 residents observed during medication administration. Observations during medication administration revealed there were two medication errors out of 25 opportunities, which resulted in an 8.00% medication error rate.
Findings included:
A review of the facility's policy titled, Medication Administration, last revised December 2021, revealed, POLICY: It is the policy of this facility that medications shall be administered as prescribed by the attending physician. PROCEDURES: .2. Medications must be administered in accordance with the written orders of the attending physician.
1. A review of the admission Record revealed Resident #67 was admitted to the facility on [DATE].
During an observation of medication administration on 07/26/2022 at 8:31 AM, Registered Nurse (RN) #2 administered a 425 mg cranberry capsule to Resident #67.
A review of the current Order Summary Report revealed a physician order, dated 07/12/2022, for a 500 milligram (mg) cranberry tablet. The order directed staff to administer 500 mg one time a day for a history of urinary tract infection.
During an interview on 07/26/2022 at 1:22 PM, RN #2 indicated she did not realize there were two different strengths of cranberry tablets in the medication cart. RN #2 stated she found the 500 mg bottle after she completed administration of Resident #67's medications.
During an interview 07/27/2022 at 8:38 AM, the Director of Nursing (DON) indicated that her expectation was for medications to be administered per the physician orders by following the six rights of medication administration.
During an interview on 07/27/2022 at 8:45 AM, the Administrator (ADM) indicated that his expectation was that medications were administered accurately to get less than a 5% error rate.
2. A review of the admission Record indicated Resident #28 was admitted to the facility with a medical history to include a diagnosis of vitamin D deficiency.
During an observation of medication administration on 07/26/2022 at 9:18 AM, Medication Aide (MA) #1 administered one tablet of vitamin D 10 micrograms (mcg), which was equivalent to 400 units, to Resident #28.
A review of Resident #28's current Order Summary Report revealed a diagnosis of vitamin D deficiency and a physician order, dated 06/17/2022, for a cholecalciferol (vitamin D3) tablet. The order directed staff to administer 1000 units one time a day.
During an interview on 07/26/2022 at 1:15 PM, MA #1 confirmed the 10-mcg bottle was equal to 400 units, and that was not the correct dose to be administered to Resident #28. MA #1 reported the resident was ordered to receive 1000 units.
During an interview 07/27/2022 at 8:38 AM, the Director of Nursing (DON) indicated that her expectation was for medications to be administered per the physician orders by following the six rights of medication administration.
During an interview on 07/27/2022 at 8:45 AM, the Administrator indicated that his expectation was that medications were administered accurately to get less than a 5% error rate.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure licensed nursing staff did not document woun...
Read full inspector narrative →
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to ensure licensed nursing staff did not document wound care treatment that had not been provided for 1 (Resident #36) of 1 resident sampled with a non-pressure related skin wound.
Findings included:
A review of the admission Record for Resident #36 revealed the facility admitted the resident with diagnoses of displaced trimalleolar fracture of left lower leg, subsequent encounter for closed fracture with routine healing, unspecified fall, subsequent encounter, and encounter for other orthopedic aftercare.
A review of the 5-day Minimum Data Set (MDS), dated [DATE], indicated Resident #36 was cognitively intact with a Brief Interview for Mental Status (BIMS) score of 15. The MDS further indicated the resident had surgical wound(s) present.
A review of the Order Summary Report revealed a physician's order, dated 07/22/2022, to cleanse the resident's left shin wound with wound cleanser, pat dry, apply medi-honey to the wound bed, and secure with a foam dressing every night.
During an observation on 07/25/2022 at 10:53 AM, Resident #36 was sitting in their room. A dressing was observed on the resident's lower left shin, dated 07/22/2022. Resident #36 revealed the dressing was covering a surgical wound where the rod was removed from their leg. Resident #36 indicated the dressing was to be changed daily but had not been changed since 07/22/2022.
During an observation on 07/26/2022 at 8:28 AM, Resident #36 was lying in bed, and the dressing to the resident's left shin was dated 07/22/2022. Resident #36 reported staff were busy at night and the dressing was not getting changed.
During an observation on 07/26/2022 at 8:36 AM, Licensed Practical Nurse (LPN) #1 removed the dressing from Resident #36's left chin and revealed the dressing had a date of 07/22/2022.
A review of Resident #36's Treatment Administration Record (TAR) for July 2022 revealed Registered Nurse (RN) #1 signed the record to indicate she provided wound care to the resident's left shin on 07/23/2022, 07/24/2022 and 07/25/2022.
During a telephone interview on 07/26/2022 at 2:37 PM, RN #1 revealed she had failed to perform the dressing change to Resident #36's left shin. RN #1 indicated she should not have documented on the TAR that the wound care was done.
In an interview on 07/27/2022 at 9:14 AM, the Director of Nursing stated the staff should not document on the TAR if the treatment was not done.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "What changes have you made since the serious inspection findings?"
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • Multiple safety concerns identified: 1 life-threatening violation(s), $79,098 in fines. Review inspection reports carefully.
- • 21 deficiencies on record, including 1 critical (life-threatening) violation. These warrant careful review before choosing this facility.
- • $79,098 in fines. Extremely high, among the most fined facilities in Colorado. Major compliance failures.
- • Grade F (38/100). Below average facility with significant concerns.
Bottom line: Trust Score of 38/100 indicates significant concerns. Thoroughly evaluate alternatives.
✓ Report will be sent to your email
About This Facility
What is Healthcare Resort Of Colorado Springs, The's CMS Rating?
CMS assigns HEALTHCARE RESORT OF COLORADO SPRINGS, THE an overall rating of 3 out of 5 stars, which is considered average nationally. Within Colorado, this rating places the facility higher than 0% of the state's 100 nursing homes. This mid-range rating indicates the facility meets federal standards but may have areas for improvement.
How is Healthcare Resort Of Colorado Springs, The Staffed?
CMS rates HEALTHCARE RESORT OF COLORADO SPRINGS, THE's staffing level at 4 out of 5 stars, which is above average compared to other nursing homes. Staff turnover is 49%, compared to the Colorado average of 46%.
What Have Inspectors Found at Healthcare Resort Of Colorado Springs, The?
State health inspectors documented 21 deficiencies at HEALTHCARE RESORT OF COLORADO SPRINGS, THE during 2022 to 2025. These included: 1 Immediate Jeopardy (the most serious level, indicating potential for serious harm or death), 19 with potential for harm, and 1 minor or isolated issues. Immediate Jeopardy findings are rare and represent the most serious regulatory concerns. They require immediate corrective action.
Who Owns and Operates Healthcare Resort Of Colorado Springs, The?
HEALTHCARE RESORT OF COLORADO SPRINGS, THE is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by THE ENSIGN GROUP, a chain that manages multiple nursing homes. With 97 certified beds and approximately 87 residents (about 90% occupancy), it is a smaller facility located in COLORADO SPRINGS, Colorado.
How Does Healthcare Resort Of Colorado Springs, The Compare to Other Colorado Nursing Homes?
Compared to the 100 nursing homes in Colorado, HEALTHCARE RESORT OF COLORADO SPRINGS, THE's overall rating (3 stars) is below the state average of 3.1, staff turnover (49%) is near the state average of 46%, and health inspection rating (2 stars) is below the national benchmark.
What Should Families Ask When Visiting Healthcare Resort Of Colorado Springs, The?
Based on this facility's data, families visiting should ask: "What changes have been made since the serious inspection findings, and how are you preventing similar issues?" "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?" These questions are particularly relevant given the facility's Immediate Jeopardy citations.
Is Healthcare Resort Of Colorado Springs, The Safe?
Based on CMS inspection data, HEALTHCARE RESORT OF COLORADO SPRINGS, THE has documented safety concerns. Inspectors have issued 1 Immediate Jeopardy citation (the most serious violation level indicating risk of serious injury or death). The facility has a 3-star overall rating and ranks #100 of 100 nursing homes in Colorado. Families considering this facility should ask detailed questions about what corrective actions have been taken since these incidents.
Do Nurses at Healthcare Resort Of Colorado Springs, The Stick Around?
HEALTHCARE RESORT OF COLORADO SPRINGS, THE has a staff turnover rate of 49%, which is about average for Colorado nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Healthcare Resort Of Colorado Springs, The Ever Fined?
HEALTHCARE RESORT OF COLORADO SPRINGS, THE has been fined $79,098 across 1 penalty action. This is above the Colorado average of $33,870. Fines in this range indicate compliance issues significant enough for CMS to impose meaningful financial consequences. Common causes include delayed correction of deficiencies, repeat violations, or care failures affecting resident safety. Families should ask facility leadership what changes have been made since these penalties.
Is Healthcare Resort Of Colorado Springs, The on Any Federal Watch List?
HEALTHCARE RESORT OF COLORADO SPRINGS, THE is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.