DENVER, CO - City Scape Rehabilitation & Care Center LLC faced significant citations during a July 2024 state inspection that documented serious violations in resident care, safety protocols, and infection control practices.
Resident Discharged Without Proper Documentation
One of the most serious violations involved the improper discharge of a resident in February 2024. Inspection records revealed that Resident #105 was escorted from the facility by law enforcement on February 20, 2024, without the facility providing required discharge documentation or proper notification to the state ombudsman.
According to progress notes, the resident "was presented with multiple options when planning to discharge, however, he refused to comply with any option." When the resident refused to leave after being told he was discharged, facility staff contacted emergency response teams and police, who transported him to a homeless shelter.
Federal regulations require nursing homes to provide 30-day written notice for facility-initiated discharges and notify the state ombudsman. The facility failed to provide either requirement. During interviews, the social services director acknowledged he "did not issue a written facility-initiated discharge notice to Resident #105 or the ombudsman." The nursing home administrator and regional operations consultant confirmed they "did not know the reason why the facility discharged the resident or why the facility had not issued a 30-day discharge notice."
The inspection found no discharge summary, assessment documentation, or proper orientation records for this resident. Medical professionals emphasize that proper discharge planning protects vulnerable residents from homelessness and ensures continuity of care. Without proper documentation and planning, residents may face dangerous gaps in medical care, medication management, and basic shelter needs.
Delayed Safety Planning for Elopement Risk
The facility failed to implement timely safety measures for a resident with documented elopement behaviors. Resident #19, who was under 65 and diagnosed with dementia and schizophrenia, displayed exit-seeking behaviors that escalated over several weeks before appropriate interventions were implemented.
Documentation showed the resident's concerning behaviors began in early June 2024, including attempting to leave with visitors and requiring frequent redirection. On June 15, the resident "shoved a staff member aside while a visitor was entering the facility and walked outside," requiring paramedic transport to the hospital for evaluation.
The most serious incident occurred on June 27, when the resident exited through a fire door and ran after a public bus. Staff searched the neighborhood but couldn't locate him, prompting police involvement and a missing person report. The resident was found by police at 1:45 a.m. the following morning and returned to the facility.
Despite these escalating incidents, the facility didn't implement a comprehensive elopement care plan until June 28, 2024 - only after the resident successfully left the premises. The director of nursing confirmed during interviews that the resident's exit-seeking behaviors "started to amplify on 6/4/24" but the elopement care plan "was not initiated until 6/28/24."
Elopement presents serious risks for residents with cognitive impairments, including exposure to weather, traffic accidents, dehydration, and inability to seek help. Industry standards require immediate assessment and intervention when elopement behaviors are identified, not after a resident has already left the facility unsupervised.
Critical Medication Management Failures
Inspectors documented a 7.14% medication error rate, exceeding the maximum allowable rate of 5%. Two residents missed critical medications during observed medication passes, highlighting systemic problems in the facility's pharmacy coordination.
On July 15, 2024, a licensed practical nurse was unable to administer Empagliflozin, a diabetes medication, to one resident because the medication hadn't arrived from the pharmacy. The same day, another nurse couldn't give Sinemet, a Parkinson's medication, to a different resident due to poor reordering procedures.
The director of nursing explained that staff failed to properly manage medication reordering timelines. For the diabetes medication, insurance restrictions limited dispensing to three-day supplies, creating frequent gaps. For the Parkinson's medication, nursing staff "did not pull the old card out of the medication cart to get it reordered" in time.
Missing diabetes medications can lead to dangerous blood sugar fluctuations, potentially causing diabetic emergencies. Interruptions in Parkinson's medications can worsen movement symptoms, increase fall risk, and significantly impact quality of life. Both medications require consistent daily administration to maintain therapeutic levels and prevent complications.
Food Safety and Sanitation Violations
Multiple food handling violations threatened resident health through potential contamination and temperature control failures. Kitchen staff failed to follow basic food safety protocols during meal preparation, including improper glove usage when handling ready-to-eat foods.
Inspectors observed a cook preparing salad while wearing the same gloves after touching food packaging, contaminated surfaces, and multiple food items. The cook "did not change his gloves after touching the outside of the lettuce bag" and continued using contaminated gloves throughout preparation. Additionally, staff members' name tags and apron strings dragged across plates used to serve residents.
Temperature control violations included nutritional supplements stored at 58 degrees Fahrenheit, well above the safe cold storage temperature of 41 degrees or below. Frozen vegetarian products were improperly stored in refrigeration instead of freezer units as required by manufacturer instructions.
Foodborne illness poses particular risks for elderly residents who may have compromised immune systems and underlying health conditions. Proper food handling, temperature control, and hygiene practices are essential to prevent outbreaks that could cause serious illness or death in vulnerable populations.
Environmental and Infection Control Deficiencies
The facility struggled with basic infection prevention, including improper room cleaning procedures and inadequate hand hygiene practices. Housekeeping staff cleaned resident bathrooms before bedrooms, potentially spreading contamination. Staff failed to change gloves between cleaning toilets and handling clean supplies, violating infection control protocols.
During mealtime observations, residents were not offered hand hygiene assistance before eating, despite available sanitizing wipes. Staff serving food didn't use hand sanitizers when moving between the kitchen and dining areas, creating additional contamination risks.
A significant pest control problem persisted despite ongoing professional treatments. Inspectors documented cockroaches, flies, and gnats throughout the facility, including near medication carts and in common areas. Residents reported seeing mice in their rooms and dining areas. Seven alert residents interviewed confirmed they had "seen pests in the facility," with several expressing concern about potential insect bites.
Medical Record Accuracy Issues
Documentation errors compromised care coordination for wound treatment. One resident's pressure injury was consistently mislabeled in medical records as being on the right heel when it was actually on the left heel. This error appeared in multiple physician orders and wound assessments over several weeks, potentially leading to incorrect treatment.
Even the wound physician incorrectly identified the injury location during interviews with inspectors. Accurate medical documentation is fundamental to patient safety, ensuring all caregivers provide appropriate treatment to the correct body areas.
Staff Training and Performance Gaps
The facility failed to maintain required performance evaluations and training records for nursing assistants. Two certified nursing aides hadn't received annual performance reviews despite being employed for multiple years. Training documentation was incomplete, and the facility lacked systems to track mandatory continuing education requirements.
A newly hired nursing aide hadn't received required dementia and abuse prevention training before working with residents. The director of nursing, who was new to the position, acknowledged the need to implement tracking systems and conduct staff audits to ensure compliance.
Additional Issues Identified
The inspection revealed several other concerning violations, including inadequate hospice care coordination with missing communication records spanning nearly three months, and environmental maintenance issues that allowed pest entry points through visible gaps in exterior doors.
These violations collectively demonstrate systemic challenges in maintaining basic care standards, resident safety protocols, and regulatory compliance at City Scape Rehabilitation & Care Center LLC.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for City Scape Rehabilitation & Care Center LLC from 2024-07-16 including all violations, facility responses, and corrective action plans.
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