DENVER, CO - Federal inspectors documented multiple safety and care violations at Highline Post Acute during an August 2024 inspection, citing the facility for medication storage lapses, improper diet preparation, food safety violations, and staff training deficiencies that affected resident care quality.
Medication Storage and Labeling Failures
Inspectors found serious medication management violations across multiple areas of the facility. The most concerning discovery involved insulin storage practices that could have compromised patient safety.
Unlabeled Insulin Poses Safety Risk
During inspection of the Cherry Creek medication cart, surveyors found a vial of glargine insulin marked only as "house stock" without any resident identification. This insulin, used for blood glucose management in diabetic patients, had been opened on August 6, 2024, but lacked proper labeling to identify which resident it belonged to.
The licensed practical nurse explained the vial was kept as facility house stock for emergencies when new physician orders hadn't yet been filled by the pharmacy. However, this practice violates medication safety protocols that require each resident to have individually labeled insulin to prevent mix-ups and potential dosing errors.
Insulin dosing errors can have severe consequences, including dangerously low blood sugar (hypoglycemia) that can cause confusion, loss of consciousness, or even death. Proper labeling ensures medications are administered to the correct patient and helps prevent cross-contamination between residents.
Improper Storage Compromises Drug Effectiveness
Additional medication storage violations included mixing different types of medications that should be stored separately. Inspectors observed Lantus insulin stored next to Latanoprost eye drops in the Capitol Hill medication cart, creating contamination risks.
The facility's medication refrigerator contained multiple violations: food items (Boost supplement drinks) were stored alongside prescription medications including controlled substances like Lorazepam and antibiotics like cephalexin. This practice violates professional standards designed to prevent contamination and maintain medication integrity.
Perhaps most concerning was the use of a dormitory-style refrigerator for medication storage. These units have freezer compartments within the main refrigeration area that can cause temperature fluctuations. Inspectors noted ice buildup in the freezer compartment, which could compromise the effectiveness of temperature-sensitive medications like Trulicity injectable pens.
Diet Preparation Failures Endanger Vulnerable Residents
Inspectors documented systematic failures in preparing mechanically altered diets for residents with swallowing difficulties, a violation that could result in choking or aspiration pneumonia.
Texture Modification Errors Create Choking Hazards
The facility failed to follow International Dysphagia Diet Standardization Initiative (IDDSI) guidelines for residents requiring modified texture diets. These standardized protocols exist to prevent aspiration, where food or liquid enters the lungs instead of the stomach, potentially causing life-threatening pneumonia.
Multiple residents received improperly prepared meals that didn't match their prescribed diet orders:
- Resident #86, prescribed a level six soft and bite-sized diet, received carrots cut into one to one-and-a-half inch pieces instead of the required one-and-a-half centimeter pieces. Her rice lacked the required gravy to help bind it together.
- Resident #23, on a pureed diet, received rice with visible pieces that weren't properly blended smooth, violating the requirement that pureed foods contain no lumps.
- Resident #81, requiring level five minced and moist texture, received carrots in large pieces instead of the required four-millimeter minced size.
Bread Products Served Against Protocol
Staff served regular dry biscuits and hamburger buns to residents requiring modified textures, directly contradicting IDDSI guidelines that prohibit regular bread products for these vulnerable individuals. One resident on a soft diet received a whole biscuit that staff cut into one-inch pieces at the table, rather than providing the prescribed pureed texture.
Kitchen staff demonstrated limited understanding of texture modification requirements. One cook admitted having no prior education on mechanically altered diets, while dietary staff incorrectly believed residents on soft diets could receive toasted buns.
Food Safety Violations Risk Foodborne Illness
Comprehensive food safety violations throughout the facility's kitchen operations created multiple contamination risks that could lead to foodborne illness outbreaks among the vulnerable resident population.
Improper Food Handling Practices
Staff repeatedly used the same gloves for multiple tasks without changing them, violating Colorado food safety regulations. Dietary workers handled meal tickets, equipment handles, and serving utensils with the same gloves used to prepare ready-to-eat foods like sandwiches and bread products.
One particularly concerning incident involved a dietary aide who wiped his nose with his wrist and gloved hand before placing the top slice of bread on a sandwich and wrapping it for service.
Temperature Control Failures
Food temperature monitoring revealed multiple violations that could promote bacterial growth:
- Cold food items including sliced tomatoes (45°F), cucumbers (50°F), and tzatziki sauce (52°F) were stored above the safe temperature of 41°F or below - Hot gyro meat measured only 116°F, well below the required 135°F minimum for safe hot food holding - Staff served the undertemperature gyro meat to a resident without reheating
Storage and Dating Violations
Inspectors found numerous expired and improperly stored food items throughout facility refrigerators:
- Heavy whipping cream expired August 13, observed during August 14 inspection - Herbal tea with use-by date of April 26, 2024 - Multiple opened and undated items including lettuce, cheese, tortillas, and condiments - A used surgical mask sitting on top of popsicles in the freezer - Personal belongings (backpacks and lunch bags) stored alongside food items
Several refrigerators lacked thermometers, preventing proper temperature monitoring to ensure food safety.
Staff Training Deficiencies Compromise Care Quality
The facility failed to provide required annual training for certified nursing aides, a violation that directly impacts the quality and safety of resident care.
Missing Required Education
Federal regulations require CNAs to complete at least 12 hours of annual in-service training covering areas including dementia care and abuse prevention. The facility could not provide documentation showing that five CNAs had completed this mandatory training.
The nursing home administrator acknowledged the facility lacked a staff development coordinator for an extended period and had recently promoted a floor nurse to fill this critical role. This staffing gap resulted in inadequate tracking and completion of required training programs.
Infection Control Knowledge Gaps
Staff demonstrated insufficient understanding of infection control protocols, particularly regarding Enhanced Barrier Precautions (EBP) for residents with medical devices like feeding tubes.
One licensed practical nurse failed to wear a required gown while providing feeding tube care for a resident with physician orders for EBP. The nurse incorrectly believed EBP requirements didn't apply to feeding tube maintenance, despite facility policy and CDC guidelines requiring full protective equipment for high-contact care activities involving indwelling devices.
Dietary Preferences Ignored
Beyond safety violations, the facility failed to accommodate basic resident food and beverage preferences. All residents in the secure unit received cranberry juice with every meal, regardless of individual preferences. Staff made no effort to offer alternatives or ask residents about drink choices during multiple observed meal services.
One resident repeatedly received incorrect meal items, including rice instead of his requested mashed potatoes, with no explanation or alternative offered by staff.
Facility Response and Oversight
The inspection revealed systematic breakdowns in multiple departments, from nursing and dietary services to administrative oversight. While facility leadership acknowledged the violations and began implementing corrective measures during the survey, the scope and severity of the findings indicate significant management and quality assurance gaps.
The violations collectively demonstrate how multiple system failures can compromise resident safety and quality of life in nursing homes, highlighting the critical importance of proper staff training, management oversight, and adherence to established safety protocols.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Highline Post Acute from 2024-08-15 including all violations, facility responses, and corrective action plans.
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