BRUSH, CO - Federal inspectors cited South Platte Rehabilitation and Nursing LLC for failing to protect residents from abuse and provide adequate psychosocial care after a resident experienced physical aggression from another resident.
The January 7, 2025 inspection revealed the facility delayed implementing trauma-informed care plans by over two months and failed to address a resident's deteriorating mental health despite clear warning signs documented in official assessments.
Physical Assault Victim Left Without Trauma Support
The inspection focused on Resident #5, who became the victim of physical aggression from another resident. Despite experiencing what facility staff later acknowledged as a traumatic incident, the nursing home waited more than two months before implementing a trauma-informed care plan on December 23, 2024.
During this delay, the resident developed significant psychological symptoms including anxiety, feelings of detachment, and persistent fearfulness related to the incident. When facility staff finally conducted a trauma interview on December 23, 2024, the resident indicated that counseling would help her deal with the trauma she had experienced.
The trauma care plan eventually implemented included offering the resident another room on the opposite hallway, which she declined, and arranging for mental health services. However, the months-long delay in recognizing and addressing the trauma violated federal requirements for timely psychosocial care.
Depression Scores Worsened Without Intervention
Formal mood assessments revealed dramatic changes in the resident's mental health following the incident. Prior to the physical aggression in July 2024, the resident scored zero on the facility's mood interview, indicating no symptoms of depression. She reported never feeling lonely or socially isolated.
Following the incident, the October 2024 mood assessment showed a concerning deterioration. The resident's score increased to six, indicating she felt down, depressed, or hopeless more than half the time over the previous two weeks. She also reported trouble sleeping and feeling tired with little energy more than half the time.
The assessment further documented that the resident sometimes felt lonely or socially isolated, a significant change from her previous responses. Despite these clear indicators of declining mental health, the facility failed to implement appropriate interventions or notify healthcare providers.
Care Planning Failures Documented
The inspection revealed multiple failures in the facility's care planning process. A depression risk care plan was not initiated until December 22, 2024 - two months after the mood assessment indicated the resident had increased signs of depression. This plan was designed to address her recent decline in health, change in living situation, and financial situation.
Federal regulations require nursing homes to develop comprehensive care plans that address residents' psychosocial needs and respond promptly to changes in condition. The facility's delayed response to documented mental health deterioration violated these requirements.
The social services director acknowledged during interviews that she should have made a quarterly progress note for the resident in October 2024 but failed to do so. She also admitted there was no social service progress note addressing the significant mood changes identified in the assessment.
Staff Observations Confirmed Declining Condition
Facility staff members observed behavioral changes consistent with the resident's deteriorating mental health. The activity director reported that the resident was coming out of her room less frequently and had been sleeping later in the mornings during the month preceding the inspection.
These observations aligned with the documented symptoms of depression and social withdrawal identified in the formal assessments. The facility's failure to connect these behavioral changes with the resident's trauma history and declining mood scores represented a breakdown in comprehensive care coordination.
Medical Standards for Trauma Response
Trauma-informed care requires immediate recognition and response to traumatic incidents in nursing home settings. Best practices dictate that facilities should implement trauma assessments and care plans within days of an incident, not months later.
Depression screening protocols mandate that facilities respond promptly to significant changes in mood assessment scores. A jump from zero to six on a depression scale represents a clinically significant change requiring immediate attention and potential medical evaluation.
Federal regulations specify that nursing homes must provide necessary care to attain or maintain each resident's highest practicable physical, mental, and psychosocial well-being. The delayed response to this resident's trauma and depression violated these fundamental care requirements.
Documentation and Communication Gaps
The inspection revealed significant gaps in documentation and communication regarding the resident's condition. The social services director claimed she sent an email requesting behavioral health services for the resident but failed to document this referral in the medical record.
When inspectors requested documentation of the behavioral health services referral and any resulting visits, the facility was unable to provide these records by the end of the survey period. This lack of documentation made it impossible to verify whether appropriate mental health services were actually provided.
The nursing home administrator confirmed during interviews that social services staff should maintain quarterly progress notes for each resident, with additional documentation when resident conditions change. The facility's failure to meet these basic documentation standards compromised continuity of care.
Regulatory Violations and Resident Impact
The citation was issued under F-tag 0742, which addresses comprehensive care plans and their implementation. Inspectors determined the violations resulted in actual harm to residents, with the potential for more than minimal harm that is not immediate jeopardy.
The resident's experience demonstrates how systemic failures in trauma response and mental health care can compound the effects of an initial incident. What began as a physical altercation between residents evolved into prolonged psychological distress due to inadequate facility response.
The inspection findings highlight broader concerns about the facility's ability to recognize, assess, and respond to residents' psychosocial needs in a timely manner. These failures can have lasting impacts on residents' quality of life and overall well-being.
South Platte Rehabilitation and Nursing LLC must submit a plan of correction addressing these deficiencies to continue participating in Medicare and Medicaid programs. The facility is required to demonstrate how it will prevent similar incidents and ensure appropriate trauma-informed care for all residents.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for South Platte Rehabilitation and Nursing LLC from 2025-01-07 including all violations, facility responses, and corrective action plans.
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