Irondale Post Acute

jeopardy to resident health or safety

morning and had placed the bed as a barrier behind his room door entrance preventing the staff from getting into his room.

Staff had to go through the bathroom from the room next door to offer breakfast to the resident and the resident got up and said expletives aggressively.

The resident continued to state I don't belong here. I want to get out of here! Redirection was attempted but was unsuccessful.

The 8/26/25 at 12:00 p.m. psychiatric follow-up note, documented by a physician's assistant, revealed that Resident #4 shared that he had had thoughts in the past about trying to leave the unit by breaking a window, but stated he would have turned himself in afterward.The 9/9/25 at 9:52 a.m. nurse note revealed Resident #4 had refused his breakfast and all his medications.

Later the resident requested his breakfast be replaced.

The nurse staff went to the kitchen to obtain a new plate and upon delivery the resident threw the plate across the dining room and stated that the nursing staff was trying to poison him with his medications and were trying to give him food from another resident.

The resident then called 911.

Police officers responded and the resident was stating that he wanted to leave and return to the homeless shelter and that he did not belong there.

The resident was also displaying paranoia related to his sister.

The police officer, the NHA and nursing staff reoriented the resident and explained cares and the process needed to be able to discharge safely.

The resident verbalized understanding.The 9/20/25 at 12:09 p.m. nurse note, written by registered nurse (RN) #2, revealed Resident #4 did not want the nurse to touch his AICD monitor.

The nurse observed the monitor was unplugged and the resident was agitated.The 9/20/25 at 12:10 p.m. medication administration note revealed the resident refused his skin assessment. RN #2 had attempted the assessment three times.The 9/20/25 at 9:00 p.m. nurse note, written as a late entry by the DON, revealed the executive director (ED), family, ombudsman, police department and medical doctor were all notified. -However, the note did not specify what the notification was regarding. -Review of Resident #4's EMR revealed there were no other progress notes documented on 9/20/25.The 9/21/25 at 3:06 a.m. nurse note, written by licensed practical nurse (LPN) #1 revealed that at 8:30 p.m. on 9/20/25 she entered Resident #4's room to give him his medications and Resident #4 was not sitting on his bed and the door to his bathroom was locked. LPN #1 returned a few minutes later and Resident #4 was still not visible in his room.

LPN #1 knocked on the bathroom door with no answer. LPN #1 opened the door and Resident #4 was not there. LPN #1 asked the certified nurse aide (CNA) #2 if he was aware that Resident #4 was not in his room. CNA #2 stated that the last time he saw Resident #4 was at dinner time and Resident #4 had refused hi

Facility ID:

IDENTIFICATION NUMBER:

A.

Building

COMPLETED

10/09/2025

STREET ADDRESS, CITY, STATE, ZIP CODE

Irondale Post Acute

7150 Poplar St Commerce City, CO 80022

SUMMARY STATEMENT OF DEFICIENCIES