Thornton Care Center

frequently and provided assistance as needed. RN #1 said he was unsure why Resident #1 had

Resident #4 used a wheelchair and had a brace for her spine fracture. LPN #1 said Resident #4

sheets with important notes for each resident. LPN #1 said that after a resident had a fall, the status of each fall and monitoring should be included in the shift report. LPN #1 said that if documentation in the EMR was not immediate, the shift report was the only way for nurses to track resident status.

LPN #1 said it was important for staff to know why residents fell so that staff could monitor the residents and provide safe care.The activities director (AD) was interviewed on 8/20/25 at approximately 2:45 p.m.

The AD said that on 7/9/25, he took residents on a scheduled activity/outing to a local restaurant.

The AD said Resident #1 fell while inside the restaurant and paramedics were contacted.

The AD said staff did not update him on Resident #1's status before the outing and he was unaware that Resident #1 had a fall earlier in the day.The NHA and the director of nursing (DON) were interviewed together on 8/20/25 at 1:20 p.m.

The NHA said the IDT reviewed every fall, the day after a fall occurred.

The DON said the IDT was responsible for reviewing care plan interventions and updating residents' care plans when appropriate.

The DON said she was unable to locate documentation of the IDT fall reviews, but she said she documented the risk reviews for each fall in the residents' EMR.

The DON said Resident #1 liked to walk to the common area to socialize and arrange flowers.

The DON said staff found the resident on the floor after her falls on 6/8/25 and 6/21/25 and the IDT determined Resident #1 had an unsteady balance.

The DON said Resident #1 was educated to use her call light to ask for assistance from staff or to call out for assistance because call lights were not available in common areas.

The DON said the IDT reviewed the 7/9/25 at 5:25 a.m. fall and determined the cause of the fall was because Resident #1 had poor safety awareness because she was carrying personal belongings while trying to ambulate with her walker to the common area.

The DON said it was important for nurses to monitor residents after they had a fall in case the resident had any injury.

She said residents that were being monitored after a fall should not attend outings away from the facility.

The DON said Resident #4 went to an appointment at Walmart on 8/4/25 and was accompanied by her spouse.

She said she was unable to locate who made the appointment and who arranged and approved for the spouse to provide transportation.

The DON said the IDT did not review the fall because Resident #4 fell at a store, was treated by paramedics, and was transferred to the hospital.

The DON said neurological assessments were completed after unwitnessed falls or when a resident had a head injury.

The DON was unable to locate neurological assessments for the 8/4/25 fall.

The NHA said he recalled discussing Resident #1 and Resident #4 after their falls but was unsure of corresponding recommendations made by the IDT.

The NHA said the documentation of the reviews that were completed by the IDT were not documented in either residents' EMRs, but he had a daily log that indicated the reviews had occurred.

The NHA said he was unable to find IDT documentation pertinent to falls for Resident #1 and Resident #4.

The NHA said the IDT needed to improve documentation of clinical discussions.

065193 09/02/2025

Thornton Care Center 501 Thornton Pkwy Thornton, CO 80229

According to the August 2025 computerized physician orders (CPO), diagnoses included epilepsy (a seizure disorder), neurocognitive condition without behavioral disturbance, unspecified intracranial injury with loss of consciousness, insomnia, osteoarthritis, sacrum (pelvic) fracture and history of falling.The 4/24/25 minimum data sets (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15.

The resident was independent from staff assistance for bed mobility, sitting and standing, transferring and walking with a walker.B.

Record reviewReview of Resident #1's August 2025 CPO revealed the following physician's orders:Levetiracetam 1000 milligrams (mg) twice a day for seizures, administer at 6:00 a.m. and 4:00 p.m., ordered on 6/5/25.A review of Resident #1's July 2025 (from 7/1/25 to 7/31/25) medication administration record (MAR) revealed that a code of 9 was documented for the administration of levetiracetam on 7/8/25 and 7/9/25.

According to the MAR, the code of 9 indicated other/see progress notes.-A review of Resident #1's progress notes on 7/8/25 and 7/9/25 failed to reveal documentation to indicate whether or not the levetiracetam medication was administered to the resident as ordered on those dates.III.

Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 9/2/25 at 4:27 p.m.

LPN #1 said he was the nurse assigned to administer medications to Resident #1 on 7/8/25 and 7/9/25. He said he documented a code of 9 for the resident's levetiracetam on both of those dates because he had been unable to locate the medication in order to administer it. He said on 7/8/25 and 7/9/25, another nurse had been able to find the medication in the facility's supply of emergency medications. LPN #1 said he had administered the medication to Resident #1 after receiving the doses from the nurse. LPN #1 said he should have documented a corresponding progress note in the EMR after the medication was administered.

The director of nursing (DON) was interviewed on 8/25/25 at 4:27 p.m.

The DON said LPN #1 should have documented a corresponding progress note in the EMR after Resident #1's levetiracetam was administered on 7/8/25 and 7/9/25.

The DON said LPN #1 was a new employee at the facility and he had been unsure how to document that the medication was administered after he had already entered a code of 9 on the MAR.