Lodge at Red Rocks, the

A complaint survey, prompted by #CO1914820, #CO1914824, #CO2566843 and #CO2564524 was conducted on 7/21/25 and 7/28/25. Two deficiencies were cited. Based on record review and interviews, the facility failed to ensure residents were free from significant medication errors for one (#1) of three residents reviewed for medications errors out of 27 sample residents. Specifically, the facility failed to ensure Resident #1 received intravenous (IV) vancomycin (an antibiotic used to treat bacterial infections) for a diagnosis of staphylococcus hominis bacteremia (a bloodstream infection) per physician' s orders. Findings include:I. Professional referenceAccording to Potter, P.A., Perry, A.G., et.al., Fundamentals of Nursing, 10 ed. (2022), E.sevier, St. Louis Missouri, pp. 606-607, "Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment."Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights:-The right medication;-The right dose;-The right patient;-The right route;-The right time;-The right documentation; and,-The right indication.II. Resident #1A. Resident statusResident #1, age 69, was admitted on 3/15.. Based on record review and interviews, the facility failed to ensure two (#5 and #12) of 14 residents were free from verbal abuse out of 27 sample residents.Resident #5 was admitted to the facility' s secured unit with diagnoses of frontal temporal neurocognitive disorder (type of dementia that leads to changes in personality, behavior and language), Huntington’s disease (progressive breakdown of the nerve cells in the brain), dementia with behavioral disturbances, tremors, and depression on 6/25/25. Despite the prison referral paperwork that identified Resident #5 had aggressive behaviors, the facility admitted the resident to the secured unit from prison. The resident had spent the majority of his life in prison or homeless. The prison’s physician recommended that the resident have a one-on-one caregiver for an adjustment period. However, record review and observations revealed the facility did not consistently implement the one-to-one caregiver.Documentation revealed Resident #5 had verbally aggressive behaviors towards other residents on the secured unit. Observations revealed Resident #5 was aggressive, yelling, screaming and shaking his fists in the faces of residents and staff. He was observed placing his face inches away from Resident #12’s face while screaming profanities at him. The facility staff were unable to redirect Resident #5 effecti..