Inspection Reports for
Medallion Post Acute Rehabilitation

The complaint investigation found that Resident #2 fell on 2/11/25, complained of severe pain (8/10) in left shoulder and hip, and requested hospital transfer immediately. The facility delayed hospital transport by 63 minutes, conducted assessment without an RN physically present, and failed to document physician orders for X-rays prior to transfer. The resident sustained serious injuries requiring surgery. The resident's representative expressed frustration over the delay and inadequate care.

The facility failed to accurately assess and evaluate Resident #2 after a fall, did not honor the resident's request for immediate hospital transfer, and delayed hospital transport by over an hour. The resident sustained a dislocated and fractured left shoulder and a fractured left hip requiring surgery. The assessment was conducted by an LPN with no RN physically present at the time of the fall, and physician orders for X-rays were not documented prior to hospital transfer.

The complaint investigation was substantiated. Resident #1 eloped from the facility on 2/1/25 and was missing for approximately 12 to 15 hours before being found by police and admitted to a hospital. Staff failed to monitor the resident every two hours as required, and the resident refused to wear a wanderguard. The facility initiated an investigation and corrective actions.

The facility failed to provide adequate supervision to Resident #1, who was at risk for elopement, resulting in the resident leaving the facility unnoticed for approximately 12 to 15 hours. Staff failed to perform required two-hour checks, and the resident was found at a local hospital after being located by police. The facility implemented corrective actions including staff education, suspension of involved staff, and systemic changes to prevent recurrence.

The facility was found to have multiple deficiencies including failure to treat residents with dignity and respect, inadequate incontinence care, failure to accommodate resident needs, unresolved noise complaints, incomplete bathing per resident preferences, unresolved grievances, maintenance and environmental issues, medication administration errors, inadequate discharge planning, insufficient assistance with activities of daily living, failure to provide appropriate wound care, nutritional care deficiencies, medication errors related to Parkinson's disease treatment, improper medication storage, failure to provide timely dental services, and lapses in infection prevention and control practices.

The complaint investigation was triggered by a smoking incident on 3/27/24 where Resident #1, a supervised smoker on oxygen, sustained first-degree burns after lighting a cigarette with oxygen cannula in place. The Colorado Department of Public Health and Environment (CDPHE) declared immediate jeopardy due to unsafe smoking practices and lack of adequate safety interventions. The immediate jeopardy was removed on 4/10/24 after the facility implemented corrective actions, but deficiencies remained.

The facility failed to ensure a safe environment for residents who smoke, particularly those on oxygen. The smoking policy and resident evaluations were not updated after the transition to a smoking facility, staff were not trained on smoking safety, and no smoking agreements were signed before the incident. Resident #1 sustained burns due to unsafe smoking practices. Although the immediate jeopardy was removed after corrective actions, deficiencies remained in policy, supervision, and implementation of safety interventions.

The facility failed to provide proper Medicare liability notices to residents, failed to provide adequate supervision and fall prevention interventions for a resident resulting in multiple falls and a major injury, and failed to adequately communicate and collaborate with the hospice provider to meet a resident's hospice care needs.

The complaint investigation focused on grievances filed by residents #11 and #23 regarding delayed call light response, inadequate toileting assistance, disrespectful staff behavior, and failure to investigate abuse allegations. Resident #23 reported a nurse kissed her without consent, and Resident #11 reported being left soiled for over 24 hours. Both residents expressed frustration and depression related to these issues. The facility failed to fully investigate these complaints or provide adequate resolution.

The facility failed to ensure residents were treated with dignity and respect, responded timely to call lights, and provided adequate assistance with toileting and incontinent care. Several residents reported feeling frustrated, humiliated, and depressed due to neglect and poor staff attitudes. The facility also failed to fully investigate allegations of abuse, including a nurse kissing a resident without consent and leaving a resident soiled for over 24 hours. Staff training on customer service and grievance handling was provided but deficiencies persisted.