COLORADO SPRINGS, CO- CHEYENNE MOUNTAIN CENTER

Based on record review and interviews, the facility failed to ensure the resident environment was kept as free from accident hazards as was possible and supervision was provided to ensure resident safety for one (#4) of five out of nine sample residents.

Specifically, the facility failed to ensure Resident #4, an independent smoker, did not exhibit unsafe smoking behaviors of smoking cigarettes in her room on multiple occasions and smoking illicit drugs in her room on one occasion (cross-reference F740 for behavioral health).

A nursing note dated 2/2/22 revealed it was noted the resident had not gone out to smoke all day and when staff checked on the resident, a strong odor of cigarette smoke was observed. The nurse did not observe the resident physically smoking a cigarette. The certified nurse aide (CNA) observed a pack of cigarettes and a lighter on the resident’s bedside table, though when the nurse entered the room, the cigarettes and lighter had been removed and the resident denied having smoking materials in her possession. The administrator was notified.

A nursing note dated 2/2/22 revealed the resident was offered nicotine replacement products which she declined. She continued to deny smoking in her room.

A nursing note dated 2/4/22 revealed the resident signed out to visit her boyfriend at 6:30 p.m.

A nursing note dated 2/16/22 revealed the resident was found in her bathroom complaining of loose stools. The nurse observed a cloud of smoke in the bathroom with the resident. The nurse notified the administrator and began 15 minute checks on the resident.

A nursing note dated 5/9/22 revealed the resident was witnessed by the nurse, smoking what appeared to be meth from a clear pipe in her room. Drug paraphernalia was confiscated. NHA, DON, and physician were notified. The police department was notified and sent out an officer to investigate as soon as possible. One-on-one (staff) observation was initiated.

-The one-to-one observations, which were 15 minute checks were discontinued after a couple days (see staff interviews below).

A nursing note dated 5/10/22 revealed the resident continued on 15 minute checks for apparently smoking meth in her room. Resident had been observed resting throughout the night and woke up at 5:30 in the morning and went to smoke a cigarette. Monitoring would continue.

A physician note dated 5/10/22 revealed the resident was seen by the physician related to the incident of being observed smoking methamphetamine in her room on 5/9/22. A urine drug screen was ordered and narcotic pain medications were held and agreed to be discontinued if drug screen came back positive.

A nursing note dated 5/12/22 revealed the resident was noted to have a cigarette smoke smell in her room, the resident denied smoking in her room. The nurse questioned the resident’s roommate and indicated that the resident was smoking in the bathroom. Nurse provided the resident with education and informed her of the danger of smoking in her room and was encouraged to go outside to smoke in the smoking area. The resident voiced her understanding.

A urine drug screen was performed on the resident on 5/10/22 and results were received on 5/12/22 the resident was found to be positive for methamphetamine.

The NHA was interviewed on 5/25/22 at 3:40 p.m. She stated she had been unaware of the resident smoking cigarettes and drugs in her room recently and once she was informed yesterday, the resident was reassessed and deemed to be a supervised smoker (the resident was assessed after being brought to the facility’s attention during the survey).