Creekside Village Rehabilitation And Nursing LLC

Based on observations and interviews, the facility failed to maintain an effective infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infectious diseases on four out of six hallwaysSpecifically, the facility failed to ensure blood sugar glucometers were disinfected appropriately between residents. Findings include: I. Professional referenceAccording to the centers for disease control (CDC), Conditions for Blood Glucose Monitoring and Insulin Administration, retrieved on 5/6/26 from https://www.cdc.gov/injection-safety/hcp/infection-control/?CDC_AAref_Val=https://www.cdc.gov/injectionsafety/blood-glucose-monitoring.html Clean and disinfect blood glucose meters after every use, per the manufacturer's instructions. Blood glucose meters can easily become contaminated during use. When used in healthcare or other group settings, germs and infections can spread if preventive measures are not in place.Dedicated meters should be stored in a manner that prevents cross-contamination and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented in order to facilitate improvement in the lives of nursing home residents through continuous attention to quality of care, quality of life, and resident safety.Specifically, the quality assurance performance improvement (QAPI) program committee failed to identify and address concerns related to quality of life and quality of care. Findings include:I. Cross-referenced citationsCross-reference F 805: The facility failed to serve correct altered diet texture per physician order, resulting in an actual choking incident. The facility failed to ensure appropriate texture meals were served to multiple residents. Resident #4 was served a regular meal instead of a minced and moist diet on 1/13/26. He experienced a choking episode that required multiple attempts of Heimlich maneuver to dislodge the food from the airway. In addition, Resident #22 and #23 were served incorrect texture diets at the time of the survey. The…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, and interview, the facility failed to provide choices for preference of bathing schedule for one (#20) of five residents reviewed for self-determination out of 24 sample residents.Specifically, the facility failed to provide Resident #20 per his preference. Findings include:I. Failure to provide shower as scheduledA. Resident #20B. Resident statusResident #20, age over 65, was admitted on [DATE]. According to the February 2026 computerized physician orders (CPO), diagnoses included fracture of left tibia, and type 2 diabetes. The 12/14/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for a mental status score of 11 out of 15. The resident required partial to moderate assistance from staff for personal hygiene and showers. C. Resident interviewResident #20 was interviewed on 2/3/26 at 12:30 p.m. He said it was impossible to receive a shower at the facility. He said when he was initially admitted , he went several weeks without…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews the facility failed to ensure two (#2 and #4) of 23 out of 24 sample residents were free from abuse and neglect.Specifically, the facility failed to ensure Resident #2 and Resident #4 were kept free from physical abuse from Resident #1.Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy, implemented 4/11/25, was provided by the nursing home administrator (NHA) on 2/9/26 at 9:15 a.m. It read in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. Abuse is defined as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish, which can include staff to resident abuse and certain resident to resident altercations.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, records review and interviews, the facility failed to adequately monitor the resident for unnecessary psychotropic medications needed to provide effective and person-centered care for one (#13) of three residents reviewed for use of psychotropic medication out of 24 sample residents. Specifically, the facility failed to:-Ensure the physician's order for Resident #13's as needed (PRN) lorazepam (antianxiety medication) was reevaluated and a rationale was provided by the physician to justify the continued use of the psychotropic medication beyond the 14-day limit; and,-Ensure behavior and side-effect monitoring were in place for Resident #13's lorazepam and Seroquel (an antipsychotic medication) medications. Findings include:I. Facility policy and procedureThe Use of Psychotropic Medications policy and procedure, revised 4/28/25, was provided by the nursing home administrator (NHA) on 2/9/26 at 2:45 p.m. It read in pertinent part, Psychotropic medications are to be used only when a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations, record review interviews, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen.Specifically, the facility failed to:-Ensure food in the dry storage area and the refrigerator were labeled appropriately; and, -Ensure a system was in place to ensure foods that were stored in the walk-in refrigerator maintained the correct temperature while the walk-in refrigerator was repaired. Findings include:I. Failure to ensure foods were labeled and datedA. Professional referenceThe Colorado Retail Food Regulations, (3/16/24) retrieved on 9/15/25 read in pertinent part, Commercially processed food: open and hold cold, refrigerated, ready-to-eat time/temperature control for safety food prepared and packaged by a food processing plant shall be clearly marked, at the time the original container is opened in a food establishment and if the food is held for more than 24 hours, to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded, the day the original container is opened in the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review, the facility failed to ensure two (#1 and #4) of six residents reviewed for abuse out of seven sample residents were kept free from abuse.Specifically, the facility failed to:-Ensure Resident #1 was kept free from physical abuse by Resident #2; and, -Ensure Resident #4 was kept free from sexual abuse by Resident #3.Findings include:I. Facility policy and procedureThe Abuse policy, revised 5/3/23, was provided by the nursing home administrator (NHA) on 9/4/25. It read in pertinent part, It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. The facility will make efforts to ensure all residents are protected from physical and psychosocial harm, as well as additional abuse, during and after the investigation. Examples include but are not limited to:-Responding…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to report alleged violations of physical abuse to the State Survey and Certification Agency in accordance with state law for two of three alleged abuse violations.Specifically, the facility failed to:-Submit a final report of the facility's investigation of a physical abuse allegation involving Resident #3 and Resident #4 to the State Agency timely; and,-Submit a final report of the facility's investigation of a physical abuse allegation involving Resident #5 and Resident #6 to the State Agency timely.Findings include:I. Facility policy and procedureThe Abuse, Neglect and Exploitation policy dated 4/11/25 was provided by the nursing home administrator (NHA) on 7/7/25 at 2:50 p.m. The policy revealed the facility would provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property.Abuse was defined as the willful infliction of injury, unreasonable confinement,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public. Specifically, the facility failed to: -Repair detached and soiled hallway ceiling tiles; -Repair improperly secured light fixtures; -Maintain swamp coolers in a safe, functional, and sanitary condition; and, -Repair sagging drywall caused by inadequate attachment to the supporting framing. Findings include: I. Facility policy and procedure A request was made to the nursing home administrator (NHA) on 5/13/25 for the facility's policy for maintaining a safe and sanitary environment; however, the policy was not provided by the end of the survey (on 5/13/25). II. Observations On 5/12/25, environmental observations of the facility were conducted throughout the day, beginning at 10:21 a.m. The following was observed. A. Ceiling tiles Several ceiling tiles were detached from their mounts. Additionally, ceiling tiles revealed structural weakening and visible wear. The surfaces of the ceiling tiles were discolored in yellow and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure two (#10 and #13) of five residents out of 11 sample residents were kept free from abuse. Specifically, the facility failed to: -Protect Resident #10 from physical abuse by Resident #12; and, -Protect Resident #13 from verbal abuse by Resident #12. Findings include: I. Facility policy and procedure The Abuse, Neglect and Exploitation policy, dated 4/11/25, was provided by the nursing home administrator (NHA) on 5/13/25 at 5:59 p.m. It read in pertinent part, It is the policy of this facility to provide protections for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property. 'Abuse' means the willful infliction of injury, unreasonable confinement, intimidation or punishment resulting in physical harm, pain or mental anguish, which can include staff to resident abuse and certain…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure that residents were free from significant medication errors for one (#1) of three residents reviewed for medication errors out of 11 sample residents. Specifically, the facility failed to ensure Resident #1 was administered antibiotic medications per physician's orders. Findings include: I. Resident #1 A. Resident status Resident #1, age [AGE], was admitted on [DATE]. According to the May 2025 computerized physician orders (CPO), diagnoses included diverticulitis of intestine part unspecified with perforation and abscess without bleeding (disease that causes inflammation and infection in the intestine), abscess of intestine, lower abdominal pain unspecified and bipolar disorder (mental illness). The 5/6/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 14 out of 15. B. Resident interview Resident #1 was interviewed on 5/12/25 at 3:28 p.m. She said the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure one (#13) of four residents investigated for abuse out of 13 sample residents was kept free from physical abuse. Specifically, the facility failed to protect Resident #13 from physical abuse by Resident #12. Findings include: I. Facility policy and procedure The Abuse policy, revised on 6/11/24, was provided by the interim nursing home administrator (INHA) on 2/20/25 at 2:42 p.m. The policy read in pertinent part, Every resident has the right to be free from abuse. All occurrences of resident abuse shall be promptly reported to the abuse coordinator for investigation. The facility will ensure that all residents are protected during and after abuse investigations by: -Responding immediately to protect the alleged victim; -Increasing supervision of the alleged victim and the other residents as indicated; and, -Providing emotional support to the resident during and after the investigation. Sexual abuse is non-consensual contact of any type with a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure residents who were unable to carry out activities of daily living (ADL) received the necessary services to maintain good grooming and personal hygiene for two (#3 and #8) of five residents reviewed out of five sample residents. Specifically, the facility failed to ensure Resident #3 and #8, who were dependent on staff for bathing, received their scheduled showers. Findings include: I. Facility policy and procedure The Shower/Bathing policy, revised October 2010, was provided by the nursing home administrator (NHA) on 9/24/24 at 1:32 p.m. The policy read in pertinent part, Shower/bathing schedules are determined based on resident preference, including type, frequency and time of day. The following information should be recorded on the resident's ADL (activities of daily living) record and/or in the resident's medical record: 1. The date and time the shower/tub bath was performed. 2. The amount of assistance required to complete…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on record review and interviews, the facility failed to provide a choice of attending physician to residents. Specifically, the facility switched to a new provider group of attending physicians and did not notify all of the residents or provide choices. Findings include: I. Facility policy and procedure The Resident Choice of Attending Physician policy was requested from the director of nursing (DON) on 7/17/24 at 11:38 a.m. -The policy was not received by the end of the survey on 7/17/24. II. Resident interviews Resident #3 was interviewed on 7/17/24 at 11:54 a.m. Resident #3 said he remembered a meeting where the new provider came and introduced herself. However, he said there was no other communication from the facility regarding a new provider. He said the decision to bring in a new provider for the facility was made by the facility corporation and he was not given a choice in the matter. He said the nursing staff told him he had to use the new provider and he had no choice in his provider. Resident #3 said he received nothing in writing about the change or what to do if…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, observations and record review, the facility failed to consistently serve food that was palatable, attractive and at a safe and appetizing temperature. Specifically, the facility failed to ensure resident food was served palatable in taste, texture and temperature. Findings include: I. Facility policy and procedure The Meal Preparation for Nutritive Value and Palatability policy, revised April 2023, was provided by quality mentor (QM) #1 on 4/1/24 at 6:38 p.m. The policy revealed in pertinent part, Food is prepared by methods that conserve nutritive value, flavor and appearance. Meal service is timed for tray/cart delivery within reasonable time limits to preserve temperature and quality of food. Resident's comments are noted in resident council meeting minutes with appropriate action taken per response or grievance form. II. Resident interviews Resident #15 was interviewed on 3/27/24 at 11:12 a.m. Resident #15 said some food tasted good but residents asked for more and sometimes the kitchen said they were out of the food item. Resident #43 was interviewed on…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen, main dining room, one of two nourishment rooms and one of two units. Specifically, the facility failed to: -Ensure staff performed hand hygiene and glassware was handled appropriately in the main dining room; -Ensure staff washed hands and changed single use gloves appropriately while plating and serving resident meals in the main kitchen; -Ensure food was labeled and dated and disposed of timely in one of two nourishment rooms; and, -Ensure food items on meal trays were covered during transport in the hallway during meal delivery to resident rooms. Findings include: I. Ensure staff performed hand hygiene and glassware was handled appropriately in the main dining room. A. Professional references The Colorado Retail Food Regulations, effective 3/16/24, were retrieved 4/8/24 from https://cdphe.colorado.gov/environment/food-regulations. The regulations read…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADL) for three (#15, #37 and #60) of seven residents reviewed for ADLs out of 29 sample residents. Specifically, the facility failed to ensure Resident #15, #37 and #60 received showers as scheduled. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADL) policy, revised March 2018, was provided by quality mentor (QM) #1 on 4/1/24 at 4:45 p.m. It read in pertinent part, Appropriate care and services will be provided for residents who are unable to carry out ADLs independently, with the consent of the resident and in accordance with the plan of care, including appropriate support and assistance with hygiene (bathing, dressing, grooming, and oral care). If residents with cognitive impairment or dementia resist care, staff will attempt to identify the underlying cause of the problem and not just assume the resident is refusing or declining care. Approaching…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to promote and maintain the residents' dignity for two (#45 and #57) of two residents reviewed for dignity and respect out of 29 sample residents Specifically, the facility failed to: -Ensure Resident #45 was offered his breakfast and lunch in a timely manner; and, -Ensure staff knocked and identified themselves prior to entering Resident #57's room. , Findings include: I. Resident #45 A. Resident status Resident #45, under age [AGE], was admitted on [DATE]. According to the April 2024 computerized physician orders (CPO), diagnoses included multiple sclerosis, chronic obstructive pulmonary disease (COPD), emphysema, cervical disc degeneration and spondylosis (degeneration of the neck). According to the 1/4/24 minimum data set (MDS) assessment, Resident #45 was cognitively intact with a brief interview for mental status (BIMS) score of 15 out of 15. He was dependent on assistance for toileting hygiene, bathing, dressing, and transfers,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents were kept free from significant medication errors for one (#1) of six residents of 29 sample residents reviewed for medication errors. Specifically, the facility failed to ensure Resident #1 received all of his medications per the physician's orders. Findings include: I. Facility policy The Medication Administration Policy, dated 2/29/24, was provided by quality mentor (QM) #1 on 4/2/22 at 5:57 p.m. The policy revealed in pertinent part, Resident medications are administered in an accurate, safe, timely, and sanitary manner. Medications are prepared, administered, and recorded only by licensed nursing, medical, pharmacy, or other personnel authorized by state laws and regulations to administer medication. Medications are administered in accordance with written orders of the attending physician or physician extender. If a dose is inconsistent with the resident's age and condition or a medication order is inconsistent with the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure one (#13) of three residents reviewed for ancillary services, such as dental services, out of 29 sample residents received routine dental care obtaining routine and 24-hour emergency dental care. Specifically, the facility failed to provide Resident #13 with routine dental care. Findings include: I. Facility policy and procedure The Dental Services policy, revised December 2016, was provided by quality mentor (QM) #1 on 4/2/24 at 5:57 p.m. The policy revealed in pertinent part, Routine and 24-hour emergency dental services are provided to our residents through a contract agreement with a licensed dentist that comes to the facility monthly, referral to the resident's personal dentist, referral to community dentists or referral to other health care organizations that provide dental services. Social services representatives will assist residents with appointments, transportation arrangements, and for reimbursement of dental services…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure the laundry area was free from multiple environmental concerns. Findings include: I. Facility policy The Submitting a Maintenance Request form was provided by quality mentor (QM) #1 on 4/2/24 at 3:13 p.m. It read in pertinent part: Maintenance requests need to be submitted. Fill out and submit the work order. Instructions for completing the work order were on the form. -A policy regarding the protocol for environmental issues within the facility was not provided by the end of the survey on 4/2/24. I. Observations and interview On 4/2/24 at 9:45 a.m. and 10:30 a.m., the facility's laundry area was observed with the environmental services director (ESD). The following concerns were observed: -The exhaust fan in the soiled linen room was not on. The fan's cover was off and wires were hanging out of the fan box. The ESD said she did not know how long the fan had been broken.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and staff interviews, the facility failed to ensure one resident (#3) of five residents' call light system was functioning out of five sample residents. Specifically, the facility failed to ensure Resident #3's room call light was functioning properly. Findings include: I. Facility policy The Accommodation of Needs policy, revised 2021, was provided by the director of nursing (DON) on 12/19/23 at 11:51 a.m. The policy revealed the facility's environment and staff behaviors were directed toward assisting the resident in maintaining and/or achieving safe independent functioning, dignity and well-being. The resident's individual needs and preferences were accommodated to the extent possible, except when the health and safety of the individual or other residents would be endangered. In order to accommodate individual needs and preferences, staff attitudes and behaviors were directed towards assisting the residents in maintaining independence, dignity and well-being to the extent…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to ensure two (#8 and #9) of three residents reviewed out of 11 sample residents for assistance with activities of daily living (ADL) received appropriate treatment and services to maintain or improve his or her abilities. Specifically, the facility failed to: -Provide consistent showers for dependent Residents #8 and #9; and, -Provide regularly scheduled personal care to Resident #8. Findings include: I. Facility policy and procedure The Activities of Daily Living (ADL) Care of Residents policy and procedure, revised in March 2018, was provided by the nurse quality manager (QM) on 9/26/23 at 5:43 p.m. It read in pertinent part Residents who were unable to carry out activities of daily living independently would receive the services necessary to maintain good nutrition, grooming and personal and oral hygiene. Residents would be provided with care, treatment and services to ensure that their activities of daily living(ADLs) do not diminish…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for six out of seven resident hallways. Specifically, the facility failed to: -Ensure a sanitary environment for resident hallways; -Clean up the dining room after an unknown resident urinated on the floor daily; and -Clean the air mattress cover for Resident #49. Findings include: I. Facility policies and procedures The Deep Clean policy, revised December 2010, was provided by the district director of clinical services (DDCS) #2 on 12/19/19 at 4:56 p.m. It documented in pertinent part .A successful preventive maintenance system is dependent on a routine schedule. Some preventive maintenance tasks are performed weekly while others are conducted monthly, quarterly, semi-annually, or annually . The Complete Room policy, revised January 2000, was provided by the housekeeping supervisor (HKS) on 12/19/19 at 3:16 p.m. It documented in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews; the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming for four (#23, #13, #77 and #76) of seven residents reviewed for activities of daily living (ADLs) out of 40 sample residents. Specifically, the facility failed to ensure Resident #23, Resident #13, Resident #77 and Resident #76 received baths/showers according to the residents bathing schedule. Cross-reference: F725 Sufficient staffing Findings include: I. Facility policy and procedure The Routine Resident Care policy, revised September 2011, provided by the director of nurses (DON) on 12/19/19 at 9:19 a.m., revealed in part, Showers, tub baths, and/or shampoos are scheduled at least twice weekly and more often as needed. II. Resident #23 Resident status Resident #23, age [AGE], was admitted on [DATE]. According to the December 2019 computerized physician orders (CPO), diagnoses included multiple sclerosis,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on resident interview, record review, and staff interviews, the facility failed to provide sufficient nursing staff to ensure the residents received the care and services they required as determined by resident assessments and individual plans of care. Specifically, the facility failed to consistently provide adequate nursing staff which considered the acuity and diagnoses of the facility's resident population in accordance with the facility assessment, resident census and daily care and services required by the residents. Cross-reference: F677 activities of daily living services for dependent residents; F679 individualized activities; F686 pressure ulcer prevention and healing; F689 accident hazards; F698 dialysis care; and F690 incontinence care. Findings include: I. Facility policy and procedure The facility Staffing policy and procedure was requested on 12/19/19 at 5:05 p.m. The district director of clinical services (DDCS) #2 stated, We don't have a specific staffing policy. We follow what is on our facility assessment, based on the needs of the residents. II. Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and staff interviews, the facility failed to ensure all drugs and biologicals were properly stored in one of two medication storage rooms and three of three medication carts. Specifically, the facility failed to ensure: -Medication carts were kept clean, free from loose pills and debris; -Medications for different routes of administration were stored separately to prevent contamination; -Medication refrigerators were kept at acceptable storage temperatures and temperatures were monitored; -Expired medications were removed from the medication refrigerators in a timely manner; and -Medications were dated when opened in order for the staff to identify when the medications should be removed from service. Findings included: I. Facility policy and procedure The facility medication storage policy was requested from the director of nursing (DON) on 12/19/19 and not received during survey. The Medication Cart Use policy was received DON on 12/19/19 at 7:48 a.m. The policy documented…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, and interviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (#95) of one out of 27 sample residents reviewed for respiratory care and one of one washer and dryer reviewed for routine cleaning/sanitization. Specifically the facility failed to ensure the proper cleaning and storage of Resident #95s continuous positive airway pressure (CPAP) equipment, and; to ensure the routine cleaning/sanitization, of a community washer and dryer, used by multiple residents on a daily basis, was completed after resident use. Findings include: I. Facility policy and procedure A. The positive air pressure (PAP) equipment cleaning and care policy, provided by the respiratory company responsible for maintenance of PAP equipment, on 12/19/19 at 12:59 p.m., read in pertinent part: Daily…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for two (#99 and #95) of two residents reviewed out of 40 residents sampled. Specifically, the facility failed to: -Develop a care plan for Resident #99 to prevent skin breakdown; and -Develop a care plan for Resident #95 related to the proper use and care of a CPAP (continuous positive airway pressure) machine. Findings included: I. Facility policy and procedure The policy, dated 11/2017, titled Comprehensive Care Plan was received from the director of nursing (DON) on 12/18/19 at 11:00 a.m. The policy documented in pertinent part care plans must include .interventions to prevent avoidable decline in function or functional level and attempt to manage risk factors. The care plan is reviewed on an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure the comprehensive care plan for two (#67 and #99) of 27 out of 44 sample residents were reviewed and revised by the interdisciplinary team. Specifically, the facility failed to ensure care plans were updated to include: -Resident #67's vital sign requirements and shunt monitoring after dialysis; and -Resident #99's individualized activities. Cross-reference F698, failure to monitor Resident #67's access site for complications after dialysis; and F679, failure to provide individualized and meaningful activities for Resident #99 Findings include: I. Facility policy and procedure The Comprehensive Care Plan policy, revised November 2017, was provided by the director of nursing (DON) on 12/18/19 at 11:00 a.m. The policy revealed the facility would develop a comprehensive person-centered care plan that identified each resident's medical, nursing, mental and psychosocial needs within seven days after completion of the comprehensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide a meaningful program of activities for one (#99) of three residents reviewed for activities of 40 sample residents. Specifically, the facility failed to implement individualized approaches for activities for resident #99, a cognitively impaired resident. Findings included: I. Facility policy and procedure The Activities Program policy, dated February 2017 was received from the director of nursing (DON) on 12/19/19 at 7:48 a.m. The policy documented in pertinent part, activities are designed to provide residents with choices of meaningful activities independently or in a group setting. II. Resident Status Resident #99, age [AGE], was admitted on [DATE]. According to the December 2019 computerized physician's orders (CPO) diagnoses included: dementia with behavioral disturbance, anxiety, post-traumatic stress disorder, obsessive compulsive disorder, and muscle weakness. The 12/2/19 minimum data set (MDS) assessment documented the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews; the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two (#206 and #67) of three residents investigated for accident hazards out of 40 sample residents. Specifically, the facility failed to ensure Resident #206 received recommended interventions resulting in falls and ensure Resident #67 received required neuro checks. Findings include: I. Facility policy and procedure The Fall Management policy, revised November 2017, provided by the director of nurses (DON) on 12/18/19 at 11:00 a.m. revealed in part, The nurse will discuss recommended interventions to reduce the potential for additional falls with the resident and/or resident's representative and document in the Care Plan and progress notes .After the at risk review meeting, the interdisciplinary (IDT) will perform the follow-up items assigned as indicated by the review .In the event a resident has a fall and it has been determined they hit…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review the facility failed to ensure one (#76) of one residents reviewed out of 40 residents sampled received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible. Specifically, the facility failed to follow the bowel and bladder assessment for Resident #76, including toileting her every two hours and providing timely incontinent care. Findings included: Cross-reference F725 Failure to ensure sufficient staffing. I. Facility policy and procedure The Bowel and Bladder management policy dated July 2017, was received from the director of nursing (DON) on 12/19/19 at 7:48 a.m. The policy documented in pertinent part, the goal of retraining for cognitively impaired residents was to increase periods of continence and reduce the potential for skin breakdown. The steps included monitoring for wetness every two hour, identify an elimination plan and initiate an individualized care plan. II. Resident status…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews the facility failed to ensure residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences for one (#67) of one out of 40 sample selected residents. Specifically, the facility did not obtain physician orders to monitor the resident's condition or access site (shunt) for complications after dialysis treatments. Cross-reference F657: Failure to ensure care plans were updated. Findings include: I. Facility policy and procedure The Hemodialysis, Care of Residents policy, revised August 2017, provided by the DON on 12/18/19 at 11:00 a.m., revealed the facility provided residents with safe, accurate and appropriate care, assessments and interventions consistent with the comprehensive care plan, the resident's goals and preferences. -Item #1: review and ensure orders upon admission were received for follow-up dialysis center appointments, shunt care,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review, observations and interviews,, the facility failed to ensure one (#51) of 40 sample residents received food and fluids prepared in a form designed to meet her needs per physician orders, and the resident's care plan. Specifically, the facility failed to ensure Resident #51 was served mechanical soft meals instead of regular texture meals. Findings include: I. Facility policy and procedure The Therapeutic Diet policy, revised September 2017, was provided by the nursing home administrator (NHA) on 12/19/19 at 2:46 p.m. It documented in pertinent part This diet offers more advanced texture that may be used to transition to a regular diet. It consists of ground meats, with soft fruits and vegetables, and most bread products . II. Resident #51 status Resident #51, over the age of 90, was admitted on [DATE]. According to the December 2019 computerized physician orders (CPOs), diagnoses included Alzheimer's disease, major depressive disorder, and muscle weakness. The 10/13/19 minimum data set…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.