Katherine And Charles Hover Green Houses

Based on observations, record review and interviews, the facility failed to ensure an infection prevention and control program was maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of four units. Specifically, the facility failed to: -Implement an effective water management plan to monitor for Legionella-Ensure staff wore the appropriate personal protective equipment (PPE) when providing incontinence care and transfers for Resident #14 and Resident #24, who was on enhanced barrier precautions (EBP) for wounds; and,-Ensure hand hygiene was performed appropriately in the dining areas. Findings include: I. Water management failures A. Professional reference According to Center for Disease Control (CDC), Controlling Legionella in Potable Water Systems, retrieved on 1/27/26 from https://ww.cdc.gov/contro.-legionella.php/toolkit/potable-water-systems-module.html Operation, maintenance, and control limits guidance: Monitor temperature, disinfectant residuals,…

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 and interviews the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Specifically, the facility failed to ensure all staff that were responsible for preparing and cooking meals for the residents were fully educated on proper food handling and food preparation. Findings include:I. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 2/4/26. It read in pertinent part, Employees are properly trained in food safety, including food allergy awareness, as it relates to their assigned duties. Food allergy awareness includes describing food identified as major food allergens and the symptoms that a major food allergen could cause in a sensitive individual who has an allergic reaction. (Chapter 2-103.11)II. Facility policy and procedureThe Food Preparation and Service policy, dated 2001, was provided by the nursing home administrator (NHA) on 1/29/26…

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 notify the one (#41) of six residents or their representative orally and in writing of a charge for an item out of 31 sample residents. Specifically, the facility failed to provide Resident #41 and his representative notification of an accidental charge for Narcan (medication used for reversal of opioid overdose) and how to get reimbursed for the accidental charge in a timely manner. Findings include: I. Resident #41A. Resident statusResident #41, age greater than 65, was admitted on [DATE]. According to the January 2026 computerized physician orders (CPO), diagnoses included cerebrovascular disease (conditions affecting the brain's blood vessels and supply), dementia, history of transient ischemic attack (stroke), anxiety disorder and muscle weakness. According to the 11/5/25 minimum data set (MDS) assessment Resident #41 had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 10 out of 15. The MDS assessment…

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.

Findings include:I. Facility policy and procedureThe Required Training policy, reviewed on 1/9/26 was provided by the nursing home administrator (NHA) on 1/29/26 at 2:02 p.m. The policy revealed the facility would comply with State and Federal regulations and requirements as they pertain to training. Every employee was also required to complete an annual training curriculum through Care Academy (and/other sources) that would be assigned according to their job responsibilities. It was the responsibility of the employee to complete the required training to maintain employment status. The policy did not address that nursing staff were to demonstrate competency in skills and techniques necessary to care for residents on an annual basis.II. Record reviewOn 1/29/26 at 7:52 a.m. an email request was made to the NHA for the facility's annual competency assessment for CNA #1, CNA #2 and CNA #12.-The facility was unable to provide documentation to show that the three selected CNAs had the specific skill sets necessary to provide competent care for residents' needs as demonstrated in an annual…

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 notify the provider when a resident had a significant change in condition requiring a need to alter treatment for two (#12 and #22) out of five residents out of 20 sample residents. Specifically, the facility failed to inform Resident #12 and Resident #22's provider when medications were not administered according to the physician's orders. Findings include: I. Facility policy The Medication and Administration of Medications policy, revised 2/6/24, was provided by the director of nursing (DON) on 2/6/24 at 2:09 p.m. It read in pertinent part,Medication technicians administering medications must use the medication list to identify and monitor for possible ineffective drug therapy and shall promptly report problems to the physician, including residents who are refusing medications. The resident's power of attorney shall also be immediately notified. II. Resident #12 A. Resident status Resident #12, age [AGE], was admitted on [DATE], discharged to 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.

Based on record review and interviews, the facility failed to implement policies and procedures to prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property for six of 60 employee files reviewed. Specifically, the facility failed to complete criminal background checks for six employees prior to the employees working with residents. Findings include: I. Facility policy and procedures The Abuse Prevention Program policy, revised December 2016, was provided by the nursing home administrator (NHA) on 11/8/23 at 2:21 p.m. It read in pertinent part, Our elders have the right to be free from abuse, neglect, misappropriation of elder property and exploitation. This includes but is not limited to freedom from corporal punishment, involuntary seclusion, verbal, mental, sexual or physical abuse, and physical or chemical restraint not required to treat the eider's symptoms. As part of the elder abuse prevention, the administration will conduct employee background checks and will not knowingly employ or otherwise engage any individual who has been…

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 services provided or arranged are delivered by individuals who have the skills, experience and knowledge to do a particular task or activity which included proper licensure or certification for one of seven licensed practical nurses (LPN). Specifically, the facility failed to ensure LPN #1 had an active license in the State registration system to ensure the licensure was aligned with the requirement of the State. Findings include: I. LPN job description The LPN job description, which was undated, was provided by the nursing home administrator (NHA) on [DATE] at 1:28 p.m. It read in pertinent part, Must possess a current, unencumbered, active license to practice as a practical nurse in the state of Colorado. II. Record review On [DATE] at 12:23 p.m. LPN #1's license was checked utilizing the Colorado Department of Regulatory Agencies ([NAME]) Division of Professions and Occupations online license verification system. -According to [NAME],…

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 each nurse aide had registry verification and had met competency evaluation requirements to provide nursing and nursing related services for five of 42 certified nurse aides (CNA). Specifically, the facility failed to ensure five CNAs (CNA #1, CNA #2, CNA #3, CNA #4 and CNA #5) who were providing resident care were certified in the State registration system. Findings include: I. Homemaker job description The Homemaker job description was provided by the NHA on [DATE] at 12:50 p.m. It read in pertinent part, Responsibilities of the homemaker include meal preparation and housekeeping. -The job description did not include resident care as part of the homemaker's responsibilities and a CNA license was not required. II. CNA job description The CNA job description was provided by the nursing home administrator (NHA) was provided on [DATE] at 2:20 p.m. It read in pertinent part, Responsibilities of the CNA include resident care and care of 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.

Based on record review and interview, the facility failed to provide training to their staff that at a minimum educate staff on activities that constitute abuse, neglect, exploitation, and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property and dementia management and resident abuse prevention. Specifically the facility failed to: -Provide effective initial hire orientation for abuse identification and prevention training or dementia management training for six of eight certified nurse aides (CNA) reviewed; and, -Provide annual abuse identification and prevention training or dementia management training for the five of eight CNAs. Findings include: I. Facility policy and procedures The Abuse Prevention Program policy, revised December 2016, was provided by the nursing home administrator (NHA) on 11/8/23 at 2:21 p.m. It read in pertinent part, Our elders have the right to be free from abuse, neglect, misappropriation of elder property and exploitation. This includes but is not…

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, record review, and policy review, the facility failed to ensure proper provision of urinary catheter care. Specifically, the facility failed to ensure 1 (Resident #24) of 2 residents' indwelling urinary catheter urine collection bag and tubing were maintained below the level of the resident's bladder to help prevent urinary tract infections. Findings included: A review of the facility's policy titled, Catheter Care, Urinary, revised 09/2014, indicated, The purpose of this procedure is to prevent catheter-associated urinary tract infections. The policy further indicated, The urinary drainage bag must be held or positioned lower than the bladder at all times to prevent the urine in the tubing and drainage bag from flowing back into the urinary bladder. A review of Resident #24's Medical Diagnosis document revealed the resident had diagnoses to include acute kidney failure, urinary retention, hydronephrosis, and a personal history of urinary tract infections. A review of 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.

Based on interviews and document review, the facility failed to ensure Payroll-Based Journal (PBJ; an electronic report that contained the number of hours every direct care staff member worked for each day of the quarter) data was reported quarterly to the Centers for Medicaid & Medicare Services (CMS) as required. This deficient practice had the potential to affect staffing information posted on consumer websites and data used in quality rating systems to help consumers understand the level and differences of staffing in nursing homes and, ultimately, had the potential to impact the quality of care delivered to residents who currently resided in the facility. Findings included: A review of a facility Staffing Summary Report, also referred to as a PBJ Report, for the period 10/01/2021 through 12/31/2021 revealed no data was reported to CMS. A review of a facility Staffing Summary Report for the period 01/01/2022 through 03/31/2022 revealed no data was reported to CMS. A review of a facility Staffing Summary Report for the period 04/01/2022 through 06/30/2022 revealed no data was…

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.