Skylake Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record review and interviews, the facility failed to ensure residents who were trauma survivors, received culturally competent, trauma-informed care in accordance with professional stands or practice and accounting for the residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for one (#144) of three residents reviewed out of 71 sample residents. Specifically, the facility failed to ensure individualized care approaches were provided for Resident #144 to prevent re-traumatization. Findings include:I. Facility policy and procedureThe Trauma Informed Care and Culturally Competent Care policy, revised August 2022, was provided by the director of nursing (DON) on 9/25/25 at 9:29 a.m. It read in pertinent part, Develop individualized care plans that address past trauma in collaboration with the resident and family, as appropriate. Identify and decrease exposure to triggers that may re-traumatize the resident.II. Resident #144A.…

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 the necessary behavioral health care and services to attain and maintain the highest practicable physical, mental and psychosocial well-being for one (#130) of three residents reviewed out of 71 sample residents.Specifically, the facility failed to:-Document resident specific care approaches, to include medication specific target behaviors and person-centered interventions for Resident #130; and,-Document attempted non-pharmacological interventions prior to the administration of a as needed (PRN) anti anxiety medication. Findings include:I. Resident #130A. Resident statusResident #130, age greater than 65, was admitted to the facility 8/21/25. According to the September 2025 computerized physician orders (CPO), the diagnosis included cognitive communication deficit and dementia with behavioral disturbances and agitation.The 8/27/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with a brief interview for mental status (BIMS) score of seven out of 15. He required substantial…

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 implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption on two of four hallways.Specifically, the facility failed to ensure safe and appropriate storage of food items in resident's personal refrigerators. Findings include: I. Professional reference The Colorado Retail Food Establishment Regulations, (3/16/24), retrieved on 9/29/25 read in pertinent part, Except during preparation, cooking, or cooling, or when time is used as the public health control, time/temperature control for safety food shall be maintained at 135 degrees Fahrenheit (F) or above, or at 41 degrees F or less (3-501.16). Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 41 degrees Fahrenheit (F) or less for 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 record review and interviews, the facility failed to establish a communication process that included how the communication would be documented between the facility and the provider for two (#11 and #9) of four residents reviewed for hospice care out of 71 sample residents.Specifically, the facility failed to establish a communication process according to the hospice agreement that included documentation of care and services provided by hospice filed and maintained for Resident #11 and Resident #99. Findings include: I. Facility policy and procedure The Hospice Program policy, revised July 2017, was provided by the nursing home administrator (NHA) on 9/25/25 at 9:30 a.m. It read in pertinent part, Our facility has an agreement in place with at least one Medicare-certified hospice to ensure that residents who wish to participate in a hospice program may do so. Hospice providers who contract with this facility must have a written agreement with the facility outlining (in detail) the responsibilities 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 observations and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection. Specifically, the facility failed to: -Ensure staff wore the appropriate personal protective equipment (PPE) when providing direct care to a resident who was on enhanced barrier precautions (EBP); and, -Follow appropriate infection control measures during wound care. Findings include: I. PPE failures A. Facility policy and procedure The Enhanced Barrier Precautions policy, undated, was provided by the director of nursing (DON) on 5/7/25 at 9:20 a.m. It read in pertinent part, Enhanced barrier precautions refer to the use of gown and gloves for use during high-contact resident care activities for residents known to be colonized of infected with a multi-drug resistant organism (MDRO) as well as those at increased risk of MDRO acquisition. High-contact resident care activities include: dressing, bathing, transferring, providing hygiene, changing…

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 staff interviews, the facility failed to have a written transfer agreement with one or more hospitals approved for participation under Medicare and Medicaid programs to reasonably ensure residents would be transferred from the facility to a hospital, and assured of timely admission to the hospital when transfer was medically appropriate. Specifically, the facility failed to ensure a written agreement was in effect with one local area hospital. Findings include: I. Record review A request was made to the director of nursing (DON) and corporate nurse consultant (CNC) #1 on 6/13/24 at 4:27 p.m., for the facility's hospital transfer agreement. -The facility was unable to provide a written agreement for the one area hospital. II. Interview The interim nursing home administrator (INHA) and CNC #1 and CNC #2 were interviewed together on 6/14/24 at 3:55 p.m. The INHA said the facility did not have a hospital transfer agreement. The INHA said no area hospitals would provide the facility with a transfer agreement because the hospitals took residents based on 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 (#1) of three residents out of 16 sample residents had the right to be informed of and participate in care plan meetings and to develop his or her treatment plan including the right to be informed, in advance, of the care to be furnished and the type of caregiver or professional that would furnish care. Specifically, the facility failed to: -Inform Resident #1's legal representative in advance of the facility's scheduled care plan meetings so the representative could participate in care planning; -Inform Resident #1's legal representative of when upcoming podiatry and dental services were to be provided so the representative could be informed and assist with treatment decisions; and, -Notify and inform Resident #1's legal representative of changes in the resident's condition, including falls. The findings include: I. Facility Policy and Procedure On 6/13/24 the Resident Representative policy, revised February 2021, was provided by 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 ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin were reported immediately for one (#1) of three residents reviewed out of 16 sample residents. Specifically, the facility failed to report an allegation of an injury of unknown origin (bite wound) to the State oversight agency within 24 hours of the injury being discovered. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, revised September 2022, was received from the director of nursing (DON) on 6/14/24 at 10:30 a.m. The policy documented in pertinent part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of property are reported to the local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported. If resident abuse,…

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 incidents of potential abuse were thoroughly investigated for one (#1) of three residents out of 16 sample residents. Specifically, the facility failed to ensure an allegation of physical abuse, reported following the discovery of an injury of unknown origin, a bite wound, was thoroughly investigated and that the resident was monitored to prevent the possibility of a repeated instance. Findings include: I. Facility policy and procedure The Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating policy, revised September 2022, was received from the director of nursing (DON) on 6/14/24 at 10:30 a.m. The policy documented in pertinent part, All reports of resident abuse (including injuries of unknown origin), neglect, exploitation, or theft/misappropriation of property are reported to the local, state and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all…

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 observation, record review and staff interview, the facility failed to store, prepare, distribute and serve food in a sanitary manner. Specifically, the facility failed to: -Ensure staff washed hands and changed single use gloves appropriately while plating and serving resident meals in the main kitchen; -Ensure food in the walk-in refrigerator and the reach-in refrigerators in the main kitchen, and in two of two resident unit snack refrigerators was labeled and dated with an open date and disposed of timely when past the used by date; and, -Ensure that expired foods were not served to residents., Findings include: I. Hand hygiene A. Professional reference The Colorado Retail Food Regulations, effective 1/1/19, were retrieved 1/11/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Food employees shall clean their hands and exposed portions of their arms as immediately before engaging in food preparation including working with exposed food, clean equipment and utensils, and unwrapped single service and single-use articles 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 and interviews, the facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection for two out of three units at the facility. Specifically, the facility failed to: -Ensure accurate transmission based precaution procedures were followed, including use of isolation signage on resident doors and following proper procedures for donning (put on) personal protective equipment (PPE) prior to entering a resident's room who was COVID-19 positive. -Ensure housekeeping staff followed appropriate infection control procedures such as hand hygiene and surface disinfectant time adherence. I. Transmission based precaution and PPE A. Professional reference According to the Centers for Disease Control (CDC) Hand Hygiene updated 5/8/23, retrieved on 1/15/24 from: https://www.cdc.gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html#r2 revealed in part,…

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 observation, record review and staff interviews, the facility failed to ensure essential laundry dryer equipment was in safe working order in the facility laundry room. Specifically, the facility failed to keep the dryer lint filters and compartments cleaned and without lint building up in three of three facility dryers. Findings include: I. Professional reference According to the US Department of Labor Occupational Safety NS Health Administration (OSHA), Laundry: Fire Hazards, 2023, retrieved 1/15/24 online form https://www.osha.gov/etools/hospitals/laundry/fire-hazards, Lint build-up on ceilings and other surfaces can increase the risk of fire. Lint build-up in lint traps within dryers can also be a hazard. It is important that employers implement a fire prevention plan in the laundry because of the fire hazards. Routine cleaning surfaces of lint and emptying of lint traps: Fire prevention plan: The purpose of a fire prevention plan is to prevent a fire from occurring. II. Dryer vent system observations On 1/8/24 at 3:00 p.m., the laundry room's three industrial dryers…

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 residents were provided prompt efforts by the facility to follow up on grievances. Specifically, the facility failed to: -Ensure grievances and or complaints were filed and the facility actions and resolutions were documented; -Ensure residents were informed of grievances outcomes and of the facility's actions to resolve grievances; -Ensure residents received a resolution to the residents' satisfaction; -Ensure staff were trained and educated on the facility's grievance process; and, -Ensure call lights were answered timely. Findings include: A. Facility policy and procedure The grievances policy and procedure, revised April 2017, was provided by the corporate nurse consultant (CNC) on 1/9/24 at 5:30 p.m. It read in pertinent part, Upon receiving agreements and complaint report, grievance officer will begin an investigation into the allegations. The department directors of any named employees will be notified of the nature of the complaint 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 seven of seven nursing staff members were able to demonstrate skills and techniques necessary to care for residents' needs. Specifically, the facility failed to: -Ensure that registered nurse (RN) #3 and licensed practical nurse (LPN) #1 had specific competencies and skill sets necessary to care for residents' needs; and, -Ensure certified nurse aides (CNA) #4, CNA #5, CNA #6, CNA #7 and CNA #8 were able to demonstrate competencies in skills and techniques necessary to care for residents' needs, as identified through resident assessments and described in the plan of care. Cross-reference F689: the facility failed to prevent accident hazards utilizing mechanical lift for transfers. Cross-reference F695: the facility failed to maintain a resident's respiratory equipment according to professional standards. Cross-refrence to F880: failure to perform hand hygiene as required and failure to offer resident hand hygiene as required. Findings include: I. Record review The employee files for RN #1, LPN #1, and CNA #3, #4,…

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 complete a performance review of every nurse aide at least once every 12 months and provide regular in-service education based on the outcome of these reviews for four of five certified nurse aides. Specifically, the facility had not completed annual performance reviews for certified nurse aide (CNA) #4, CNA #6, CNA #7 and CNA #8, in order to determine potential training needs. Cross-reference F947 failure to ensure CNAs received adequate training as required. Cross-reference F726 failure to assess nursing staff's competency and skill for quality care. Findings include: I. Facility policy and procedure The In-Service Training, Nurse Aide policy and procedure, revised August 2022, was provided by the corporate nurse consultant (CNC) on 1/10/24 at 1:00 p.m. It revealed in pertinent part, The facility completed a performance review of nurse aides at least every 12 months. In-service training is based on the outcome of the annual performance reviews. Annual in-services ensure the continuing competence of nurse aides, address…

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 a residents diagnosed with dementia, received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental and psychosocial well-being for four (#110, #115, #126 and #134) of 10 residents reviewed for dementia care out of 54 sample residents. Specifically, the facility failed to address wandering behavior and provide meaningful activities for Residents #110, #115, #126 and #134, who had a diagnosis of dementia and resided in the secure unit of the facility. Findings include: I. Facility policy The Dementia policy, revised November 2018, was received on 1/9/24 at 3:30 p.m. by the corporate nurse consultant (CNC). It read in pertinent part: For the individual with confirmed dementia, the interdisciplinary team (IDT) will identify a resident-centered care plan to maximize remaining function and quality of life. Nursing assistants will receive initial training in the care of residents…

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 ensure facility menus met the needs of residents and were followed. Specifically, the facility failed to ensure menu items were not omitted from the lunch menu service for 16 of 16 residents with prescribed puree, mechanical soft and bite size diet orders. Findings include: I. Facility policy and procedure The Food and Nutrition Services policy and procedure, dated 2001, was provided by the corporate nurse consultant (CNC) on 1/9/24 at 4:07 p.m. It revealed in pertinent part, Each resident is provided with a nourishing, palatable, well balanced diet that meets his or her special dietary needs taking into consideration the preferences of each resident. Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive and it is served at a safe and appetizing temperature. If an incorrect meal is provided to a resident or a meal does not appear palatable, the nursing staff will report it to the food service manager so that a new…

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 at a palatable temperature. Findings include: I. Facility policy and procedure The Food and Nutrition Services policy and procedure, dated 2001, was provided by the corporate nurse consultant (CNC) on 1/9/24 at 4:07 p.m. It revealed in pertinent part, Food and nutrition services staff will inspect food trays to ensure that the correct meal is provided to each resident, the food appears palatable and attractive and it is served at a safe and appetizing temperature. If an incorrect meal is provided to a resident or a meal does not appear palatable, nursing staff will report it to the food service manager that a new food tray can be issued. II. Resident interviews Resident #19 was interviewed on 1/3/24 at 11:17 a.m. Resident #19 said the food was either too hot or cold. She said she had asked the staff to reheat her food. Resident #102 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to provide food and beverages that accommodated resident preferences for two (#46 and #134) of 10 residents reviewed food and beverage preferences out of 54 sample residents. Specifically, the facility failed to offer food choices according to Residents #46 and #134's preferences. Findings include: I. Facility policy The Food and Nutrition services policy, revised October 2017, was received on 1/9/24 at 3:30 p.m. by the corporate nurse consultant (CNC). It read in pertinent part: Each resident is provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. The multidisciplinary staff, including nursing staff, the attending physician and the dietitian will assess each resident's nutritional needs, food likes, dislikes and eating habits, as well as physical, functional, and psychosocial factors that affect eating 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 provide training to their staff that at a minimum educates 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 resident abuse prevention for 71 of 96 nursing staff. Specifically, the facility failed to ensure nursing staff including 71 of the facility's hired certified nurse aides (CNA), registered nurses (RN) and licensed practical nurses (LPN) (#2) received annual abuse identification, prevention and reporting training in the past 12 calendar months. Findings include: I. Facility policy The In-Service Training, All Staff policy, revised August 2022, was provided by the clinical nurse consultant (CNC) on 1/9/24 at 4:06 p.m. The policy read in pertinent part: All staff must participate in initial orientation and annual in-service training. Required training topics include the following: Preventing abuse, neglect, exploitation, 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 interviews and record review, the facility failed to ensure nurse aides received the required number of annual in-service training hours to ensure continued competence for four of five nurse aides reviewed. Specifically, the facility failed to ensure certified nurse aides (CNA) #4, #6, #7 and #8 received 12 hours of continuing education annually. Cross-reference F943 failure to ensure all staff received training on abuse prevention, identification and reporting. Cross-reference F949 failure to ensure all clinical staff received training on the topic of dementia managed care. Findings include: I. Facility policy and procedure The In-Service Training, Nurse Aide policy and procedure, revised August 2022, was provided by the corporate nurse consultant (CNC) on 1/10/24 at 1:00 p.m. It revealed in pertinent part, Inservice training is based on the outcome of the annual performance reviews. Annual in-services ensure the continuing competence of nurse aides, are no less than 12 hours per employment year, address areas of weakness as determined by nurse aide performance reviews,…

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 interview and record review, the facility failed to develop, implement and maintain an effective training program for all staff, which includes, at a minimum, training on behavioral health based on requirements and as outlined in the facility's assessment for 75 out of 96 nursing staff. Specifically, the facility failed to ensure that all nursing staff including 75 of the facility's hired certified nurse aides (CNAs), registered nurses (RNs) and licensed practical nurses (LPNs) received training on behavioral health issues to include care specific to the individual needs of residents who were diagnosed with dementia and how to promote meaningful activities and dementia specific care that promoted engagement and positive meaningful relationships. Cross-reference F744 failure to provide dementia-focused care. Findings include: I. Facility policy The In-Service Training, All Staff policy, revised August 2022, was provided by the clinical nurse consultant (CNC) on 1/9/24 at 4:06 p.m. The policy read in pertinent part: All staff must participate in initial orientation and 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.

Based on record review and interviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown origin were reported immediately for one (#102) resident reviewed out of 54 sample residents. Specifically, the facility failed to report an allegation of abuse within 24 hours to the State Survey Agency. Findings include: I. Facility policy and procedure The Abuse policy and procedure, revised 12/31/15, was provided by the nursing home administrator (NHA) on 1/3/24 at 11:30 a.m. It read in pertinent part The facility is required to report all allegations of abuse, including injuries of unknown source and misappropriation of resident property must report even if there is no reasonable suspicion within two (2) hours. II. Allegation of abuse On 1/4/24 at 1:55 p.m. Resident # 102 said a male certified nurse aide (CNA) was rough with her during care within the last two weeks; sometime in December 2023. She said she did not report the violation but was afraid of him working with her. At 2:35 p.m. the NHA 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review and interviews, the facility failed to ensure the resident environment was as free from accident hazards as possible for two (#19 and #46) of four out of 54 sample residents. Specifically, the facility failed to: -Ensure staff received training on safe operating procedures when using a mechanical lifts for Resident #19; -Ensrure staff transferred Resident #19 between surfaces safely using safe transfer techniques; and; -Implement effective interventions for Resident #46 who had known elopement attempts from eloping the building unbeknown to staff and becoming a missing person. Cross-reference F726 failure to ensure nursing staff had the skills and competencies to provide safe and effective care. Findings include: I. Mechanical lift procedure A. Professional reference According to Foundations Assisting with Home Care, Procedure- Assisting with the Use of a Hydraulic Lift, [NAME], K.B., O'Hara-[NAME], E., [NAME], A.C., and SUNY (State University New York) at [NAME], retrieved…

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 (#85) of one resident who required continuous positive airway pressure (CPAP) respiratory therapy received the care consistent with professional standards of practice out of 54 sample residents. Specifically, for Resident #85 the facility failed to: -Ensure a physician's order was in place for the use of CPAP therapy; -Ensure a care plan focus was in place for the residents CPAP therapy, to include the type of equipment and device settings; when to administer CPAP therapy including frequency; methods of monitoring the resident's use in case of complications;and, -Ensure staff set up the resident's CPAP machine with distilled water. Findings include: I. Facility policies and procedures The CPAP support policy, revised March 2015, was provided by the corporate nurse consultant (CNC) on 1/9/24 at 4:06 p.m. The policy revealed in pertinent part: Provide the spontaneously breathing resident with continuous positive airway pressure…

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 staff interviews the facility failed to implement policies and procedures related to pneumococcal immunizations for one (#46) of five residents reviewed for immunizations out of 54 sample residents. Specifically, the facility failed to offer Resident #46 additional recommended doses of the pneumococcal vaccination. Findings include: I. Professional reference According to the Centers for Disease Control and Prevention (CDC) Recommended Immunization Schedule for Adults Aged 19 Years or Older, United States, 2023, retrieved on 1/10/24 from https://www.cdc.gov/vaccines/schedules/downloads/adult/adult-combined-schedule.pdf, revealed in pertinent part: Routine vaccination-pneumococcal: routine vaccination for those age [AGE] years or older who have previously received only the PPSV23 (pneumococcal polysaccharide vaccine): one dose of PCV15 (pneumococcal conjugate vaccine) or one dose of PCV20. Administer either PCV15 or PCV20 at least 1 year after the last PPSV23 dose. II. Facility policy…

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, interviews, and facility policy review, the facility failed to store, distribute, and serve food in accordance with professional standards of food service safety in 1 of 1 kitchen. Specifically, the facility: - Failed to ensure food items in the walk-in cooler and freezer were properly sealed, labeled, and dated when opened. - Failed to ensure food items that were visibly spoiled were removed from stock / discarded. - Failed to ensure a refrigerator on Arbor Unit, where residents' food was stored, was maintained in proper working order. - Failed to ensure an ice chest used to pass ice/water to residents on Arbor Unit was cleaned/sanitized after becoming contaminated. - Failed to ensure food delivered from the kitchen was covered during transport to a resident. These failed practices had the potential to affect 174 residents who received food from the kitchen, including 11 residents who also received food from the refrigerator and ice chest on Arbor Unit. Findings included:…

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, observation, resident and staff interviews the facility failed to promote privacy while providing incontinence care when the resident's privacy curtain did not provide full privacy. This occurred for 1 of 1 resident (Resident #117) reviewed for incontinence care. Findings included: Resident #117 was admitted to the facility on [DATE]. The quarterly Minimum Data Set (MDS) dated [DATE] revealed Resident #117 was cognitively intact. During an interview with Resident #117 on 9-12-22 at 9:32am, the resident stated she was concerned about her privacy because her privacy curtain did not extend all the way around. The resident stated she had reported the issue to a nurse but could not remember the nurse's name. Observation of the privacy curtain occurred on 9-12-22 at 9:32am. The observation revealed the curtain was not wide enough to extend all the way around the resident exposing either the resident's roommate window which had the blinds pulled up or the door while staff performed care to…

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 reviews, the facility failed to complete a Level II Preadmission Screening and Resident Review (PASRR) when Resident #17 was diagnosed with a new mental illness. This deficient practice affected Resident #17, 1 of 3 sampled residents reviewed for PASRR. Findings included: Review of Resident #17's Colorado Pre-admission and Resident Review Program Level I Identification Screen dated 10/16/2017, revealed there was no major mental illness or psychiatric diagnosis identified for the resident. A review of Resident #17's admission Record revealed the facility admitted Resident #17 on 05/30/2018. According to the admission Record, on 12/16/2019, the resident received new diagnoses of depressive episodes and post-traumatic stress disorder (PTSD). Review of a quarterly Minimum Data Set, dated [DATE] revealed Resident #17 had a Brief Interview for Mental Status score of 15, indicating the resident was cognitively intact. During an observation and interview on 09/12/2022 at…

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.