Arbor View Care Center

F-F561 for failure to honor resident preferences.

Resident #6 said the agency staff did not know what the shower schedule was or who was to provide showers. She said the staff frequently said they were understaffed and could not provide showers. She said

the facility used to have a shower aide, but with the new management, the shower aide position was eliminated. She said it was impossible to get a shower per her preference or at all.

Resident #81 said she had memory problems and would frequently forget things. She said, in the past, nursing staff would keep a reminder in her room about her shower days, but she said the sign was gone and agency staff did not know when her shower days were.

Resident #92 and Resident #58 said agency staff frequently did not show up for work and were late.

Resident #92 said staff frequently walked into his room in the middle of the night to check on his roommate and would turn the light on at the sink area instead of next to his roommate and it would frequently wake him up. He said he asked nurses not to turn on the light at the sink area, but it continued to happen.

Resident #58 said, during the shift changes, all staff would loudly argue at the nurses station about assignments.

IV. Record review

Resident council minutes were reviewed for the last six months.

The 7/17/24 resident council meeting documented a concern that certified nurse aides (CNA) were not working as a team and showers were not done as scheduled.

-Both concerns were marked as resolved, however, there was no added information to explain how the concerns were resolved or if the residents were satisfied with the resolution to the concerns.

V. Staff interviews

Licensed practical nurse (LPN) #5 was interviewed on 7/30/24 at 10:45 a.m LPN #5 said the facility was understaffed especially on the Aspen unit where resident care was more heavy than on other units.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 35 065330 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065330 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor View Care Center 7991 W 71st Ave Arvada, CO 80004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 LPN #5 said she was aware of Resident #65's preference for the leg catheter bag on Sundays. She said when she worked on the weekends she would help him with it. She said she did not know how agency staff Level of Harm - Minimal harm or could be aware of personal preferences since it was not documented anywhere. potential for actual harm LPN #5 said on most days they did not have shower aides and CNAs were responsible for providing Residents Affected - Some showers. She said she did not know shower preferences for any of the residents who had shower concerns.

She said it was the CNAs responsibility to locate a binder at the nurses station and figure out who was due for showers.

CNA #9 was interviewed on 7/30/24 11:47 a.m. CNA #9 said he used to be a shower aide at the facility but since a full time position as shower aide was eliminated with the new management, he was working as a CNA on various shifts. He said, on some rare occasions like today (7/30/24), he was assigned to work as a shower aide.

CNA #9 said the facility used to have a schedule for showers where he and other CNAs were assigned to complete the showers. However, he said with new changes and new agency staff in the building, the old schedule did not work because agency CNAs would tell the facility staff what they would do and would not do. He said the rest of the staff would have to scramble and do extra work to provide the care that agency staff would not do. He said agency staff were frequently late or did not show up for work at all and that compromised the care for residents. He said he was certain many showers were missed for residents due to late arrivals and call offs by agency staff.

Registered nurse (RN) #2 was interviewed on 7/30/24 at 11:59 a.m. RN #2 said she was an agency nurse and worked in the building on several occasions on different shifts, including weekends. She said she did not know about shower preferences as it was CNAs responsibility to provide showers.

RN #2 said she did not know anything about Resident #65's routine on Sundays. She said her orientation to

the unit consisted of shift to shift reports from nurses. She said all preferences residents could communicate directly to staff. She said when residents could not communicate, staff could call family and ask about preferences.

CNA #11 was interviewed on 7/30/24 12:23 p m. CNA #11 said she was new to the unit and worked different shifts. She said she did not know when residents were to receive showers. She said she looked at the roster

the facility provided to her before shifts and said showers or any specific resident preferences were not mentioned on that roster.

The director of nursing (DON) was interviewed in the presence of a nursing home administrator (NHA) on 7/30/24 at 5:20 p.m. The DON said the facility had identified that shower preferences were missed, and they were actively working on implementing a new system to ensure showers were provided per preferences. She said unit managers were working to ensure that agency staff had easy access to residents' preferences and would be updating it on the rosters that staff received at the beginning of the shift.

The DON said the facility did employ agency staff and all staff were provided with the policies and expectations of the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 35 065330 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065330 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor View Care Center 7991 W 71st Ave Arvada, CO 80004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0585 The NHA said the facility had agency staff in the building for some time and recently switched to a different company. He said agency staff received the same orientation to the unit as other new staff. He said staff who Level of Harm - Minimal harm or were familiar with the unit were expected to help and assist new staff with details of care. potential for actual harm

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 35 065330 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065330 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor View Care Center 7991 W 71st Ave Arvada, CO 80004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50690

Residents Affected - Few Based on observations, record review and interviews, the facility failed to ensure one (#93) of three residents reviewed for nutrition received the care and services necessary to meet their nutritional needs and maintain their highest physical well-being out of 51 sample residents.

Resident #93 was admitted to the facility for long term care on 3/27/24 with diagnoses of severe dementia with mood disturbance, hypothyroidism (underactive thyroid), depression and dysphagia of the oropharyngeal stage (food sticks to the mouth or throat or gets pocketed in cheeks).

Upon admission (3/27/24), Resident #93 weighed 114.6 pounds (lbs). On 4/4/24 the facility placed the resident on restorative dining services, however, observations during the survey revealed the resident did not receive consistent assistance at meals.

On 5/20/24, the resident weighed 112.6 lbs and on 6/20/24 the resident weighed 106 lbs. The resident sustained a 5.9% (6.6 lbs) weight loss from 5/20/24 to 6/20/24 in one month, which was considered severe.

On 7/21/24 the resident weighed 100.5 lbs. At this time the resident sustained an additional 5.2% (5.5 lbs) weight loss from 6/20/24 to 7/21/24 in one month, which was considered severe. On 7/23/24 the facility implemented a four ounce house nutritional supplement.

Due to the facility's failures to provide total assistance in a timely manner and consistently offer alternatives of equal nutritional value and accurately record her food intake, Resident #93 sustained a 9.1% (10.1 lbs) weight loss in three months, which was considered severe.

Findings include:

I. Facility policy and procedure

The Weight Management policy, revised 2/29/24, was provided by the nursing home administrator (NHA) on 5/30/24 at 5:30 p.m. It revealed in pertinent part,

Residents identified with weight change will be assessed by the interdisciplinary team (IDT), and further interventions will be implemented to minimize the risk for further weight change where possible and to promote weight stability.

All residents will be weighed upon admission, then weekly or as indicated by physician orders. Results will be documented in the medical record.

Residents will be screened by a registered dietitian (RD) or designee for their risk for weight change on admission, quarterly, annually, and with significant change of condition with completion of the minimum data set (MDS).

Residents with weight variance (loss or gain) are reweighed. Significant/severe weight variance is defined as: 5 percent (%) in one month; 7.5% in three months; or 10% in six months

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 35 065330 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065330 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor View Care Center 7991 W 71st Ave Arvada, CO 80004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 Residents identified at risk for weight change will have interventions implemented to minimize the risk for additional weight change included in their plan of care. This may include supplements, RD evaluation and Level of Harm - Actual harm assisted dining.

Residents Affected - Few The following categories of residents should be weighed weekly unless otherwise indicated: residents with significant weight changes until weight is stabilized as defined in the policy; as determined by the physician, DON (director of nursing), RD (registered dietitian), or IDT teams discretion.

The IDT meets weekly to review residents with identified weight changes, develops a plan, implements, evaluates, and re-evaluates interventions to minimize the risk for weight change.

Nursing staff are responsible to communicate weight changes to the attending physician and resident's family. The nurse documents the notification in the medical record.

Nursing staff is to notify food and nutrition services and the RD of a resident's weight change. The RD further assesses the resident to determine root cause of the weight change and makes recommendations to reduce or stabilize the weight change.

Nursing staff or the RD are to notify the speech therapist (ST) if swallowing or chewing problems are suspected.

II. Resident #93

A. Resident status

Resident #93, age 85, was admitted on [DATE REDACTED]. According to the July 2024 computerized physician orders (CPO), diagnoses included severe dementia with mood disturbance, hypothyroidism, depression and dysphagia of the oropharyngeal stage.

The 6/28/24 minimum data set (MDS) assessment documented the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of three out of 15. The resident required substantial/maximum assistance with showering and personal hygiene, and supervision and/or touching assistance with eating.

-However, according to the 6/6/24 physician's order, the resident required total supervision and assistance with meals.

The assessment documented the resident was 66 inches (five feet, six inches) tall, and weighed 106 lbs. It indicated the resident had weight loss (a loss of 5% or more in the last month, or 10% or more in the last six months). The resident had no signs or symptoms of a possible swallowing disorder.

B. Observations

During a continuous observation on 7/24/24, beginning at 12:04 p.m. and ending at 1:37 p.m., the following was observed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 35 065330 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065330 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor View Care Center 7991 W 71st Ave Arvada, CO 80004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 At 12:10 p.m., Resident #93 was served a chicken salad sandwich, a cup of diced oranges and a glass of water. She took small sips of the water unassisted. Certified nurse aide (CNA) #3 sat down next to the Level of Harm - Actual harm resident and assisted her with two bites of the sandwich and then left the room at 12:24 p.m.

Residents Affected - Few -The resident did not touch her food until another CNA returned.

At 12:39 p.m., Resident #93 took a few bites of her sandwich after prompting from CNA #3. CNA #3 left the resident.

At 12:55 p.m. Resident #93 tried to eat her diced mandarin oranges by picking up the cup of oranges and sipping the fruit and juice from the cup. She spilled the juice from the cup, but was unable to get any mandarin oranges in her mouth.

-No staff member assisted the resident in her attempts to eat her mandarin oranges.

At 12:57 p.m., Resident #92, who was sitting at another table, moved to Resident #93's table and tried to help her eat her oranges. Resident #93 took a bite from the spoon full of oranges and then Resident #92 returned to his table.

-Resident #93 did not receive any additional assistance from staff members and was not able to feed herself.

At 1:07 p.m., the resident's meal was taken away from her. She had eaten one-fourth to one-third of the sandwich and one quarter of the cup of oranges,

-However, the amount of food Resident #93 ate, charted at 3:01 p.m., was recorded as 51 to 75%.

During a continuous observation on 7/25/24, beginning at 11:57 a.m. and ending at 1:15 p.m., the following was observed:

Resident #93 was assisted by a staff member to the dining room. She received an egg salad sandwich, a cup of tater tots, a piece of apple pie and a glass of water for lunch.

At 12:57 p.m. Resident #93 was assisted by CNA #7. She ate two bites of her egg salad sandwich, a few tater tots and a few sips of water. The resident ate less than 25% of her meal and started tearing-up, breathing heavily and was confused. She coughed and then CNA #7 prompted her to go to her room and relax. Resident #93 said she was tired.

-Resident #93 was not offered any alternative to her lunch or any additional drinks.

Meal intake documentation at 11:00 a.m. and 11:32 a.m, read the resident consumed 76 to 100% of her meal.

-However, observations revealed she consumed less than 25% of her meal.

During a continuous observation on 7/29/24, beginning at 12:10 p.m. and ending at 1:15 p.m., the following was observed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 35 065330 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065330 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor View Care Center 7991 W 71st Ave Arvada, CO 80004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 At 12:10 p.m., Resident #93 was assisted to the dining room.

Level of Harm - Actual harm At 12:24 p.m., an unidentified licensed practical nurse (LPN) approached the resident's table and asked another resident if she wanted anything to drink and offered her choices, then she left. Resident #93 had no Residents Affected - Few food or drink in front of her. Resident #93 cried out softly, Why didn't you ask me? I don't have anything. There were no staff nearby to hear Resident #93's question. When the staff returned, they did not ask Resident #93 what she would like to drink.

At 12:25 p.m. Resident #93 received her lunch, which consisted of iced tea in a sealed cup with two handles,

a peanut butter and jelly sandwich and a cup of diced peaches. Resident #93 sat at the table talking quietly to herself. There were no staff members assisting the resident with her meal.

At 12:29 p.m., Resident #93 took one sip from her fruit cup and took one bite of her sandwich without assistance.

At 12:45 p.m., CNA #1 sat down next to the resident and assisted her with her meal.

At 12:54 p.m., CNA #1 asked Resident #93 if she was done eating and the resident said yes. CNA #1 asked

the resident if she could drink some more tea. Resident #93 did not reply and did not drink any more. The resident's meal was removed from the table.

The resident ate one-fourth of the sandwich, four diced peaches, and drank two or three sips of the tea.

-The meal intake, documented at 3:18 p.m. indicated Resident #93 ate 26 to 50% of her lunch.

During a continuous observation on 7/29/24, beginning at 5:41 p.m. and ending at 5:55 p.m., the following was observed:

At 5:55 p.m. Resident #93 was finished eating. She had eaten one-fourth of the sandwich, one-third of the cookie and drank approximately one-fourth of the water.

-Meal intake documentation at 5:00 p.m. indicated the resident ate 26 to 50% of her dinner.

During a continuous observation on 7/30/24, beginning at 9:15 a.m. and ending at 10:24 a.m., the following was observed:

At 9:15 a.m. Resident #93 was assisted to the dining room.

At 9:50 a.m., Resident #93 was served her breakfast which consisted of a banana, a glass of juice, one pancake and a glass of water.

At 9:57 a.m., Resident #93 tried to drink her juice and it spilled. LPN #2 cleaned the spill and re-filled her cup. LPN #2 did not assist the resident with drinking.

At 10:01 a.m., Resident #93 sat at the table and fiddled with the banana. LPN #2 sat across the table from

the resident, occasionally interacting with her. LPN #2 was charting on her computer. She did not assist the resident with her meal.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 35 065330 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065330 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor View Care Center 7991 W 71st Ave Arvada, CO 80004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 At 10:24 a.m., Resident #93 said she had enough. CNA #7 asked if she wanted more water. The resident said yes and had one sip. The resident consumed one-third of the pancake, approximately three-fourths of Level of Harm - Actual harm the banana and less than eight ounces of fluid between the water and juice.

Residents Affected - Few -However, meal intake documentation at 10:49 a.m. indicated the resident ate 76 to 100% of her breakfast.

C. Record review

The nutrition care plan, revised 3/29/24, revealed Resident #93 had the potential for nutritional problems related to her health status, secondary to her multiple disease processes. Interventions included explaining and reinforcing to the resident the importance of maintaining her diet ordered, encouraging the resident to comply, and explaining the consequences of refusal risk factors, monitoring weights as ordered, monitoring/documenting and reporting as needed any signs and symptoms of swallowing difficulties, refusal to eat, or if she appeared concerned during meals, obtaining food preferences and offering as able, offering food alternates of equal nutritional value, providing the ordered diet, monitoring and recording intake each meal and having the RD evaluate and make diet changes and recommendations as needed.

Resident #93's weights were documented in the resident's electronic medical record (EMR) as follows:

-On 3/27/24, the resident weighed 114.6 pounds;

-On 4/5/2024, the resident weighed 115.5 pounds;

-On 4/8/2024, the resident weighed 115.5 pounds;

-On 4/9/2024, the resident weighed 112.6 pounds;

-On 4/16/2024, the resident weighed 114.9 pounds;

-On 4/23/2024, the resident weighed 110.6 pounds;

-On 5/8/2024, the resident weighed 111.9 pounds;

-On 5/13/2024, the resident weighed 110.2 pounds;

-On 5/20/2024, the resident weighed 112.6 pounds;

-On 5/28/2024, the resident weighed 111.2 pounds;

-On 5/30/2024, the resident weighed 111.0 pounds;

-On 6/7/2024, the resident weighed 107.8 pounds;

-On 6/20/2024, the resident weighed 106.0 pounds;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 35 065330 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065330 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor View Care Center 7991 W 71st Ave Arvada, CO 80004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 -On 6/27/2024, the resident weighed 105.5 pounds;

Level of Harm - Actual harm -On 7/7/2024, the resident weighed 100.5 pounds;

Residents Affected - Few -On 7/11/2024, the resident weighed 103.0 pounds;

-On 7/21/2024, the resident weighed 100.5 pounds; and,

-On 7/25/2024, the resident weighed 100.5 pounds.

-Resident #93 lost 7 lbs (6.2%) from 5/20/24 to 6/20/24 in one month, which was considered severe.

-The resident lost 7 lbs (6.5%) from 6/7/24 to 7/7/24 in one month, which was considered severe.

-The resident lost 10.1 lbs (9.1%) from 4/23/24 to 7/25/24 in three months, which was considered severe.

The 4/2/24 food preferences document revealed the resident had an excellent appetite and liked all food, with fish being her least favorite. She had not lost or gained weight recently. She drank milk. She liked dairy, vegetables, fruits, meat, protein, and carbohydrates like rice, potatoes, bread and cereal. She preferred water and was encouraged to drink four glasses per day. The document revealed her family brought her soda.

On 4/4/24, a food and nutrition progress note revealed Resident #93 was underweight due to inadequate energy intake. The resident was referred to the restorative dining program for meal assistance, and RD #1 recommended a nutritional supplement, however the resident and her family refused the supplement as they preferred food and snacks brought by the family.

The 5/22/24 and 5/29/24 weight meeting notes revealed Resident #93 continued to have weight loss. The resident ate 51 to 100% of most meals, which was a decrease in intake. She still had family-provided snacks

in her room. The resident had recently reported jaw pain and was on antibiotics for a urinary tract infection. Both were resolved by 5/29/2024. The recommendations were to continue the restorative dining program and weekly weight meetings. The notes documented the resident's food preferences were discussed with the resident's daughter on 5/29/24.

The 6/5/24 weight meeting note revealed Resident #93 was still on restorative dining and ate 76 to 100% of most of her meals the past week, occasionally less. She had snacks in her room and was on a regular diet with thin liquids. She received occupational therapy and had a new order for a speech therapy (ST) evaluation due to swallowing concerns.

The 6/7/24 nursing progress note revealed the resident had a ST evaluation on 6/6/24 to address safe swallow function and diet tolerance, compensatory strategies and cueing.

The 6/12/24 weight meeting note revealed that based on the resident's weight on 6/7/24, she had lost 3.2 lbs

in one week. Resident #93 received restorative-dining assistance and generally consumed 51 to 100% of her meals. The note documented that daily menu items were discussed and the resident was told she could bring in fast food.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 35 065330 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065330 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor View Care Center 7991 W 71st Ave Arvada, CO 80004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 The 6/24/24 restorative nursing note revealed the resident required varying degrees of verbal/tactile encouragement. She continued to need set up assistance and reminders to take sips of liquid after each bite. Level of Harm - Actual harm She consumed 75% of her food at each meal.

Residents Affected - Few The 7/3/24 weight meeting note revealed, based on the resident's weight on 6/27/24, she had a weight loss of 0.5 lbs in one week. The resident received physical therapy (PT) as of 6/26/24, and consumed 26 to 50% of most of her meals, occasionally more. The note documented she had snacks in her room and she continued to be monitored in weight meetings.

The 7/10/24 weekly nursing note revealed the resident had no weight loss.

-However, a review of the resident's recorded weights revealed she had lost five pounds between 6/20/24 and 7/7/24.

The 7/11/24 progress note revealed the resident had lost five pounds in 10 days and another weight would be obtained for accuracy. The resident was re-weighed and weighed 103 lbs. The note revealed the resident continued to lose weight. Her intake was generally 26 to 50% of meals and 75% while receiving restorative nursing services. Resident #93 coughed with meals, causing herself to vomit and that it had been happening for over one month. The resident was eating a sandwich at the time and an RN assessessed the resident and determined the resident was not choking. The note documented this was a problem with the resident's teeth, but a speech evaluation was discussed.

The 7/17/24 weight meeting note revealed the resident's weight had increased by 2.5 pounds in five days to 103 lbs.

Weight meeting notes between 7/22/24 and 7/24/24 revealed the resident consumed 50% or more of her meals but was still losing weight. The resident's doctor and daughter were updated and a daily four ounce nutritional supplement was ordered on 7/24/24.

The 7/29/24 restorative nursing note revealed Resident #93 needed total assistance with food intake, and continued verbal/tactile cueing to drink fluids at most meals. She ate 50 to 75% of her meals, and recommendations included continuing with the restorative nursing program and re-evaluating as needed.

-Review of Resident #93's meal intake record revealed between 7/1/24 and 7/30/24, the resident consumed 50% or less of over half of her meals.

The July 2024 CPO revealed the following orders:

-Regular diet, easy to chew, thin liquids total supervision/assistance, no straws, use of two handed cups with

a lid, and that softer textures may be ordered if appropriate, ordered on 6/6/24.

-A four ounce house stock supplement once a day, ordered 7/23/24.

A review of the July 2024 medication administration record (MAR) revealed Resident #93 was consuming an average of 27% from 7/23/24 to 7/29/24.

III. Staff interviews

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 35 065330 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065330 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor View Care Center 7991 W 71st Ave Arvada, CO 80004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 CNA #3 was interviewed on 7/30/24 at 10:31 a.m. CNA #3 said Resident #93 could not say what she wanted or liked to eat. She said, through trial and error, the facility determined she preferred sandwiches. She said Level of Harm - Actual harm sandwiches were easier for her to pick up and the restorative nurse aide who worked with her suggested them. She said Resident #93 needed varying amounts of assistance depending on her mood. She said the Residents Affected - Few resident did not have a physical problem preventing her from being able to pick up her food, it was her mood that interfered. CNA #3 said if the resident was sad or anxious, she started crying, coughing and occasionally vomited, which prevented her from finishing eating. CNA #3 said staff talked to her to keep her occupied and happy, because then she would eat more. She said the resident's appetite had been pretty poor the last few weeks and thought she was now on an oral nutritional supplement.

LPN #1 was interviewed on 7/30/24 at 12:53 p.m. LPN #1 said she noticed the resident needed assistance with eating and had asked staff to help her eat. She said if a resident could not state their food preferences,

she would ask whoever was caring for them before they were admitted to the facility.

The dietary manager (DM) was interviewed on 7/30/24 at 1:44 p.m. The DM said Resident #93's food and drink preferences changed depending on her level of confusion. She said she thought the CNAs chose her meals. The DM said, per the resident's EMR, she started taking a house supplement on 7/23/24 because

she had a 7.5% weight loss of 11 lbs. She said the restorative nursing program had requested sandwiches for the resident to help her regain some independence with eating. The DM said she sometimes gave the resident handheld snacks, such as brownies and sweets.

RD #2 was interviewed on 7/30/24 at 2:01 p.m. RD #2 said Resident #93 had lost about 10 lbs since April 2024, but was fairly stable until July 2024. RRD #2 said the provider and the resident's daughter were notified of the weight loss, a supplement was ordered and the resident started working with the restorative nursing program. She said originally, the resident refused the supplement, but after losing weight and talking to the resident's daughter, she agreed to take it. RD #2 said if the restorative nursing staff found something a resident liked, they offered that in addition to regular food items on the menu. She said Resident #93's food preferences were discussed at the care conference with the resident's daughter in April 2024. RD #2 said

they learned the resident preferred home foods, grilled items, fast food and snacks that the family brought to

the facility. RD #2 said the facility did not document consumption of family snacks because those were considered self-administered.

The director of rehabilitation (DOR) was interviewed on 7/30/24 at 2:01 p.m. The DOR said when the weight loss was noticed in April 2024, the resident was added to the restorative program for eating and swallowing.

She said for the past month (July 2024) the resident needed almost total assistance with eating and cueing, including showing her the motions and providing some touch-assist. She said sometimes the resident ate by herself, but other times she needed full assistance. She said the resident's meal intake stayed consistent between 50 to 75%.

CNA #4 was interviewed on 7/30/24 at 3:03 p.m. CNA #4 said Resident #93 could point to pictures of food and say yes or no but could not say verbally what she wanted to eat. She said when she asked the resident what she wanted to eat, she offered the main entree first and showed her pictures so the resident could choose, before offering her a sandwich. She said she had never seen snacks in the resident's room and that her family was rarely there. She said she only saw Resident #93 snacking when occupational therapy was evaluating her. She said some of the CNAs had snacks that residents could eat, but she had not seen Resident #93 eating them and had never seen documentation of snacks eaten.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 35 065330 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065330 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor View Care Center 7991 W 71st Ave Arvada, CO 80004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0692 CNA #5 was interviewed on 7/30/24 at 3:14 p.m. CNA #5 said the CNAs took meal orders and circled chosen items on the meal ticket. He said CNAs kept track of how much residents ate, especially residents Level of Harm - Actual harm who received meal assistance or were being watched for weight loss. He said if a resident ordered a sandwich, chips and jello for lunch and they only ate one-fourth of the sandwich, he would document that the Residents Affected - Few resident ate 0 to 25% of the meal. He said if a resident ate that little of a meal, he would write a progress note and tell the nurse. He said if the decreased intake became a trend, it should be documented in the resident's EMR.

LPN #3 was interviewed on 7/30/24 at 3:18 p.m. LPN #3 said she never saw snacks in the resident's room that the family had provided. She said she had seen the resident eat snacks before that were provided by one of the CNAs who had snacks for residents. LPN #3 said, in addition to the drinks Resident #93 had at meals, she encouraged fluids throughout the day and tried to give her water from her pitcher. She said the resident had not shown any signs of dehydration.

RD #1 was interviewed via the phone on 7/30/24 at 4:16 p.m. RD #1 said she had only been employed at the facility for 24 hours so she did not know Resident #93 personally. She said she reviewed the resident's EMR and said the resident had weight loss of 7.5% since 5/8/24, which she considered significant. She said the resident was around 110 lbs to 111 lbs in April 2024, then had steady weight loss since May 2024. RD #1 said, given that information, she would have done a full assessment, requested the resident's food and liquid intake, and talked to nursing staff. She said if the resident was able, she would talk to the resident. She said

she would have written a progress note, particularly if the weight loss occurred between quarterly assessments.

RD #1 said in April 2024, the previous RD had recommended adding a nutritional supplement after dinner.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 35 065330 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065330 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor View Care Center 7991 W 71st Ave Arvada, CO 80004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Provide safe and appropriate respiratory care for a resident when needed.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 37166 potential for actual harm Based on observations, record review and interviews, the facility failed to ensure two (#56 and #21) of five Residents Affected - Few residents reviewed for oxygen therapy was provided respiratory care consistent with professional standards of practice out of 51 sample residents.

Specifically, the facility failed to:

-Ensure Resident #56's CPAP (continuous positive airway pressure) machine was working appropriately and used as ordered by the physician; and,

-Ensure Resident #21 was wearing oxygen as ordered by the physician.

Findings include:

I. Facility policy and procedure

The Oxygen Administration policy and procedure, reviewed June 2023, was provided by the nursing home administrator (NHA) on 7/30/24 at 4:43 p.m. It read in pertinent part,

Oxygen is administered under orders of the physician. Staff shall document the initial and ongoing assessment of the resident's condition warranting oxygen and the response to oxygen therapy.

-The policy did not include any pertinent information for the use of CPAP/biPAP (bilevel positive airway pressure) machines.

II. Resident #56

A. Resident status

Resident #56, age 79 , was admitted on [DATE REDACTED]. According to the July 2024 computerized physician orders (CPO), diagnoses included acute and chronic respiratory failure with hypoxia (decreased oxygen levels), chronic obstructive pulmonary disease (COPD) and dependance on supplemental oxygen.

The 6/27/24 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief

interview for mental status (BIMS) score of 13 out of 15. She was receiving oxygen therapy.

-CPAP therapy was not documented on the assessment.

B. Observations and resident interview

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 35 065330 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065330 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor View Care Center 7991 W 71st Ave Arvada, CO 80004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Resident #56 was interviewed on 7/24/24 at 3:11 p.m. Resident #56 was wearing oxygen via nasal cannula. At the bedside, a CPAP machine was observed on the table. Resident #56 said she had not used the CPAP Level of Harm - Minimal harm or machine for at least three months. She said the machine was broken. She said the staff were aware that it potential for actual harm was broken. She said the staff would come and tell her that they would take care of it but no one did. She said the facility had new staff every day and she could not remember the names of all the staff who knew Residents Affected - Few about the broken machine.

C. Record review

The oxygen therapy care plan, initiated 5/21/24, indicated Resident #56 required a CPAP machine for effective symptom management of COPD. Interventions included administering supplemental oxygen as ordered, ensuring the oxygen tubing was connected to the CPAP unit and verifying the liter flow prior to CPAP mask placement.

-The care plan referred to machine BIPAP or CPAP interchangeably and the specific settings were not documented.

-Review of the July 2024 CPO revealed Resident #56 did not have a physician's order for the use of a CPAP or BiPAP.

Review Resident #56's physician progress notes between 5/1/2424 and 7/30/24 revealed a note on 5/20/24 that documented the resident was not using the CPAP machine because it was leaking water on her face when she was using it. The physician recommended service or replacement of the CPAP as soon as possible.

-However, there was no additional documentation indicating the facility had attempted to service or replace

the CPAP machine.

D. Staff interviews

Certified nurse aide (CNA) #10 was interviewed on 7/25/24 at 2:30 p.m. CNA #10 said she did not know if

the resident used a CPAP or BiPAP machine. She said she worked the morning shift and she had not observed the resident wearing the mask early in the morning.

Registered nurse (RN) #2 was interviewed on 7/25/24 at 2:43 p.m. RN #2 said she did not know if the resident should or should not use the CPAP machine. She reviewed the physician's orders and said the resident did not have a physician's order for the CPAP machine. She said she was an agency nurse and did not know the resident well enough to know if the resident used the machine in the past.

Licensed practical nurse (LPN) #1 was interviewed on 7/25/24 3:36 p.m. LPN #1 said she was a unit manager. She said she was new to the unit and today (7/25/24) was her eighth day of work on the unit. She said she remembered from the recent care conference that the resident was not using the CPAP machine but she did not know why and she did not ask the resident about it.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 35 065330 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065330 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor View Care Center 7991 W 71st Ave Arvada, CO 80004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 The director of nursing (DON) was interviewed on 7/25/24 at 3:57 p.m. The DON said she did not know if the resident was using the CPAP machine. She reviewed the physician's orders and said the resident did not Level of Harm - Minimal harm or have a physician's order for the use of a CPAP machine. She said she was not aware that the machine was potential for actual harm broken and did not know why it was not serviced since the physician's recommendation in May 2024.

Residents Affected - Few The DON said she would clarify the need for the CPAP machine with the physician and find out what needed to be fixed.

50690

III. Resident #21

A. Resident status

Resident #21, age greater than 65, was admitted on [DATE REDACTED]. According to the July 2024 CPO, diagnoses included dementia without mood disturbances, anemia (not enough oxygen in the cells to fuel the body), and

a history of COVID-19 and stroke (blocked blood flow to the brain).

The 6/7/24 MDS assessment documented the resident had severe cognitive impairment with a BIMS score of three out of 15. The resident required substantial assistance with personal hygiene, showering, bathing, toileting and dressing her lower body. She required moderate assistance for dressing her upper body and supervision and/or touching assistance with eating. She required substantial assistance for rolling in bed and for most transfers.

The assessment documented the resident was on oxygen.

B. Observations

On 7/25/24 at 9:55 a.m. Resident #21's nasal cannula (tubing device that supplies oxygen through the nose) was not in her nose properly (only one of two nasal prongs was in her nose).

At 10:07 a.m. the resident's nasal cannula was completely out of her nose.

At 2:35 p.m. CNA #1 assisted the resident in her wheelchair to an activity. CNA #1 carried the portable oxygen on her back but the nasal cannula was not in the resident's nose.

On 7/29/24 at 9:14 a.m. Resident #21 was lying flat in bed. The nasal cannula was not in her nose but was laying on her bed.

At 11:29 a.m. Resident #21 was awake, lying flat in bed. The nasal cannula was not in her nose.

C. Family member interview

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 35 065330 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065330 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor View Care Center 7991 W 71st Ave Arvada, CO 80004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 Resident #21's representative was interviewed on 7/30/24 at 11:05 a.m. Resident #21's representative said a few days prior to the survey, the resident called at night with a confusing question. He said he came to the Level of Harm - Minimal harm or facility the next morning and said the resident was more confused than normal. He said the resident's nasal potential for actual harm cannula was not in her nose and was on top of the oxygen machine by the closet. The representative said he assumed that meant she did not get her oxygen overnight. He said he thought a CNA noticed in the morning Residents Affected - Few and told the NHA because the NHA called the family later that day. He said there had been a few times he had noticed the nasal cannula had not been in her nose and the resident did not have the dexterity to put it back in herself. He said the staff did check her oxygen levels but he was not sure how often. The representative said the staff told him that even when she was not wearing her oxygen, her saturations were within normal limits.

D. Record review

The July 2024 CPO revealed the resident had a physician's order that indicated to administer oxygen at a rate of two liters per minute via nasal cannula every shift for hypoxia, ordered 4/12/24.

The care plan, revised on 9/19/23, revealed the resident had oxygen therapy related to ineffective gas exchange. The oxygen was ordered at two liters per minute continuously. Interventions included changing her position often to ease movement and drainage of fluid in the lungs, positioning the resident to facilitate breathing and oxygenation by assisting her into an upright position whenever possible.

The care plan revealed if the resident was on her side, her good side should be down (damaged lung facing up). The care plan indicated the resident should be monitored for signs and symptoms of respiratory distress and, if noted, reported to the physician.

-The care plan did not address interventions to ensure the resident was wearing her nasal cannula and getting her oxygen as ordered.

A review of the resident's electronic medical record (EMR) revealed between 7/1/24 and 7/29/24, the resident's oxygen saturations were documented three times per day and were 90% or above. On 7/12/24,

they were not documented in the morning check.

E. Staff interviews

CNA #8 was interviewed on 7/30/24 at 12:44 p.m. CNA #8 said the CNAs and the nurses checked Resident #21's nasal cannula to make sure it was in. She said the resident sometimes took off the cannula to blow her nose and forgot to put it back in. She said the resident could not put it back in herself. CNA #8 said for the past three weeks she had been working at the facility and it had always been in.

LPN #2 was interviewed on 7/30/24 at 12:56 p.m. LPN #2 said Resident #21 was on two liters of oxygen continuously but sometimes she took it off. LPN #2 said the resident could not put the nasal cannula back in her nose herself so staff frequently checked on her to make sure it was in.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 35 065330 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065330 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor View Care Center 7991 W 71st Ave Arvada, CO 80004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0695 LPN #3 was interviewed on 7/30/24 at 3:20 p.m. LPN #3 said the staff frequently checked on Resident #21 at night to make sure her nasal cannula was in because she had a history of removing it. She said she noticed Level of Harm - Minimal harm or it was not in her nose sometimes. She said if she noticed it was out of her nose she would put it back in. She potential for actual harm said oxygen saturation levels were checked every shift for all residents on oxygen and more often if their oxygen had not been on consistently. Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 35 065330 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065330 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor View Care Center 7991 W 71st Ave Arvada, CO 80004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0732 Post nurse staffing information every day.

Level of Harm - Potential for 47536 minimal harm Based on observations, interviews and record reviews, the facility failed to post nurse staffing information Residents Affected - Many daily.

Specifically, the facility failed to:

-Post the daily number of hours worked for each nursing staff category in a clear and readable format.

Findings include:

I. Observations

On 7/29/24 and 7/30/24 the daily staff information that was posted was dated 7/25/24.

II. Staff interview

The director of nursing (DON) was interviewed on 7/30/24 at 10:38 a.m. The DON said the posted nursing staff schedule information was posted near the front desk of the facility. She said the staff information should be posted daily. She said the posted schedule which was dated 7/25/24 was outdated. The DON said the scheduler was responsible for updating and posting the daily staff information.

The scheduler was interviewed on 7/30/24 at 10:47 a.m. The scheduler said it was her responsibility to post

the daily staff information and she had delegated the task to her assistant. The scheduler said she was unsure why the staff schedule information had not been updated after 7/25/24. She said she would follow up with her assistant and educate her assistant with the posting requirement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 35 065330 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065330 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor View Care Center 7991 W 71st Ave Arvada, CO 80004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 Ensure medication error rates are not 5 percent or greater.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50690 potential for actual harm Based on observations, record review and interviews, the facility failed to ensure the medication error rate Residents Affected - Some was less than five percent (%).

Specifically, the facility had a medication error rate of 16.1%, or five errors out of 31 opportunities for error.

Findings include:

I. Professional reference

According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed. (2020), Elsevier, St. Louis Missouri, pp. 606-607, retrieved on 7/31/24, Take appropriate actions to ensure the patient receives medication as prescribed and within the times prescribed and in the appropriate environment. Professional Standards such as nursing scope and standards of practice apply to the activity of medication administration. To prevent medication errors, follow the seven rights of medication administration consistently every time you administer medications. Many medication errors can be linked in some way to an inconsistency in adhering to these seven rights: the right medication, the right dose, the right patient, the right route, the right time, the right documentation and the right indication.

II. Facility policy and procedure

The Medication Administration policy, revised 2/29/24, was provided by the nursing home administrator (NHA) on 7/30/24 at 5:30 p.m. It read in pertinent part,

Medications are to be administered in an accurate, safe, timely, and sanitary manner. Medication is to be given in compliance with physician orders.

The Medication Time and Administration Guidelines were provided by the NHA on 7/25/24. The guidelines read in pertinent part,

To better comply with our resident's rights, we have adopted the following guidelines for medication passing.

Routine medications will be passed according to the following schedule:

-EA: early am (6:00 a.m.);

-AM: upon arising (6:00 a.m. - 11:00 a.m.);

-MD: midday (11:00 a.m. - 1:00 p.m.);

-PM: afternoon (4:00 p.m. - 7:00 p.m.); and,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 35 065330 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065330 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor View Care Center 7991 W 71st Ave Arvada, CO 80004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 -BT: bedtime (7:00 p.m.- 10:00 p.m.).

Level of Harm - Minimal harm or Medications scheduled between 11:00 p.m. and 6:00 a.m. will be documented as time specific. potential for actual harm III. Observations Residents Affected - Some

On 7/24/24 during a continuous observation, beginning at 9:30 a.m. and ending at 11:30 a.m., registered nurse (RN) #1 was observed passing medications to residents.

At 9:30 a.m. RN #1 was administering medications to Resident #87.

The medication administration record (MAR) for July 2024 read that Resident #87 was due for the following medications:

-Lactaid 3,000 units to be administered at 7:30 a.m. for lactose intolerance; and,

-Fluticasone propionate nasal spray, two sprays in each nostril to be given in the morning for allergies.

RN #1 could not locate the appropriate dose of Lactaid medication in his cart. He went to the unit manager for help. While RN #1 was trying to locate the appropriate dose of Lactaid medication, he locked all other medications in his cart.

At 10:45 a.m., after locating the correct dose of Lactaid, RN #1 returned to his medication cart, added the medication to the medication cup containing Resident #87's other oral medications and proceeded to the resident's room to administer the medications. He did not take the resident's fluticasone propionate nasal spray to the room with the other medications. RN #1 administered the medications and returned to his medication cart.

-RN #1 administered Resident #87's Lactaid two hours and 15 minutes after the allowed administration time.

-RN #1 failed to administer the nasal spray to Resident #87.

On 7/29/24 at 9:23 a.m., licensed practical nurse (LPN #2) was observed during medication administration for Resident #97. LPN #2's medication screen listed three medications that were color-coded red, which indicated the medications were late (see interviews below). The late medications were as follows:

-Celecoxib 200 milligrams (mg) two times a day for pain, scheduled at 8:00 a.m.;

-Clobazam 20 mg tablet, give 40 mg two times a day for seizures, scheduled at 8:00 a.m.; and,

-Lacosamide 50 mg two times a day for seizures, scheduled at 8:00 a.m.

-LPN #2 administered the three medications at 9:23 a.m. (23 minutes after the allowed administration time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 35 065330 Department of Health & Human Services Printed: 09/17/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065330 B. Wing 07/30/2024

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Arbor View Care Center 7991 W 71st Ave Arvada, CO 80004

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0759 IV. Staff interviews

Level of Harm - Minimal harm or LPN #4 was interviewed on 7/24/24 at 10:05 a.m. LPN #4 said that when items were color-coded red on the potential for actual harm medication administration record (MAR), it meant that something was late or missing.

Residents Affected - Some RN #1 was interviewed on 7/24/24 at 10:50 a.m. RN #1 said he was an agency nurse and this was his first day working on the unit. He said he did not know specific preferences for the residents and it took extra time for him to find out what the preferences were. He said, for example, he had to approach Resident #87 three times before he was able to administer her morning medications. RN #1 said initially Resident #87 said she would take her medications only with warm to hot water due to her tooth sensitivity. He said when he came back with warm water she did not like that he had mixed her miralax medication with the hot water and he had to remix the miralax in a separate cup and bring a fresh cup of hot water.

He said because he had to approach Resident #87 three times with her medications, he forgot about her nasal spray.

LPN #2 was interviewed during medication administration on 7/29/24 at 9:23 a.m. LPN #2 said she had a lot of medications to give and she was behind and did not want to be slowed down by being interviewed.

The DON was interviewed on 7/30/24 at 5:14 p.m. The DON said all medications that were labeled as AM could be administered any time between 6:00 a.m. and 11:00 a.m. However, she said medications that were scheduled at a specific time should be administered as scheduled. The DON said because it was not possible to administer all medications at the exact scheduled hour, it was acceptable to administer medications one hour before or one hour after the documented scheduled time. She said she was not aware that medications were not administered on time. She said she would audit the medication administration to ensure all medications were administered on time.

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