Riverdale Post Acute

F-F609 for failure to report an allegation of abuse to the State Agency.

The NHA said he did not interview any other residents, as CNA #4 said no other residents were in the hallway because the incident occurred overnight. The NHA said he did not feel the need to interview any other residents as they had not seen Resident #62 that night.

50690

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0600 III. Incident of physical abuse between Resident #97 and Resident #34 on 2/28/25

Level of Harm - Minimal harm or A. Facility investigation potential for actual harm

The facility's investigation was provided by the NHA on 3/25/25 at 1:00 p.m., revealed the following: Residents Affected - Some

On the morning of 2/28/25, a physical altercation was witnessed between Resident #34 and Resident #97.

The altercation occurred in the hallway near Resident #34's bedroom. LPN #6 immediately separated the two residents and both residents were placed on 15-minute checks for the investigation period. LPN #6 assessed both residents and no injuries were present.

Resident #34 said he could not recall the altercation with Resident #97.

Resident #97 could not communicate any recollection of the incident to staff.

Other residents from the unit and staff witnesses were interviewed and revealed the following:

Other residents from the same unit stated that they got along with Resident #34 and Resident #97 and did not have any instances of abuse to report. The staff witnesses stated that Resident #97 was walking down

the hallway and Resident #34 was in his way. Resident #34 was facing away from Resident #97. Resident #97 attempted to move Resident #34 from behind when Resident #34 reached back and made contact with Resident #97, without looking to see who was behind him.

CNA #9 said that on 2/8/25 at approximately 9:30 a.m., she heard a loud noise in the hall and saw Resident #34 and Resident #97 fighting. She said she did not see any contact between the residents, but saw Resident #97 attempt to pick up his walker to hit Resident #34. She said she told Resident #97 everything was okay and tried to re-direct him away from Resident #34. She said when Resident #97 returned and walked near Resident #34 again another staff member re-directed Resident #97 back to his room and he laid down for a nap.

LPN #6 said that on 2/8/25 at approximately 9:30 a.m., there was an altercation between Resident #34 and Resident #97. The altercation occurred in the hallway near Resident #34's bedroom. LPN #6 said that Resident #97 attempted to pass by Resident #34 in the hall and pushed Resident #34 aside. LPN #6 said Resident #34 became upset and attempted to hit Resident #97. LPN #6 said the situation did not escalate because the residents were separated. LPN #6 said the residents were assessed and no injuries were found.

The NHA and the residents' representatives were notified.

Care plans were reviewed and no changes were made. The altercation was unsubstantiated as an act of abuse.

-However, abuse occurred because Resident #97 attempted to hit Resident #34 with his walker and Resident #34 retaliated and made physical contact with Resident #97.

B. Resident #34 (assailant and victim)

1. Resident status

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0600 Resident #34, age 71, was admitted on [DATE REDACTED] and readmitted on [DATE REDACTED]. According to the March 2025 CPO, diagnoses included unspecified dementia with behavioral disturbances. Level of Harm - Minimal harm or potential for actual harm The 2/4/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairment with

a BIMS) of three out of 15. He walked independently but was dependent on staff assistance for all ADLs. Residents Affected - Some

The assessment indicated the resident had fluctuating inattention and disorganized thinking. He had delusions and physical behavioral symptoms directed toward others on one to three days during the assessment look-back review period. He had behavioral symptoms not directed toward others on a daily basis.

2. Record review

Resident #34's medication care plan, revised 6/14/22, identified the resident was at risk of complications related to antipsychotic medication use for diagnoses of insomnia and dementia with behavioral disturbances. Resident #34's trigger behaviors for mood stabilizer use were impulsiveness and erratic/irrational response to stimuli. His trigger behaviors for antipsychotic use were physical aggression and erratic/irrational responses to stimuli. Interventions included administering antipsychotic medications as ordered and monitoring for any adverse side effects of medication use, consulting with pharmacy and the physician to consider dosage reduction when clinically appropriate, at least quarterly, and monitoring and documenting the resident's trigger behaviors (revised 2/18/23), giving the resident space when he was aggressive or upset, not approaching the resident from behind or the side due to the resident's visual impairments (revised 6/13/23), leading Resident #34 back to areas where staff were positioned in order to keep him visible, encouraging him to stay clear of door ways (revised 7/27/23) and keeping Resident #34 in line of sight if possible (revised 3/28/24).

Resident #34's care plan for behaviors, initiated 4/13/22, revealed Resident #34 had behaviors including aggressiveness towards peers and staff and poor impulse control related to dementia, traumatic brain injury, post-traumatic stress disorder (PTSD) and a history of work as a prison guard. The resident had a history of attempting to, or threatening to hit staff. He hallucinated (reached for things that were nonexistent), had poor safety awareness and attempted to self-transfer. Resident #34's triggers included others speaking to him or about him and others approaching or touching him from the back or side and surprising him. Pertinent interventions included monitoring behavior episodes and attempting to determine the underlying cause, documenting behavior and potential causes, praising any indication of progress/improvement in behavior (initiated 4/13/22), performing frequent checks for 72 hours following any verbal or physical aggression observed or reported and providing opportunities for positive interaction and attention re-evaluation of medication management due to the resident's continued behaviors (revised 2/18/23), de-escalation by sitting with him with his back against a wall, when agitated, staff should offer him fluids and his preferred snacks (revised 3/13/23) and frequent checks and back scratches. He enjoyed being called gorgeous while having his back scratched (revised 2/26/24).

A review of Resident #34's March 2025 CPO revealed the following physician's orders:

Behavior monitoring for antipsychotic medication use every shift, ordered 12/12/24.

Monitoring effectiveness of interventions for behaviors, ordered 12/12/24.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0600 Monitor resident every shift due to physical aggression initiated, monitor physical aggression until 2/11/25 at 11:59 p.m., ordered 2/9/25. Level of Harm - Minimal harm or potential for actual harm A change in condition progress note, dated 2/8/25, revealed Resident #34 initiated an act of physical aggression. Resident #34's vital signs were within normal limits, and he had no changes in mental or Residents Affected - Some physical status. The resident's representative was notified of the incident.

An interdisciplinary team (IDT) progress note, dated 2/10/25, revealed Resident #34 had risk factors that contributed to his behavior, including a traumatic brain injury, dementia, poor situational and safety awareness. Interventions included separating the two residents, and for staff to ensure that other residents did not approach Resident #34 from behind.

C. Resident #97 (victim and assailant)

1. Resident status

Resident #97, age 85, was admitted on [DATE REDACTED], readmitted on [DATE REDACTED] and discharged on [DATE REDACTED]. According to the March 2025 CPO, diagnoses included unspecified dementia with behavioral disturbances.

The 1/21/25 MDS assessment documented the resident had severely impaired cognition with a BIMS score of zero out of 15. He required partial or maximum assistance for transfers and used a walker for mobility. He required touching assistance or supervision with walking.

The assessment indicated the resident had daily behaviors that were not directed toward others.

2. Record review

Resident #97's behavioral care plan, revised 2/3/25, revealed the resident had a behavior problem related to his dementia, language and cultural barrier and he made nonsensical statements. He had a history of physical aggression towards females and was also possessive and overprotective of his belongings, peers and partners. The resident paced and sometimes inadvertently ran into others while walking. Pertinent interventions included providing frequent checks following any verbal or physical aggression, intervening as necessary to protect others, approaching him and speaking in a calm manner, diverting his attention, removing him from the situations to an alternate location if needed, monitoring behavior episodes and attempting to determine the underlying cause, documenting behavior and potential causes, praising any indication of progress/improvement in behavior and staff to ensure the resident was not too close to others while walking in the hallway.

A progress note, dated 2/8/25, revealed an altercation between Resident #34 and Resident #97 occurred in

the hallway. Resident #97 attempted to pass by Resident #34, pushing Resident #34 aside. Resident #34 got upset and swung at Resident #97. The two residents were separated. No injuries were found. The NHA and Resident #97's legal guardian were notified.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0600 An IDT progress note, dated 2/10/25, revealed on 2/8/25 at 12:41 p.m. there was a physical altercation between Resident #97 and another resident (Resident #34) while passing in the hallway. Resident #97 Level of Harm - Minimal harm or inadvertently pushed Resident #34 aside while walking past his wheelchair. Resident #34 swung at Resident potential for actual harm #97 in response. The residents were immediately separated. No injuries were noted. The NHA was notified. Staff was to monitor for Resident #97 to have a path clear of wheelchairs while walking in the hallway. Residents Affected - Some

A progress note, dated 3/11/25 at 11:59 p.m., revealed completion of 72 hours of frequent 15-minute checks for Resident #97. No problems were reported.

D. Staff interviews

LPN #2 was interviewed on 3/26/25 at 3:28 p.m. LPN #2 said she could not remember who the aggressor was in the altercation between Resident #34 and Resident #97. She said what she remembered was that Resident #97 used to pace the hall with his walker. She said he was usually calm and collected, but at times

the halls got crowded with residents. She said Resident #34 did sometimes have aggressive behaviors.

CNA-Med #1 was interviewed on 3/26/25 at 3:45 p.m.CNA-Med #1 said she was not working the day of the altercation between Resident #97 and Resident #34. She said when she returned to work two days later, Resident #34 and Resident #97 were both being documented on frequently due to the altercation. She said

she was told by the previous nurse that Resident #97 had been in a bad mood that day (2/8/25) and rammed his walker into the back of Resident #34's wheelchair. She said Resident #34 was easily triggered, sometimes mean, and had previously attempted to hit staff. She said staff normally walked away and let Resident #34 calm down when he was agitated, or staff who had good rapport with him would calm him down. She said she did not know if contact was made during the altercation on 2/8/25, but staff were told to keep an eye on both of the residents. She said she did not think the police were called, but families/representatives and the physician were notified.

IV. Incident of physical abuse of Resident #42 by Resident #58 on 3/10/25

A. Facility investigation

The facility's investigation was provided by the NHA on 3/25/25 at 1:00 p.m. revealed the following:

On 3/10/25 an incident occurred between Resident #58 and Resident #42. Resident #58 allegedly made contact with another resident (Resident #42). Resident #58 attempted to kick Resident #42. The incident was witnessed by staff.

Residents and staff from the unit were interviewed, statements were obtained from staff and the victim (Resident #42) was interviewed. The DON assessed Resident #42 and found no injuries. The assailant (Resident #58) was discharged to the hospital because he was unable to be redirected.

Resident #42 (victim) had a history of delusions, and verbal aggression towards peers and staff. Resident #42 had a BIMS of 15 and had not been involved in any other occurrences in the past year. Resident #58 had a BIMS of three, required assistance for ADLs, and had a history of verbal and physical aggression towards staff and residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0600 Resident #58 had become physically aggressive towards other residents when they had food he wanted. When staff attempted to re-direct him, he sometimes attempted to hit staff. Resident #58 wandered into other Level of Harm - Minimal harm or residents' rooms. potential for actual harm There was a care plan for his behaviors, including a communication board, anticipating his needs, offering Residents Affected - Some snacks and redirecting. Resident #58 had been involved in other occurrences of physical abuse on 11/19/24, 1/18/25, 1/20/25.

Staff stated that Resident #58 had been having more behavioral episodes recently. They were unable to identify why, except that the resident had a history of being physically aggressive towards others. There were no interactions between the victim (Resident #42) and Resident #58 leading up to the incident on 3/10/25. Care plans and documentation were reviewed. The conclusion was that there was contact made but that it did not rise to the definition of abuse.

-However, abuse occurred because Resident #58 willfully kicked Resident #42 (see witness statements below).

Changes were made to Resident #58's plan, including discharging him to the hospital with possible re-evaluation at a future date. The police, ombudsman, family/guardian, and physician were notified.

Interviews during the investigation revealed the following:

On 3/10/25, CNA-Med #1 reported that she saw Resident #58 open his bedroom door, quickly walk over to

the dining room and start kicking Resident #42, who was sitting in the dining room watching television. CNA-Med #1 said she separated the residents and Resident #58 shoved her into the medication cart. Other staff intervened quickly and re-directed Resident #58 back to his bedroom to lay down. Both residents were assessed and no injuries were noted. The physician, ombudsman and the corporate support person were called. Resident #58 was transferred to the hospital non-emergently. When the emergency medical technicians (EMTs) arrived, Resident #58 had to be restrained and sedated. Resident #58 was taken to the emergency room because he had become a danger to himself and others and he could not be redirected.

Resident #42 was interviewed on 3/10/25 by the DON, immediately after the incident. Resident #42 said he was sitting in the dining room watching television when Resident #58 started kicking him. Resident #42 said

he was fine and did not get hurt and just went back to watching television.

<[TRUNCATED]

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0609 Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50219

Residents Affected - Few Based on record review and interviews, the facility failed to report alleged violations of potential abuse to the State Survey and Certification Agency in accordance with state law for one (#62) of nine residents reviewed for abuse out of 36 sample residents.

Specifically, the facility failed to report an incident of potential sexual abuse involving Resident #62 to the State Survey Agency (SSA).

Findings include:

I. Facility policy and procedure

The Abuse, Neglect, Exploitation and Misappropriation Prevention Program policy, revised April 2021, was provided by the nursing home administrator (NHA) on 3/23/25 at 12:41 p.m. It read in pertinent part, Residents have the right to be free from abuse.

The facility will identify and investigate all possible incidents of abuse, neglect, mistreatment, or misappropriation of resident property. The facility will investigate and report any allegations within timeframes required by federal requirements.

II. Resident #62

A. Resident status

Resident #62, age 65, was admitted on [DATE REDACTED]. According to the March 2025 computerized physician orders (CPO), diagnoses included sexual dysfunction and major depressive disorder.

The 12/17/24 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. The resident needed setup or cleanup assistance for most activities of daily living (ADL).

The MDS assessment documented the resident did not have physical or verbal behaviors directed toward others or other behavioral symptoms not directed toward others.

B. Record review

The behavioral care plan, initiated 7/17/2020 and revised 4/14/23, revealed Resident #62 made verbally explicit comments and suggestions toward staff, masturbated in front of staff, asked female staff members if

he could touch them or if the staff could touch him in a sexually inappropriate way. Pertinent interventions included explaining or reinforcing why his behavior was inappropriate or unacceptable, administering medications as ordered, educating staff on the importance of respecting Resident #62's wishes and emphasizing sexual outlet was a normal function, monitor behavioral episodes and attempt to determine an underlying cause, redirecting any inappropriate public exposure and intervening as necessary to protect the rights and safety of others.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0609 The antipsychotic medication care plan, revised 12/30/24, revealed Resident #62 required an antipsychotic medication as evidenced by inappropriate sexual behavior, delusions and hallucinations. Pertinent Level of Harm - Minimal harm or interventions included administering antipsychotic medications as ordered, observing Resident #62's mood potential for actual harm and response to the medication, and observing and recording the effectiveness of the drug treatment as indicated. Residents Affected - Few

A progress note, dated 3/21/25 at 12:39 p.m., revealed an unidentified CNA witnessed Resident #62 masturbating in another resident's room. The other residents slept through the situation and did not wake up.

The CNA relocated Resident #62 away from the room and told the resident he could not perform those actions in others' rooms. The director of nursing (DON) spoke with Resident #62 and gave him choices to ensure his safety and the safety of others, and the resident agreed to relocate to the all-male secured unit.

The nursing staff were to continue to monitor Resident #62 for hypersexual behaviors.

The facility's incident investigation, undated, was provided by the NHA on 3/24/25 at 4:21 p.m. The investigation included a statement from certified nurse aide (CNA) #4, which revealed on 3/21/25 between 1:30 a.m. and 2:00 a.m., CNA #4 observed Resident #62 as he was halfway into Resident #39 and Resident #59's room. Resident #62 had exposed his genitals and was masturbating in the room. CNA #4 took Resident #62 back to his room and told him he could not be in other residents' rooms.

Resident #39 was interviewed by the NHA on 3/21/25. Resident #39 said she did not have any incidents of abuse to report. Resident #39 said she felt safe in the facility. Resident #39 said she did not notice any disturbances during her sleep. Resident #39 said there was nothing else she wanted to share.

Resident #59 was interviewed by the NHA on 3/21/25. Resident #59 said she did not have any incidents of abuse to report. Resident #59 said she felt safe in the facility. Resident #59 said she did not notice any disturbances during her sleep. Resident #59 said there was nothing else she wanted to share.

-However, the facility failed to report the sexual abuse incident to the State Agency.

III. Staff interviews

The DON was interviewed on 3/26/25 at 4:40 p.m. The DON said the incident involving Resident #62 happened overnight on 3/21/25. The DON said he received a call from CNA #4 who told him she was in another resident's room, heard a noise, and saw Resident #62 halfway in the doorway of Resident #59 and Resident #39's shared room. CNA #4 said Resident #62 had his genitals exposed and was masturbating.

The DON said when he came in later on the morning of 3/21/25, the facility staff interviewed Resident #62 and discussed what his next steps would be. The DON said he notified the NHA of the incident immediately.

The NHA was interviewed on 3/26/25 at 5:15 p.m. The NHA said any allegations of abuse needed to be reported to him regardless of the time. The NHA said if he was not available, abuse allegations should be reported to the nurse on-call. The NHA said any abuse allegations needed to be reported to the State Agency within 24 hours. The NHA said after reporting the allegation, the facility staff would launch an investigation, ask for staff statements, and interview any residents within the vicinity of the incident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0609 The NHA said he was notified the morning of 3/21/25 about Resident #62's incident the night prior. The NHA said he got a statement from the CNA who witnessed the incident and that he interviewed Resident #59 and Level of Harm - Minimal harm or Resident #39 and they were both asleep. The NHA said he asked both of the residents if they felt safe and if potential for actual harm they had witnessed any abuse, and neither resident expressed any knowledge of the situation. The NHA said he had not reported the incident to the State Agency as he had reached out to one of the facility's Residents Affected - Few clinical consultants and was told the incident was not abuse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0656 Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50219

Residents Affected - Some Based on record review and interviews, the facility failed to develop a comprehensive care plan for three (#1, #75 and #249) of six residents out of 36 sample residents for services to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being.

Specifically, the facility failed to:

-Ensure a comprehensive care plan was developed to address Resident #1's use of supplemental oxygen and a peripherally inserted central catheter (PICC); and,

-Ensure a comprehensive care plan was developed to address Resident #75 and Resident #249's insomnia.

Findings include:

I. Facility policy and procedure

The Comprehensive Person-Centered Care Plans policy, revised March 2022, was provided by the nursing home administrator (NHA) on 3/26/25 at 6:42 p.m. The policy read in pertinent part, The care plan interventions are derived from a thorough analysis of the information gathered as part of the comprehensive assessment.

Assessments of residents are ongoing and care plans are revised as information about the residents and the residents' conditions change.

The interdisciplinary team reviews and updates the care plan when there has been a significant change in

the resident's condition and at least quarterly.

II. Resident #1

A. Resident status

Resident #1, age greater than 65, was admitted on [DATE REDACTED]. According to the March 2025 computerized physicians orders (CPO), diagnoses included schizoaffective disorder (mental illness), vascular dementia and cellulitis of the left lower limb.

The 2/7/25 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. The resident required supervision to maximum assistance for most activities of daily living (ADL).

B. Resident and resident representative interview

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0656 Resident #1 and her representatives were interviewed together on 3/23/25 at 10:33 a.m. The resident's representatives said Resident #1 had an infection in her leg which became swollen and was treated with Level of Harm - Minimal harm or antibiotics. The resident's representatives said the facility placed a PICC line for the antibiotics. The potential for actual harm resident's representatives said Resident #1 usually had her nasal cannula on and that she had been treated for pneumonia the week prior. Residents Affected - Some Resident #1 said she needed supplemental oxygen all the time.

C. Record review

The end of life care plan, initiated 3/24/25 (during the survey process), revealed Resident #1 was receiving hospicare care. Pertinent interventions included providing supplemental oxygen as ordered.

-Review of the comprehensive care plan, revised 3/24/25, did not reveal any focus or other interventions related to Resident #1's use of supplemental oxygen.

-Review of the comprehensive care plan, revised 3/24/25, did not reveal any focus or interventions related to Resident #1's PICC line or maintenance of the PICC line.

Review of the March 2025 CPO revealed the following physician's orders:

Midline intravenous (IV) placement, ordered 3/7/25;

Radiographs to check for midline (PICC) placement, ordered 3/7/25;

Normal saline flush solution, with instructions to use 10 milliliters (ml) intravenously two times a day for cellulitis/pneumonia. Flush before and after medication, ordered 3/7/25;

Vancomycin IV solution 750 milligrams (mg) per 150 ml, with instructions to use 750 mg intravenously every 12 hours for cellulitis for ten days, ordered 3/6/25 and discontinued 3/13/25;

Vancomycin IV solution 500 mg per 150 ml, with instructions to use 1000 mg intravenously every 12 hours for cellulitis until 3/17/25, ordered 3/6/25;

PICC line dressing change every seven days, ordered 3/25/25 (during the survey process); and,

Oxygen 4 liters per minute (LPM) via nasal cannula. Check oxygen saturation each shift and as needed. Notify healthcare provider if saturation is less than 90%, ordered 3/23/25 (during the survey process).

A progress note, dated 3/5/25 at at 10:14 a.m., revealed Resident #1 was receiving supplemental oxygen.

A progress note, dated 3/7/25 at 10:14 a.m., revealed Resident #1 was ordered to receive an IV antibiotic and a PICC line was requested.

A progress note, dated 3/13/25 at 3:44 p.m., revealed Resident #1 was receiving continuous supplemental oxygen via nasal cannula.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0656 D. Staff interviews

Level of Harm - Minimal harm or The MDS coordinator (MDSC) was interviewed on 3/26/25 at 3:30 p.m. The MDSC said she reviewed the potential for actual harm care plan and confirmed Resident #1's care plan did not address her use of oxygen or the use of the PICC line. The MDSC said the care plan should have interventions to elevate the head of the bed, ensure they Residents Affected - Some were following physician's orders and also to check oxygen saturation levels.

The MDSC said the care plan needed to include interventions for the PICC line that included keeping the line patent and monitoring for infections and directions for flushing.

III. Resident #75

A. Resident status

Resident #75, age 78, was admitted on [DATE REDACTED]. According to the March 2025 CPO, diagnoses included dementia with anxiety, adult failure to thrive, insomnia and depression.

The 2/11/25 MDS assessment revealed the resident was cognitively intact with a BIMS score of 14 out of 15.

The resident required supervision or touching assistance with most ADLs.

The assessment documented the resident took several high-risk medications including antidepressants, antianxiety, antipsychotic, anticonvulsants, and opioids.

B. Record review

Review of Resident #75's comprehensive care plan, revised 2/25/25, did not reveal any focus or interventions related to her diagnosis of insomnia or use of medications to treat her insomnia.

Review of the March 2025 CPO revealed the following orders:

Trazodone 100 mg oral tablet, instructions to give one tablet by mouth at bedtime for insomnia associated with depression, ordered 2/5/25;

Melatonin 3 mg oral tablet, instructions to give two tablets by mouth one time a day for insomnia, ordered 2/5/25 and discontinued 3/25/25 (during the survey process); and,

Melatonin 3 mg oral tablet, instructions to give one tablet by mouth at bedtime for insomnia, ordered 3/25/25.

C. Staff interviews

Licensed practical nurse (LPN) #1 was interviewed on 3/26/25 at 12:45 p.m. LPN #1 said Resident #75 received trazadone for insomnia. She said the resident complained of not being about to sleep. She said the resident's hours of sleep were tracked. She said she slept during the day and that could affect her sleeping at night. She said the care plans were updated by the MDSC.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0656 The MDSC was interviewed on 3/26/25 at 3:30 p.m. The MDSC said each resident had a plan of care. She said the plan of care began on the admission with a baseline care plan. She said she was responsible to Level of Harm - Minimal harm or complete the care plan, however, the nurses and other departments were responsible to update the care potential for actual harm plan as needed.

Residents Affected - Some The MDSC reviewed the care plan for Resident #75 and confirmed there was not a care plan for insomnia.

She said a care plan to help with interventions for sleep should be written.

20287

IV. Resident #249

A. Resident status

Resident #249, age 77, was admitted on [DATE REDACTED]. According to the March 2025 CPO, diagnoses included dementia with severe agitation, insomnia and alcohol dependence with alcohol induced persisting.

The 3/4/25 MDS assessment revealed the resident had severe cognitive impairments with a BIMS score of three out of 15. The resident required supervision or touching assistance with most ADLs.

The assessment documented the resident was prescribed several high-risk medications including antidepressants, antipsychotic, and opioids.

B. Record review

Review of Resident #249's comprehensive care plan, revised 3/19/25, did not reveal any focus or interventions related to her diagnosis of insomnia.

Review of the March 2025 CPO revealed the following orders:

Trazodone 50 mg oral tablet, instructions to give one tablet by mouth at bedtime for insomnia associated with depression, ordered 3/6/25.

C. Staff interviews

LPN #2 was interviewed on 3/26/25 at 12:45 p.m. LPN # 2 confirmed Resident #249 received trazadone for insomnia. She said her sleep hours were tracked. She said due to her dementia diagnosis, she sundowned and she was up at night at times.

The MDSC was interviewed on 3/26/25 at 3:30 p.m. The MDSC reviewed the care plan for Resident #249 and confirmed there was no care plan for insomnia. She said a care plan to help with interventions for sleep should be written.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0678 Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47151

Residents Affected - Few Based on record review and interviews, the facility failed to document resuscitation choices accurately in the medical record for one (#50) of three residents reviewed for advanced directives out of 36 sample residents.

Specifically, the facility failed to document Resident #50's refusal to complete a medical orders for scope of treatment (MOST) form (a legal document that allows individuals to outline their wishes for medical interventions and end-of-life care, ensuring their preferences are followed in the event of a serious illness or decline in health) upon admission to the facility or that the resident's resuscitation choices were discussed with the resident or the resident's representative.

Findings include:

I. Resident #50

A. Resident status

Resident #50, age greater than 65, was admitted on [DATE REDACTED]. According to the [DATE REDACTED] computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD - a lung disease with airway obstruction), chronic respiratory failure, type 2 diabetes mellitus, opioid dependence, history of venous thrombosis and embolism (condition involving blood clots), hypertension and stage 2 and stage 3 pressure ulcers.

The [DATE REDACTED] 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. The resident was dependent on care for hygiene and bed mobility and needed set-up assistance for eating.

B. Record review

A review of Resident #50's [DATE REDACTED] CPO revealed Resident #50 had a physician's order for full code (resuscitation status indicating cardiopulmonary resuscitation (CPR) should be conducted if the resident's heart stopped beating), ordered [DATE REDACTED] (during the survey).

A review of Resident #50's [DATE REDACTED] interdisciplinary team (IDT) care conference summary documented Resident #50 attended the care conference. The care conference summary revealed a section of preferred intensity of care and advanced directives with the following options to review: advanced directives, current wishes and physicians orders for life sustaining treatment.

-The advanced directives, current wishes and physician's orders for life-sustaining treatment sections were not documented to indicate whether or not the facility had discussed them with the resident or the resident's representative during the care conference.

Additionally, the care conference summary included a progress note section which documented a summary of Resident #50's overall care and progress. The progress note section documented Code status.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0678 -However, the facility failed to document what Resident #50's actual code status (CPR versus no CPR) was

in the progress note summary. Level of Harm - Minimal harm or potential for actual harm -Review of Resident #50's electronic medical record (EMR) failed to reveal documentation to indicate the resident refused to sign a MOST form upon his admission to the facility on [DATE REDACTED]. Residents Affected - Few II. Staff interviews

The director of nursing (DON) and the regional clinical resource (RCR) were interviewed together on [DATE REDACTED] at 10:30 a.m. The DON said Resident #50 declined to initiate a MOST form upon his admission to the facility ([DATE REDACTED]) and the residents' declination was documented in his care conference notes.

-However, review of the care conference notes did not reveal that the resident's declination to sign the MOST form or the resident's resuscitation choices had been discussed (see record review above).

The RCR said the default physician's order for a resident who did not have a completed MOST form would include an order for a full code (all life sustaining treatments) status.

III. Facility follow up

On [DATE REDACTED] at 5:26 p.m. an email was received from the RCR confirming the facility did not have documentation that specifically mentioned Resident #50's refusal to review or sign a MOST form or that the resident's resuscitation choices had been discussed with the resident or the resident's representative.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0684 Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50219 potential for actual harm Based on record review and interviews, the facility failed to ensure one (#1) of one resident received Residents Affected - Few treatment and care in accordance with professional standards of practice out of 36 sample residents.

Specifically, the facility failed to obtain a physician's order and provide routine maintenance and care for a peripherally inserted central catheter (PICC) for Resident #1.

Findings include:

I. Professional reference

According to The National Institutes of Health (NIH) PICC Line Placement (1/10/24), retrieved on 4/2/25 from https://www.ncbi.nlm.nih.gov/books/NBK573064/, Dressings should be changed at least once weekly or per policy and manufacturer's guidelines. After each use, the PICC line should be flushed with normal saline and heparin solution.

Nurses are responsible for day-to-day care, education, and monitoring of patients with PICC lines, reporting any concerns promptly.

Careful monitoring and maintenance of these lines are paramount in preventing procedural complications.

II. Resident #1

A. Resident status

Resident #1, age greater than 65, was admitted on [DATE REDACTED]. According to the March 2025 computerized physicians orders (CPO), diagnoses included schizoaffective disorder, vascular dementia and cellulitis of the left lower limb.

The 2/7/25 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. The resident required supervision to maximum assistance for most activities of daily living (ADL).

B. Resident representative interview

Resident #1's representatives were interviewed on 3/23/25 at 10:33 a.m. The resident's representatives said Resident #1 had an infection in her leg which became swollen and was treated with antibiotics. The resident's representatives said the facility placed a PICC line for the antibiotics.

C. Resident interview and observations

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0684 Resident #1 was interviewed on 3/24/25 at 9:38 a.m. Resident #1 said she had a shower earlier that morning (3/24/25). Resident #1's PICC line dressing was pulling away from her skin around the top and sides and Level of Harm - Minimal harm or was visibly soiled with brown material. A date was written on the bandage, but the date was mostly washed potential for actual harm away and it was difficult to read the date.

Residents Affected - Few Resident #1 was interviewed again on 3/25/25 at 8:53 a.m. Resident #1 said the dressing on her PICC line had not been changed that morning (3/25/25) or the day prior (3/24/25). Resident #1's PICC line dressing was pulling away from her skin around the top and sides and was visibly soiled with brown material. A date was written on the bandage, but the date was mostly washed away and it was difficult to read the date.

Resident #1 was interviewed a third time on 3/26/25 at 9:37 a.m. Resident #1 said the nursing staff had changed her PICC line dressing that morning (3/26/25). Resident #1 said the nursing staff flushed her PICC line once a day.

D. Record review

Review of the comprehensive care plan, revised 3/24/25, did not reveal any focus or interventions related to Resident #1's PICC line or maintenance of the PICC line.

Review of the March 2025 CPO revealed the following physician's orders:

Midline intravenous (IV) placement, ordered 3/7/25.

Radiographs to check for midline (PICC) placement, ordered 3/7/25.

Normal saline flush solution, with instructions to use 10 milliliters (ml) intravenously two times a day for cellulitis/pneumonia. Flush before and after medication, ordered 3/7/25.

Vancomycin IV solution 750 milligrams (mg) per 150 ml, with instructions to use 750 mg intravenously every 12 hours for cellulitis for ten days, ordered 3/6/25 and discontinued 3/13/25.

Vancomycin IV solution 500 mg per 150 ml, with instructions to use 1000 mg intravenously every 12 hours for cellulitis until 3/17/25, ordered 3/6/25.

PICC line dressing change every seven days, ordered 3/25/25 (during the survey).

A progress note, dated 3/7/25 at 10:14 a.m., revealed Resident #1 was ordered to receive an IV antibiotic and a PICC line was requested.

A progress note, dated 3/7/25 at 12:58 p.m., revealed a PICC line was placed in Resident #1's right arm. The nurse requested a physician's order for radiographs to check the placement of the PICC line and a physician's order to flush the PICC line.

-The progress note did not indicate the nurse requested a physician's order for PICC line dressing changes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0684 A progress note, dated 3/10/25 at 1:05 p.m., revealed Resident #1 was able to receive her antibiotics IV since she had been cleared to use the PICC line for medication administration. Resident #1's PICC line did Level of Harm - Minimal harm or not show any signs or symptoms of redness, swelling or infection. potential for actual harm

A progress note, dated 3/18/25 at 11:19 p.m., revealed Resident #1 had completed her course of IV Residents Affected - Few antibiotics. Resident #1's PICC line was still in place, had been flushed, and did not have any redness noted to the area.

-There was no documentation in the resident's electronic medical record (EMR) to indicate Resident #1's PICC line dressing had been changed since it was initially inserted on 3/7/25.

E. Staff interviews

Licensed practical nurse (LPN) #1 was interviewed on 3/26/25 at 10:34 a.m. LPN #1 said Resident #1 was

on IV antibiotics in early March 2025 to treat her cellulitis. LPN #1 said Resident #1's physician thought the resident should have her PICC line in place for a few more days following the end of her antibiotic treatment

on 3/17/25, but she said it would likely be discontinued that day (3/26/25). LPN #1 said Resident #1's PICC line dressing was changed the night prior (3/25/25), and had been changed every week. LPN #1 said Resident #1 still needed a physician's order for the PICC line dressing. LPN #1 said the resident should have

a physician's order in place to change the PICC line dressing each week.

-However, there were no dressing changes documented in Resident #1's EMR from 3/7/25 through 3/25/25 (see record review above).

-Additionally, there was no physician's order to change the PICC line until 3/25/25, during the survey (see

record review above).

The director of nursing (DON) was interviewed on 3/26/25 at 7:11 p.m. The DON said Resident #1 had her PICC line in place for at least two weeks. The DON said the resident needed to have an order from the physician for a PICC line prior to the line being placed. The DON said the facility usually put in a physician's order for weekly PICC line dressing changes at the same time as the physician's order for the PICC line itself.

-However, the order for weekly PICC line dressing changes was not added to Resident #1's CPO until 3/25/25, during the survey (see record review above).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47151 Residents Affected - Few Based on observations, record review and interviews, the facility failed to ensure three (#97, #37 and #47) of eight residents reviewed for accident hazards out of 36 sample residents remained as free from accidents as possible.

Resident #97, who was known to be at risk for falls, was admitted on [DATE REDACTED] with diagnoses of dementia, hearing impairment, unsteady and shuffling gait, and right sided weakness. The facility initiated a fall care plan which included interventions of anticipating and meeting the resident's needs, encouraging rest periods when signs of fatigue were noted, ensuring that the resident wore appropriate footwear when ambulating and keeping the resident in line of sight as needed.

Resident #97 sustained falls with injury on 12/30/24 (abrasion to the right side of his head), 1/12/25 (laceration to his head) and 1/19/25 (abrasion to the back of his head). Resident #97 was sent to the emergency department (ED) for evaluation and treatment after each of the three falls.

However, the facility failed to implement new fall interventions until 1/22/25 (after the third fall), when an intervention of a soft helmet for the resident to wear while awake was initiated.

On 2/22/25 Resident #97 experienced another fall while ambulating in the hallway which resulted in a laceration to the back of his head and required the resident to again be sent to the ED for evaluation and treatment of a subarachnoid hemorrhage (bleeding into the space between the brain and the arachnoid membrane, one of the protective layers covering the brain). The facility failed to implement any new fall interventions upon the resident's return to the facility on [DATE REDACTED].

On 2/24/25 Resident #97 experienced another fall on 2/24/25 that resulted in a large amount of bleeding to

the resident's head in the same area as the resident's laceration that resulted from his fall on 2/22/25. The resident still had staples in his head from the previous fall on 2/22/25. The resident was again sent to the ED where he received six additional sutures for treatment of the laceration. The resident returned to the facility

on [DATE REDACTED] and the facility ordered a medical grade ribcap helmet (a medical grade helmet which offers 360 degree protection to the head).

Staff interviews during the survey (see interviews below) revealed Resident #97 was not wearing the soft helmet initiated on 1/22/25 when he fell on [DATE REDACTED] and 2/24/25 and the facility failed to ensure Resident #97 was encouraged to wear his safety helmet prior to his falls on 2/22/25 and 2/24/25.

Due to the facility's failure to implement timely and effective interventions following each of Resident #97's falls, and the facility's failure to ensure care planned interventions were followed, the resident sustained head injuries, which required transfer to and treatment in the ED, from multiple falls.

Additionally, the facility failed to ensure staff transferred Resident #37 and Resident #47 appropriately, according to their documented transfer status.

Findings include:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0689 I. Facility policy and procedure

Level of Harm - Actual harm The Fall and Fall Risk, Managing policy, revised March 2018, was provided by the nursing home administrator (NHA) on 3/25/25 at 3:25 p.m. It read in pertinent part, Based on previous evaluations and Residents Affected - Few current data, the staff will identify interventions related to the resident's specific risks and causes to try to prevent the resident from falling and to try to minimize complications from falling.

Environmental risk factors that contribute to the risk of falls include wet floors, poor lighting, incorrect bed height or width, obstacles in the footpath, improperly fitted or maintained wheelchairs and footwear that is unsafe or absent. Resident conditions that may contribute to the risk of falls include fever, infection, delirium and cognitive impairment, pain, lower extremity weakness, poor grip strength, medication side effects, orthostatic hypertension, functional impairments, visual deficits and incontinence. Medical factors that contribute to the risk of falls include arthritis, heart failure, anemia, neurological disorders and balance and gait disorders.

If falling recurs despite initial interventions, staff will implement additional or different interventions, or indicate why the current approach remains relevant. If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on the assessment of the nature or category of falling, until falling is reduced or stopped, or until the reason for the continuation of the falling is identified as unavoidable. In conjunction with the attending physician, staff will identify and implement relevant interventions to try to minimize serious consequences of falling.

The staff will monitor and document each resident's response to interventions intended to reduce falling or

the risks of falling. If the resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not have been previously identified.

II. Resident #97

A. Resident status

Resident #97, age greater than 65, was admitted on [DATE REDACTED]. According to the March 2025 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, chronic kidney disease, hearing loss, repeated falls and encephalopathy (medical conditions affecting brain function).

The 2/6/25 minimum data set (MDS) assessment revealed Resident #97 had severe cognitive impairment with a brief interview for mental status (BIMS) score of zero out of 15. He needed substantial assistance with transfers, used a walker and needed supervision or touching assistance with ambulation.

B. Record review

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0689 Resident #97's fall care plan, initiated 11/22/22, documented he was at risk for injury related to falls, a diagnosis of dementia, hearing impairment, unsteady and shuffling gait and right sided weakness. Pertinent Level of Harm - Actual harm interventions included anticipating and meeting the resident's needs (initiated 11/22/22), encouraging rest periods when signs of fatigue were noted (initiated 11/22/22), ensuring that the resident wore appropriate Residents Affected - Few footwear when ambulating, (initiated 11/22/22), educating the resident, family and caregivers about safety reminders and what to do if a fall occurred (initiated 7/7/23), resident to be in line of sight as needed (initiated 3/6/24), soft helmet while awake (initiated 1/22/25), staff to ensure the resident was not too close to others while walking in the hallway (initiated 1/22/25) and medical-grade helmet (initiated 2/24/25).

A review of Resident #97's electronic medical record (EMR) revealed the following progress notes:

A 12/30/24 charting note, documented at 8:00 p.m,. revealed that Resident #97 had a fall. The resident was using a walker, going too fast and lost his balance. The resident was wearing non-skid socks on both feet and his walker was in front of him. The resident hit his head, either on the dresser or the night stand, and had

an abrasion to the right side of his head and an egg-sized lump. The resident was not taking any anti-coagulant medications (blood thinners). The resident had major difficulty attempting to walk to his bed and kept holding his head at the site of impact. The resident was sent out to the ED for evaluation.

A 12/31/24 charting note, documented at 11:15 p.m., revealed that Resident #97 returned from the hospital at 11:15 p.m. The resident had another fall while in the hospital.

-The facility failed to initiate any new fall interventions following the resident's 12/30/24 fall (see care plan above).

A 1/3/25 weekly summary note, documented at 9:55 a.m., indicated that Resident #97 had no falls or injuries

the previous week.

-However, the resident progress notes documented the resident had a fall on 12/30/24 that resulted in an abrasion to the right side of his head and an egg-sized lump.

A 1/10/25 progress note, documented at 11:36 a.m., revealed that the floor staff observed Resident #97 with worsened balance, leaning to the right side, and staff had to watch the resident closely and provide physical support when walking at times with a walker.

A 1/13/25 interdisciplinary team (IDT) note, documented at 9:41 a.m., revealed that on 1/12/25 at 2:00 a.m., Resident #97 was seen sliding to the floor by a certified nurse aide (CNA). Resident #97 hit the back of his head and sustained a laceration to the head without a change of consciousness. The resident was sent to

the ED for evaluation.

-The facility failed to initiate any new fall interventions following the resident's 1/12/25 fall (see care plan above).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0689 A 1/19/25 charting note, documented at 6:45 p.m., revealed that Resident #97 had a fall in the hallway while other residents were gathering for a cigarette break. The resident hit his head multiple times on the wall Level of Harm - Actual harm when he fell . Neurological assessments and frequent checks were initiated and the resident was found to have an abrasion to the back of his head approximately three centimeters (cm) in diameter. The nurse on the Residents Affected - Few unit notified the physician and the resident was sent to the ED for further evaluation.

A 1/24/25 note, documented at 11:40 a.m., revealed that Resident #97 continued on therapy services three times a week for a fall and decreased strength. The resident continued to use a four-wheeled walker for ambulation and did very well unless he was tired. Staff encouraged the resident to rest between meals and when he was noticeably becoming unstable, as evidenced by the resident beginning to [NAME] to the right and run into walls. The resident could be difficult to redirect due to a language barrier and dementia diagnosis.

A 2/21/25 progress note, documented at 6:43 p.m. revealed that Resident #97 continued to use a walker to ambulate in the hallways. He was encouraged to wear a helmet and to take rest breaks through the day, but was resistant to this guidance.

-However, the resident's fall care plan failed to indicate the resident refused to wear his helmet or take rest breaks (see care plan above).

A 2/22/25 progress note, documented at 3:15 a.m., revealed that Resident #97 was walking in the hallway with a walker and fell on his back, resulting in a laceration to the back of his head. Pressure was applied to stop the bleeding. The resident was able to squeeze a staff member's hand and sit upright on his own. A registered nurse (RN) was notified. The resident was sent to the hospital for treatment and evaluation.

-The progress note failed to document if Resident #97 was wearing a protective soft helmet, per the care planned interventions on 1/22/25 (see care plan above).

-The facility failed to document refusals by Resident #97 to wear the care planned soft helmet or attempts by staff to encourage the resident to wear it.

-The facility failed to initiate any new fall interventions following the resident's 2/22/25 fall (see care plan above).

A 2/23/25 progress note, documented at 12:04 p.m., revealed that Resident #97 was readmitted to the facility, was confused and wandering frequently between hallways and his room. The resident required frequent staff monitoring for high risk of falling.

A 2/23/25 progress note, documented at 4:10 p.m., revealed that Resident #97 returned to the facility from

the hospital for treatment of a subarachnoid hemorrhage following a fall at the facility. The resident had sutures on the back of his head.

A 2/24/25 progress note, documented at 6:50 p.m., revealed that a staff member was called to

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0689 come and help with Resident #97 due to a fall and a large amount of bleeding to the resident's head. The resident still had staples in his head from his previous fall on 2/22/25. Staff applied pressure to the resident's Level of Harm - Actual harm wound and the resident was sent out to the ED for further evaluation.

Residents Affected - Few A 2/24/25 progress note, documented at 11:43 p.m., revealed that Resident #97 returned to the facility with a head laceration that was repaired with six additional sutures. The resident had a 10 cm laceration to the back of his head and returned to the facility at 10:05 p.m.

-The progress note failed to document if Resident #97 was wearing a protective soft helmet, per the care planned interventions on 1/22/25.

-The facility failed to document refusals by Resident #97 to wear the care planned soft helmet or attempts by staff to encourage the resident to wear it.

A 2/25/25 nurse's note, documented at 4:07 p.m., revealed that a ribcap helmet was ordered for Resident #97and staff were to encourage the resident to wear the helmet, and the resident's care plan was updated.

The resident was to have a one-to-one sitter until the helmet was received.

A 2/28/25 progress note documented, at 9:31 a.m., revealed that Resident #97's therapy for fall risk had been discontinued. The resident had fallen in the past week with head injuries and had been under one-to-one staff supervision. According to the hospital physician, the resident had a history of stroke which caused him to walk with weight on his heels and he was prone to falling backward.

Review of Resident #97's post-fall assessments revealed the following:

A 12/30/24 post-fall assessment was completed for Resident #97 and he was categorized as a moderate fall risk. The post-fall assessment documented the resident had multiple falls the last six months and strayed off

the straight path of walking but failed to document the resident used a walker.

A 1/15/25 post-fall assessment was completed for Resident #97 and he was categorized as a moderate fall risk and strayed off the straight path of walking. However, the post-fall assessment documented the resident had one to two falls in the last six months, contrary to the previous assessment on 12/30/24 that documented

he had multiple falls in the same time frame. The 1/15/25 assessment additionally failed to document the resident used a walker.

A 1/20/25 post-fall assessment was completed for Resident #97 and he was categorized as a moderate fall risk. The post-fall assessment documented the resident had multiple falls in the last six months and strayed off the straight path of walking. However, the resident's use of psychotropic medications and laxatives were not documented on the assessment and the assessment failed to document that the resident used a walker.

A 2/25/25 post-fall assessment was completed for Resident #97 and he was categorized as a moderate fall risk. The post-fall assessment documented the resident had one to two falls in the last six months and the resident's use of psychotropic medications and laxatives were not indicated on the assessment. The assessment documented the resident used a walker.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0689 -However, the resident had five falls in the last 60 days (see above) and was ordered risperidone starting 1/30/25, neither of which was indicated on the assessment. The assessment additionally failed to document Level of Harm - Actual harm the resident strayed off the straight path of walking as indicated on the previous post fall assessments (12/30/24, 1/15/25, 1/20/25). Residents Affected - Few

The fall investigations for Resident #97's falls on 2/22/25 and 2/24/25 were provided by the NHA on 3/24/25 at 3:23 p.m.

-The fall investigations failed to document if Resident #97 was wearing a soft helmet as a fall prevention.

C. Staff interviews

Licensed practical nurse (LPN) #4 was interviewed on 3/25/25 at 2:55 p.m. LPN #4 said Resident #97's fall

on 2/22/25 occurred near the end of her shift. LPN #4 said the resident would walk around with a walker several times during the course of the night. LPN #4 said he would take his walker and follow around the edge of the wall, catching the wheel of his walker on the wall, and he would do that several times during the night. LPN #4 said she told the CNAs to keep an eye on Resident #97 and that the resident had a history of falling backwards.

LPN #4 said when Resident #97's fall occurred on 2/22/25, she was at the medication cart and passing medications. She said the resident was bleeding a lot from his head and was sent to the hospital. LPN #4 said there was a physician's order for the resident to wear a helmet from a previous fall, but the helmet did not fit and the resident would not wear it. LPN #4 said the order was discontinued and he did not have a current order for a helmet. LPN #4 said she had the CNAs check the room for a helmet but they were unable to locate one.

CNA #8 was interviewed on 3/25/25 at 3:00 p.m. CNA #8 said when Resident #97 fell on [DATE REDACTED], staff were getting a group of residents together to smoke and Resident #97 was ambulating with a walker. CNA #8 said Resident #97 was supposed to have a special helmet but the resident took the helmet off. CNA #8 said the resident was on every 15-minute checks and was supposed to be getting a hard helmet. CNA #8 said the resident did wear the grippy socks. She said he was not wearing a helmet when he fell a second time on 2/24/25.

The director of nursing (DON) and the NHA were interviewed together on 3/26/25 at 10:20 a.m. The DON said the facility had a soft shell to fit inside the normal hat Resident #97 wore regularly. The DON said it was care planned to encourage Resident #97 throughout the shift to wear his protective helmet and there was no set amount of times to remind him.

-However, the care plan did not indicate staff were to encourage the resident to wear his protective helmet (see care plan above).

The DON said staff tried to anticipate Resident #97's behavior. The DON said a soft shell helmet would benefit Resident #97 more when he was ambulating. The DON said the resident did not wear the rib cap helmet in the bed due to skin breakdown. The DON said Resident #97 swatted at his hand when he had tried to put the helmet on him.

The NHA said Resident #97 was not wearing his helmet when he fell on [DATE REDACTED].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0689 III. Resident #37

Level of Harm - Actual harm A. Resident status

Residents Affected - Few Resident #37, age greater than 65, was admitted on [DATE REDACTED]. According to the March 2025 CPO, diagnoses included hemiplegia (paralysis on one side of the body) and hemiparesis (weakness on one side of the body) following cerebral infarction (stroke), type 2 diabetes mellitus, dementia, anxiety, difficulty walking and heart failure.

The 12/31/24 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of five out of 15. The resident was dependent on care for all activities of daily living (ADL) except eating, where

she needed set up assistance.

The MDS assessment did not document use of a mechanical lift or prior falls.

B. Record review

Resident #37's fall care plan, revised 11/6/24, documented she was at high risk for falls due to incontinence, paralysis, psychoactive drug use, was unaware of safety needs and declined therapy. Pertinent interventions, revised 4/1/24, included to anticipate and meet Resident #37's needs. A fall mat intervention was initiated 10/11/24.

Resident #37's ADL care plan, revised 7/16/24, documented she had a self care performance deficit due to hemiplegia and dementia. Pertinent interventions, initiated 7/16/24, included that Resident #37 was totally dependent on staff for repositioning and turning in bed and required a hoyer lift (mechanical lift) with two staff members for transfers.

A 3/23/25 nursing progress note, documented at 7:30 p.m., revealed that a CNA was transferring Resident #37 into bed. The CNA then came out of the room and said the resident was on the floor. The CNA said that

she lowered the resident to the floor.

Resident #37's 3/23/25 fall investigation was provided by the NHA on 3/24/25 at 3:23 p.m. The fall investigation documented Resident #37's fall happened during a transfer and the CNA said the resident tripped over oxygen tubing and the floor mat was also in the way during the transfer.

-However, per Resident #37's ADL care plan, the resident was supposed to be a two-person transfer with a hoyer lift (see care plan above).

Resident #37's 3/24/25 post-fall assessment documented the resident's gait analysis as unable to independently come to a standing position.

C. Staff interviews

CNA #3 was interviewed on 3/25/25 at approximately 3:00 p.m. CNA #3 said Resident #37 needed a mechanical lift for transfers and the assistance of two staff members to transfer. CNA #3 said she was aware Resident #37 had fallen previously. CNA #3 said Resident #37 could transfer while standing from her bed to her chair but needed to have two staff members assist her closely and she usually used the mechanical lift for transfers.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0689 The DON was interviewed on 3/26/25 at 10:20 a.m. The DON said Resident #37's care plan indicated the mechanical lift was to be used to transfer Resident #37. The DON said it was against company policy to Level of Harm - Actual harm transfer Resident #37 without the mechanical lift. The DON said the facility staff directly transferred the resident to her bed without the mechanical lift on 3/23/25 and one CNA was present in the room at the time Residents Affected - Few instead of two.

50219

IV. Resident #47

A. Resident status

Resident #47, age less than 65, was admitted on [DATE REDACTED]. According to the March 2025 CPO, diagnoses included multiple sclerosis (a disease that causes breakdown of the protective covering of nerves), history of traumatic brain injury, epilepsy and encephalopathy (a medical condition that affects brain function).

The 2/13/25 MDS assessment revealed the resident was moderately cognitively impaired with a BIMS assessment score of 12 out of 15. The resident was dependent on staff for most ADLs.

The assessment documented the resident was dependent on staff for all transfers.

B. Record review

The functional abilities care plan, revised 8/1/24, revealed Resident #47 required staff assistance with ADLs due to his multiple sclerosis and history of traumatic brain injury. Pertinent interventions included Resident #47 requiring extensive total assistance with bathing and showering and requiring a hoyer lift with two staff members for transfers, revised 10/18/24.

The fall care plan, initiated 12/16/24 and revised 2/12/25, revealed Resident #47 was at risk for falls due to altered balance while standing, a history of falls and an unsteady gait. Pertinent interventions included having two staff members to assist with transfers with a hoyer lift (initiated 4/29/24), engaging with Resident #47 and reminding him to stay seated until the hoyer lift transfer was complete (initiated 6/30/24) and only using the hoyer lift for transfers (initiated 2/6/25).

-However, the resident had already had an intervention for transfers with two people and a hoyer lift which was initiated on 4/29/24, 10 months prior to the hoyer lift intervention implemented on 2/6/25.

The facility fall report, dated 12/31/24 at 10:45 a.m., revealed Resident #47 was receiving a shower when he fell . An unidentified CNA was transferring Resident #47 to a chair when the resident slipped, the CNA was unable to hold him and the resident fell . According to the CNA, Resident #47 hit his head on the wall. No injuries or bruises were observed during the nurse's assessment and Resident #47's range of motion and behavior were at baseline. The RN was notified. The report documented physiological factors contributing to

the fall included weakness.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0689 A change in condition form, dated 12/31/24 at 11:57 a.m., revealed Resident #47 fell in the shower room. Resident #47 slipped during a transfer and fell down. Resident #47 hit his head on the wall during the fall. Level of Harm - Actual harm Resident #47 was not in distress and his vital signs were within normal limits.

Residents Affected - Few A post-fall rehabilitation screening, dated 12/31/24 at 1:55 p.m., revealed Resident #47 fell during an assisted transfer. Resident #47 was dependent for transfers, and the physical therapist recommended using

a mechanical lift and rolling shower chair for showers.

-However, per the resident's care plan, the resident had required the use of a hoyer lift for transfers since 4/29/24 (see care plan above).

An interdisciplinary team (IDT) note, dated 1/2/25 at 9:32 a.m., revealed that on 12/31/24 at approximately 10:45 a.m., Resident #47 was in the shower room with a shower aide and slipped on the floor. The CNA reported Resident #47 hit his head. Risk factors included the lift protocol was not followed and Resident #47 was impulsive and had poor safety awareness. Prior interventions included having physical therapy evaluate Resident #47, a floor mat by Resident #47's bedside and his bed in the lowest position. Interventions put into place included re-educating staff on the facility's lift policy.

The facility fall report, dated 2/6/25 at 6:43 p.m., revealed Resident #47 had a witnessed fall. The report documented an unidentified CNA called the nurse into Resident #47's room around 4:30 p.m. to assist the resident on the floor in his room. The nurse entered Resident #47's room and observed him lying down on

the floor. The RN in the building was called to assess Resident #47. No physical injuries were noted at the time and Resident #47 said he was tired and wanted to stay in bed. Resident #47 was assisted by four staff members back into bed, his vital signs were taken and a neurological assessment was performed.

An IDT note, dated 2/7/25 at 10:32 a.m., revealed that on 2/6/25 at 6:43 p.m., Resident #47 was assisted to

the floor by a CNA during a transfer due to weakness. No pain or injuries were identified. Resident #47 was assisted back into his bed per his request by four staff members. Resident #47 stated he was tired. Risk factors included weakness, dementia and a history of falls. Prior interventions included having physical therapy evaluate and treat Resident #47, a floor mat on Resident #47's bedside and his bed in lowest position, and re-educating the staff on the facility lift policy. Interventions initiated included only using a hoyer lift for transfers.

-However, per the resident's care plan, the resident had required the use of a hoyer lift for transfers since 4/29/24 (see care plan above).

A post-fall rehabilitation screening, dated 2/7/25 at 1:49 p.m., revealed Resident #47 was attempting to transfer during the fall. The physical therapist recommended using a mechanical lift for improved safety with transfers.

-However, per the resident's care plan, the resident had required the use of a hoyer lift for transfers since 4/29/24 (see care plan above).

C. Staff interviews

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0689 CNA #5 was interviewed on 3/26/25 at 9:30 a.m. CNA #5 said Resident #47 needed to be transferred using

a hoyer lift. CNA #5 said Resident #47 could stand with two staff members assisting him early in the Level of Harm - Actual harm mornings, and mainly needed to use the hoyer lift after lunch.

Residents Affected - Few -However, according to the resident's care plan, the resident was to be a hoyer lift for all transfers (see care plan above).

CNA #2 was interviewed on 3/26/25 at 10:13 a.m. CNA #2 said Resident #47 usually needed to use a hoyer lift to transfer. CNA #2 said in the mornings, if Resident #47 felt good he could stand, but he generally needed to use the hoyer lift. CNA #2 said they would often only have one CNA to operate a hoyer lift rather than two, but over the last two months they had enough staff to have two staff members operating the hoyer lifts.

LPN #1 was interviewed on 3/26/25 at 10:34 a.m. LPN #1 said Resident #47 needed to transfer with the hoyer lift, but sometimes had good days where he did not need to use the lift. LPN #1 said Resident #47 needed to use the hoyer lift since he had a decline the month prior.

-However, according to the resident's care plan, the resident had been care planned to use a hoyer lift for transfers since 4/29/24 (see care plan above).

The director of rehabilitation (DOR) was interviewed on 3/26/25 at 12:56 p.m. The DOR said Resident #47 needed to be transferred with a hoyer lift at all times.

The MDS coordinator (MDSC) was interviewed on 3/26/25 at 3:36 p.m. The MDSC said Resident #47 needed to be transferred using the hoyer lift exclusively. The MDSC said Resident #47 had multiple sclerosis and was wheelchair-bound when he was admitted but had experienced a continuous decline in mobility. The MDSC said Resident #47 used to transfer by stand and pivot method but had a few falls in which his legs buckled under him. The MDSC said Resident #47's fall in February 2025 was related to a transfer during which he tried to self-transfer and was caught by the facility staff. The MDSC said Resident #47's fall in December 2024 occurred as a CNA was transferring him in the shower room and he fell .

The DON was interviewed on 3/26/25 at 4:40 p.m. The DON said Resident #47 needed to be transferred with a hoyer lift at all times. The DON said Resident #47 used to transfer via stand and pivot a year prior (2024). The DON said Resident #47's fall on 12/31/24 went directly against the facility's no-lift policy.

The DON said Resident #47 was a known hoyer lift user and the resident could not coordinate balancing weight on his legs. The DON said the CNA was trying to transfer Resident #47 to his wheelchair when he fell

on [DATE REDACTED]. The DON said Resident #47's fall on 2/6/25 was unwitnessed. The DON said Resident #47 had rolled out of bed and onto the floor.

-However, the facility fall report documented Resident #47's fall as witnessed, and the IDT note on 2/7/25 documented the fall occurred during a transfer and the CNA lowered the resident to the floor due to weakness (see record review above).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47151 potential for actual harm Based on observations, record review and interviews, the facility failed to ensure one (#50) of three residents Residents Affected - Few out of 36 sample residents received the care and services necessary to meet their nutrition needs to maintain their highest level of physical well-being.

Specifically, the facility failed to weigh Resident #50, who was identified to have potential nutrition problems, upon admission to monitor the resident's nutritional status.

Findings include:

I. Facility policy and procedure

The Weight Assessment and Interventions policy, revised March 2022, was provided by the nursing home administrator (NHA) on 3/26/25 at 9:09 a.m. It read in pertinent part, Residents weights are monitored for undesirable or united weight loss or gain. Residents are weighed upon admission and at intervals established by the interdisciplinary team (IDT). Weights are recorded in each unit's weight record chart and

in the individual's medical record. Any weight change of 5% or more since the last weight assessment is retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the dietitian in writing.

Care planning for weight loss or impaired nutrition is a multidisciplinary effort and includes the physician, nursing staff, the dietitian, the consultant pharmacist and the resident or resident's legal surrogate. If a resident declines to participate in a weight loss goal, the dietitian will document the resident's wishes and those wishes will be respected.

II. Resident #50

Resident #50, age greater than 65, was admitted on [DATE REDACTED]. According to the March 2025 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD - a lung disease with airway obstruction), chronic respiratory failure, type 2 diabetes mellitus, opioid dependence, history of venous thrombosis and embolism (condition involving blood clots), hypertension and stage 2 and stage 3 pressure ulcers.

The 2/14/25 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. The resident was dependent on care for hygiene and bed mobility and needed set-up assistance for eating.

The MDS assessment documented the resident did not refuse care. The MDS assessment did not have a recorded weight.

III. Resident interview

Resident #50 was interviewed on 3/25/25 at 3:35 p.m. Resident #50 said he had lost weight and used to be overweight. He said he could not remember anyone asking to weigh him at the facility.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 IV. Record review

Level of Harm - Minimal harm or Resident #50's nutritional care plan, documented the resident had potential nutritional problems due to a potential for actual harm diagnosis of diabetes mellitus type 2 with a medication in place, a diagnosis of COPD, history of a right above knee amputation and wounds. Pertinent interventions included to notify the physician of significant or Residents Affected - Few severe weight loss or weight gain, initiated 2/17/25.

According to the March 2025 CPO the resident had a physician's order to be weighed weekly times four weeks, ordered 2/10/25.

The 2/17/25 nutritional risk assessment documented the resident weighed 186 pounds (lbs) in the hospital

on 2/1/25 (prior to admission). The assessment documented the resident refused an admission weight. It documented to obtain a weight as the resident allowed and to monitor the residents weights for trends. The resident's usual body weight (UBW) was documented as unknown and the resident's estimated protein needs of 102 grams (g) of protein were calculated to support wound healing. The assessment also documented diet alone was not enough to meet the resident's estimated calorie and protein needs and the resident's meal intakes were varied. The goal was for the resident to meet estimated nutritional needs and for healing and weight stabilisation was acceptable, and to monitor weight for trends and follow up for significant changes. The assessment documented recommendations to add liquid protein 30 milliliters (ml) twice a day.

-However, a review of Resident #50's electronic medical record (EMR) revealed no additional recorded weights or attempts to obtain a weight for Resident #50 until 3/24/25 (during the survey) when the facility documented the resident refused to be weighed. The only documented refusal of weight by Resident #50 was in the 2/17/25 nutritional risk assessment.

V. Staff interviews

Licensed practical nurse (LPN) #1 was interviewed on 3/25/25 at 3:22 p.m. LPN #1 said when a resident was admitted to the facility they should be weighed the first three days per facility protocol. LPN #1 said if a resident's weights were stable then they would be weighed monthly after that. LPN #1 said that a provider could put in an order for more frequent weights based on the resident's initial weights.

Certified nurse aide (CNA) #3 said she tried to weigh Resident #50 and he refused to be weighed. CNA #3 said it was difficult to weigh the resident because they needed two staff members to lift him and the resident said it was painful for him. CNA #3 said if a resident refused to be weighed the CNA told a nurse so the nurse could follow up with the resident before documenting the resident refused.

-However, review of Resident #50's EMR did not include documentation indicating the facility had attempted to weigh the resident other than the 2/17/25 nutrition assessment (see record review above).

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0693 Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50219

Residents Affected - Few Based on observations, record review and interviews, the facility failed to ensure residents with a feeding tube received appropriate treatment and services for one (#96) of three residents reviewed out of 36 sample residents.

Specifically, the facility failed to ensure Resident #96 was assessed to ensure her safety while self-administering her tube feedings.

Findings include:

I. Facility policy and procedure

The Enteral Nutrition (feeding tube) policy, revised November 2018, was provided by the nursing home administrator (NHA), on 3/26/25 at 11:43 a.m. It read in pertinent part, Adequate nutritional support through enteral nutrition is provided to residents as ordered.

Staff caring residents with feeding tubes are trained on how to recognize and report complications associated with the insertion and/or use of a feeding tube, such as aspiration, skin breakdown around the insertion site, and clogging of the tube.

Residents receiving enteral nutrition are periodically reassessed for the continued appropriateness and necessity of the feeding tube. Results of these assessments are documented and any changes are made to

the care plan.

II. Resident status

Resident #96, age less than 65, was admitted on [DATE REDACTED]. According to the March 2025 computerized physician orders (CPO), the diagnoses included moderate protein-calorie malnutrition, eating disorder and adult failure to thrive.

The 2/18/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview status (BIMS) score of 12 out of 15. The resident was independent for eating and required supervision or touching assistance for all other activities of daily living (ADL).

The assessment documented the resident was receiving 51% or more of her calories through a feeding tube and 501 cubic centimeters (cc) a day of fluid through a feeding tube.

III. Observations and resident interview

On 3/25/25 at 9:16 a.m. Resident #96 said she administered her own bolus tube feedings. Resident #96 was administering her tube feeding by herself and no staff were present in the room.

At 5:28 p.m. Resident #96 had just depressed the plunger of a syringe into her feeding tube. No staff were present in Resident #96's room.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0693 IV. Record review

Level of Harm - Minimal harm or The enteral nutrition care plan, initiated 2/17/25 and revised 3/4/25, revealed Resident #96 required enteral potential for actual harm nutrition related to her eating disorder. Pertinent interventions included checking the tube placement every shift and prior to feeding or administering medications, providing enteral nutrition as ordered, flushing the Residents Affected - Few tube with 30 milliliters (ml) of water before and after medication administration and monitoring the resident for any nausea, vomiting, or discomfort with each feeding.

The ADL care plan, initiated 3/4/25, revealed Resident #96 had a self-care performance deficit due to her eating disorder and failure to thrive. Resident #96 was very private but needed supervision for safety. Pertinent interventions included Resident #96 administered her own tube feeding as she did not eat by mouth and providing/encouraging fluids.

The nutrition care plan, initiated 2/17/25 and revised 3/4/25, revealed Resident #96 had a nutritional problem due to her eating disorder, malnutrition and anxiety. The care plan documented Resident #96 refused to allow staff to administer her tube feedings. Pertinent interventions included providing enteral nutrition and water flushes per physician's order.

Review of the March 2025 CPO revealed the following physician's orders for Resident #96:

Tube Feeding: Nutren 2.0 (enteral feeding formula) or equivalent, give one carton four times per day via bolus per PEG (percutaneous endoscopic gastrostomy) tube, ordered 2/17/25.

Check PEG tube placement before use, ordered 2/13/25;

Keep head of bed elevated at least 30 degrees during tube feedings and for at least thirty minutes after tube feed administration, ordered 2/13/25;

G-tube (feeding tube) site: cleanse with normal saline, pat dry and apply split gauze every shift. Notify provider if signs or symptoms of infection occur, ordered 2/13/25; and,

Enteral feed: flush 30 ml of water before and after tube feeding administration four times daily, ordered 2/17/25.

The nutritional risk assessment, dated 2/15/25 at 4:58 p.m., revealed Resident #96 said she had been self-administering her tube feeding for three weeks prior to admitting to the facility, was taught how to do so when she was in the hospital and had no questions regarding her tube feeding. The nursing staff reported Resident #96 was particular with her treatments, as she did not allow the staff to administer her tube feedings and often refused to have her PEG tube checked. The registered dietitian (RD) recommended offering snacks between meals and having staff monitor Resident #96 as she self-administered her tube feeding and water flushes.

-Review of Resident #96's electronic medical record (EMR) did not reveal any assessments indicating Resident #96 was evaluated and safe to self-administer her tube feedings or physician's orders for the resident to self-administer.

V. Staff interviews

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0693 Licensed practical nurse (LPN) #1 was interviewed on 3/26/25 at 9:42 a.m. LPN #1 said Resident #96 did not let the nursing staff provide her with any treatment and wanted to do her treatments herself. LPN #1 said the Level of Harm - Minimal harm or nursing staff should be at Resident #96's bedside to monitor the resident during her tube feedings to ensure potential for actual harm the resident was administering the feeding and water flushes correctly and according to the physician's order. LPN #1 said there should be a physician's order for Resident #96 to self-administer her tube feedings. Residents Affected - Few LPN #1 said Resident #96's physician was aware she was administering her own tube feedings. LPN #1 said there had not been any formal assessment completed or documented in Resident #96's EMR indicating she was able to self-administer her tube feedings. LPN #1 said Resident #96's tube feeding care and self-administration of tube feedings should be on her care plan.

The director of nursing (DON) was interviewed on 3/26/25 at 11:00 a.m. The DON said the nursing staff should be in the room with Resident #96 whenever she administered her own tube feeding. The DON said Resident #96 should not have been self-administering her tube feedings independently and without supervision from the nursing staff. The DON said Resident #96 should be evaluated to ensure she was completing all of the steps involved in administering her tube feeding correctly. The DON said Resident #96's physician had watched her self-administer her tube feeding and did not have any concerns at the time. The DON said Resident #96's self-administration and staff supervision should be on her care plan.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 Residents Affected - Few administration error rate was not greater than five percent (%).

Specifically, the facility's medication administration error rate was 6.06%, or two errors out of 33 opportunities for error.

Findings include:

I. Professional reference

According to [NAME], P.A., [NAME], A.G., et.al., Fundamentals of Nursing, 10 ed., E.[NAME], St. Louis Missouri, pp. 606-607. 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:

1. The right medication

2. The right dose

3. The right patient

4. The right route

5. The right time

6. The right documentation

7. The right indication.

II. Observations

On 3/25/25 at 8:56 a.m. licensed practical nurse (LPN) #3 was preparing and administering medications for Resident #52. The resident had physician's orders for the following medications:

Omeprazole delayed release oral capsule 40 mg (milligram), give one capsule via percutaneous endoscopic gastrostomy tube (PEG) tube two times a day for gastroesophageal reflux disease (GERD), ordered 1/20/25.

-LPN #3 administered omeprazole 20 mg, not omeprazole 40 mg as indicated in the physician's order.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 Lidocaine 4% external patch, apply topically (to the skin) to the left shoulder every morning and at bedtime for pain, ordered 3/19/25. Level of Harm - Minimal harm or potential for actual harm -LPN #3 applied the lidocaine patch to Resident #52's right shoulder, not the left shoulder as indicated in the physician's order. Residents Affected - Few III. Staff interviews

LPN #3 was interviewed on 3/25/25 at 11:56 a.m. LPN #3 said she thought she had put the lidocaine patch

on Resident #52's left shoulder, but she said because of the position the resident was lying in, she accidentally placed it on the resident's right shoulder instead. She said she gave one capsule of omeprazole 20 mg to Resident #52 and she should have given two capsules because she needed 40 mg. She said she should have given the resident another 20 mg capsule of omeprazole.

The director of nursing (DON) was interviewed on 3/26/25 at 4:15 p.m. The DON said physician's orders should be double-checked when administering medications.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm 47151

Residents Affected - Some Based on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs.

Specifically, the facility failed to ensure residents who were prescribed mechanically altered diets had food prepared according to their diet orders of puree and mechanical soft as indicated on their meal tray cards.

Findings include:

I. Facility policy and procedure

The Therapeutic Diets policy, undated, was provided by the nursing home administrator (NHA) on 3/26/25 at 11:32 a.m. It read in pertinent part, Diet orders should match the terminology used by the food and nutrition services department. A therapeutic diet is considered a diet ordered by a physician, practitioner, or dietitian as part of treatment for disease or clinical condition, to modify specific nutrients in the diet, or to alter the texture of a diet, for example: altered consistency diet. If a mechanically altered diet is ordered, the provider will specify the texture modification. The dietitian, nursing staff and attending physician will regularly review

the need for, and resident acceptance of, prescribed therapeutic diets.

II. Record review

The menu extensions and modifications for modified texture diets were provided by the dietary director (DD)

on 3/26/25 at 5:00 p.m.

The menu extensions documented the following modifications for the mechanically altered food items served

during lunch meal service on 3/25/25:

-The regular diet included beef tostadas, shredded lettuce and tomato, ground green chili stew and fruit crisp.

-The mechanically altered diet included puree beef tostadas, no lettuce and tomato, ground green chili stew and sliced peaches.

-However, the modified texture diet menu extensions did not specifically state a mechanical soft altered diet as listed on the resident's meal tickets, but listed a mech altered diet. The extensions also included IDDSI mince and moist level five and soft and bite size level six which the facility had not yet transitioned to use (see the interviews below).

III. Meal service observation and test tray

During a continuous observation on 3/25/25, beginning at 11:10 a.m. and ending at 12:37 p.m., the following was observed during the meal preparation and service in the main kitchen:

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0805 The posted menu was beef tostada with shredded lettuce and tomato and fruit crisp.

Level of Harm - Minimal harm or At 11:21 a.m. a resident's lunch plate was assembled by cook (CK) #1 with a crisp, fried tostada shell topped potential for actual harm with ground beef and a fruit crisp was placed on the tray by dietary aide (DA) #1. The meal ticket on the tray documented a mechanical soft-ground texture and the tray was placed in a cart for delivery. Residents Affected - Some -However, according to the meal extensions, the resident should have received a pureed beef tostada. (see meal extensions above)

All 11:22 a.m. a residents meal tray was assembled by CK #1. DA #1 placed a fruit crisp on the tray. The meal ticket on the tray documented a mechanical soft-ground texture and the tray was placed in a cart for delivery.

-However, according to the meal extensions, the resident should have received peach slices, not fruit crisp (see meal extensions above).

At 11:33 a.m. a resident's lunch plate was assembled by CK #1 with a crisp, fried tostada shell topped with ground beef. The meal ticket on the tray documented a mechanical soft-ground texture.

-However, according to the meal extensions, the resident should have received a pureed beef tostada. (see meal extensions above)

At 12:00 p.m. a puree plate was prepared and served to a resident. The plate consisted of puree meat, mashed potatoes and a puree green vegetable. The resident's meal ticket documented a puree diet texture.

-The puree vegetable served to the resident included peas which should not have been pureed (see

interview below).

At 12:16 p.m. the DD said to CK #1 that the fried tostada shells were a choking hazard.

At 12:20 p.m. the DD removed the puree meat from the steam table and placed the puree meat in a food processor to blend the food. The DD said he wanted to make sure the food was the right consistency. The puree meat was placed back in the steam table for meal service.

At 12:00 p.m. a puree plate was prepared and served to a resident. The plate consisted of puree meat, mashed potatoes and a puree green vegetable.

-The puree vegetable served to the resident included peas which should not have been pureed (see

interview below).

At 12:31 p.m. The DD said to CK #1 that for a mechanical soft diet texture the tortilla should always be bite size and soft while he cut a soft flour tortilla and placed the pieces on a plate. The DD said he had not reviewed the modified texture diet menu extensions.

-However, according to the meal extensions, the resident should have received a pureed beef tostada and not a cut-up soft flour tortilla. (see meal extensions above)

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0805 At 12:35 p.m. a puree test tray was provided. The puree texture test tray consisted of puree beef, mashed potatoes, pureed peas and carrots and chocolate pudding for dessert. Level of Harm - Minimal harm or potential for actual harm -The puree vegetable served to the resident included peas which should not have been pureed (see

interview below). Residents Affected - Some -The peas and carrots provided on the test tray had visible pieces of carrots and peas in the puree peas and were not smooth. The puree meat had small visible lumps.

IV. Staff interviews

CK #1 and the DD were interviewed together on 3/25/25 at approximately 12:30 p.m. (during meal service). CK #1 said the facility had a book of modified texture diet menu extensions in the kitchen.

The DD said the facility had modified texture diet menu extensions but he needed to check with the registered dietitian (RD) to see if the modified texture diet menu extensions were correct.

The DD and the NHA were interviewed together on 3/26/25 at 12:00 p.m.

The DD said the facility was transitioning to IDDSI and was in the process of training the staff to the proper standards on IDDSI. The DD said the residents prescribed a puree diet had received puree peas and carrots for lunch on 3/25/25. The DD said the staff should not have pureed the peas and he noticed the puree peas

after the meals had been sent to residents. The DD said a food with a hull, such as peas, should not be pureed. The DD said the facility would transition to minced and moist level five and soft and bite size level six diet textures (of IDDSI diets) to replace the mechanical soft diet texture the facility used. The DD said he was notified during lunch by facility staff the modified diet textures were incorrect, but it was too late to do anything about it. The DD said if modified textures were served incorrectly the residents were at risk for choking.

The NHA said all staff were trained during their initial onboarding on how to recognize modified textures.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0812 Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47151

Residents Affected - Many Based on observations, record review and interviews, the facility failed to store, prepare, distribute, and serve food in a sanitary manner in the main kitchen and in three of three unit nourishment refrigerators.

Specifically the facility failed to:

-Ensured the nourishment room refrigerators were maintained at a safe temperature;

-Ensure health shakes were labeled in the unit nourishment refrigerators; and,

-Ensure the floor, walls and ice machine in the main kitchen were maintained in a clean and sanitary condition.

Findings include:

I. Ensure safe cold food holding temperatures were maintained and health shakes were labeled in the nourishment refrigerators

A. Professional reference

The Colorado Retail Food Establishment Rules and Regulations, ([DATE REDACTED]), retrieved on [DATE REDACTED], 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 at 41 F or less. (,d+[DATE REDACTED].16)

B. Observations

On [DATE REDACTED] at 10:30 a.m. the following was observed in a south unit nourishment refrigerator and freezer:

-Six health shake cartons; the directions printed on the side of the carton read to use the thawed product within 14 days. There was no pull date or written expiration date on the thawed health shakes;

-There was brown liquid splattered on the sides and spilled on the bottom of the freezer and inside the door shelf; and,

-A box of turkey pot pie was in the freezer with an expiration date of [DATE REDACTED] with a name written on the box.

On [DATE REDACTED] at 2:25 p.m. the following was observed in the south unit nourishment refrigerator:

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0812 -There was brown liquid splattered on the sides and spilled on the bottom of the freezer and inside the door shelf; Level of Harm - Minimal harm or potential for actual harm -A box of turkey pot pie in the freezer with an expiration date of [DATE REDACTED]; and,

Residents Affected - Many -Nine health shake cartons; the directions printed on the side of the carton read to use the thawed product within 14 days. There was no pull date or written expiration date on the thawed health shakes.

The [DATE REDACTED] ([DATE REDACTED] to [DATE REDACTED]) temperature log for the south unit nourishment refrigerator was reviewed.

The temperatures were recorded as follows:

-On [DATE REDACTED] the temperature was 42 F.

-On [DATE REDACTED] the temperature was 46 F.

-On [DATE REDACTED] the temperature was 42 F.

-On [DATE REDACTED] the temperature was 45 F.

-On [DATE REDACTED] the temperature was 48 F.

-On [DATE REDACTED] the temperature was 45 F.

-On [DATE REDACTED] the temperature was 43 F.

-The recorded refrigerator temperatures were above the acceptable cold holding temperature of 41 F and there was no evidence to indicate the temperature was corrected (see professional reference above).

An unidentified certified nurse aide (CNA) looked at the frozen turkey pot pie with the expiration date of [DATE REDACTED] and said the resident whose name was written on the box was no longer at the facility and placed the expired product back in the freezer.

On [DATE REDACTED] at 2:40 p.m. the following was observed in the men's secured unit nourishment refrigerator:

-Three health shake cartons; the directions printed on the side of the carton read to use the thawed product within 14 days. There was no pull date or written expiration date on the thawed healthsakes.

On [DATE REDACTED] at 2:45 p.m. the following was observed in the Aspen unit nourishment refrigerator :

-Seven health shake cartons; the directions printed on the side of the carton read to use the thawed product within 14 days. There was no pull date or written expiration date on the thawed healthsakes.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0812 The [DATE REDACTED] ([DATE REDACTED] to [DATE REDACTED]) temperature log for the aspen unit nourishment refrigerator was reviewed.

The temperatures were recorded as follows: Level of Harm - Minimal harm or potential for actual harm -On [DATE REDACTED] the temperature was 42F.

Residents Affected - Many -On [DATE REDACTED] the temperature was 42 F.

-On [DATE REDACTED] the temperature was 42 F.

-On [DATE REDACTED] the temperature was 48 F.

-On [DATE REDACTED] the temperature was 46 F.

-The recorded refrigerator temperatures were above the acceptable cold holding temperature of 41 F and there was no evidence to indicate the temperature was corrected (see professional reference above).

C. Staff interviews

The director of nursing (DON) was interviewed on [DATE REDACTED] at approximately 3:25 p.m. The DON said the dietary staff managed the unit nourishment refrigerators.

CNA #2 was interviewed on [DATE REDACTED] at approximately 2:30 p.m. CNA #2 said the overnight nursing staff checked the nourishment refrigerator temperatures and removed expired products.

Certified nurse aide with medication aide (CNA-Med) #1 said the night shift usually checked the nourishment refrigerator temperatures and she said she would check the temperatures of the nourishment refrigerators again for accuracy.

The dietary director (DD) and the nursing home administrator (NHA) were interviewed together on [DATE REDACTED] at 12:00 p.m. The NHA said the dietary department was responsible for recording the nourishment refrigerators temperatures and checking for expired products. The NHA said the nourishment refrigerator in the south unit was running a high temperature (out of range) because the thermometer was in the door but they moved the thermometer back inside the refrigerator. She said when they moved the thermometer the temperature was reading within normal limits.

The DD said that unit refrigerator temperatures and maintenance of the product would be corrected. The DD said since the refrigerator temperatures were running high, the staff should take the temperature of the food

in the refrigerator to ensure it was a safe temperature, and if the food was not a safe temperature after 30 minutes the food would be discarded. The DD said he was going to go through the product in the unit refrigerators and clean them out.

The NHA said he was not sure if the facility provided education to the CNAs on refrigerator temperature maintenance so they would notice if the temperature was out of range during their use of the refrigerators.

II. Maintain a clean and sanitary kitchen environment

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0812 A. Professional reference

Level of Harm - Minimal harm or The Colorado Retail Food Establishment Rules and Regulations, ([DATE REDACTED]), retrieved [DATE REDACTED] read in potential for actual harm pertinent part, Materials for indoor floor, wall, and ceiling surfaces under conditions of normal use shall be: smooth, durable, and easily cleanable for areas where food establishment operations are conducted; and Residents Affected - Many nonabsorbent for areas subject to moisture such as food preparation areas, walk-in refrigerators, warewashing areas, and areas subject to flushing or spray cleaning methods. (,d+[DATE REDACTED].11)

B. Facility policy and procedure

The Sanitization policy, revised [DATE REDACTED], was provided by the NHA on [DATE REDACTED] at 11:32 a.m. It read in pertinent part, All kitchens, kitchen areas and dining areas are kept clean, free from garbage and debris and protected from rodents and insects. All equipment, food contact surfaces and utensils are cleaned and sanitized using heat or chemical sanitizing solutions. Ice machines and ice storage containers are drained, cleaned and sanitized per manufactures instructions.

C. Observations

The initial kitchen tour was conducted on [DATE REDACTED] at 9:10 a.m. The following was observed:

-Approximately ten missing coving tiles (a curved tile that transitions the floor to the wall) behind the ice machine extending under the clean side of the dish machine table. The pipe extending from the back of the ice machine was dripping onto the floor instead of the drain and created standing water that pooled into the grout between the existing floor tiles. Four coving tiles were damaged and separated from the wall. The wall behind the ice machine was bowed out into the kitchen;

-The aluminum filter on the back of the ice machine was caked with brown debris; and,

-A large section extending approximately ten feet long and a foot wide revealed an exposed, uneven and rough concrete floor that was missing kitchen floor tiles.

A kitchen walk through was conducted in the main kitchen on [DATE REDACTED] from 11:10 a.m. through 1:30 p.m. The following was observed:

-Approximately ten missing coving tiles behind the ice machine and extending under the clean side of the dish machine table (a curved tile that transitions the floor to the wall) were missing. The pipe extending from

the back of the ice machine was dripping onto the floor instead of the drain and created standing water that pooled into the grout between the existing floor tiles. Four coving tiles behind the ice machine were damaged and separated from the wall.

The wall behind the ice machine was bowed out into the kitchen;

-The aluminum filter on the back of the ice machine was caked with brown debris; and,

-A large section extending approximately ten feet long and a foot wide revealed an exposed, uneven and rough concrete floor that was missing kitchen floor tiles.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0812 D. Staff interviews

Level of Harm - Minimal harm or The NHA was interviewed on [DATE REDACTED] at approximately 3:30 p.m. The NHA said he was not aware that the potential for actual harm filter on the back of the ice machine had not been cleaned and had not seen the tiles behind the dish machine. He said he was not aware the ice machine was dripping onto the floor. The NHA said the kitchen Residents Affected - Many floor was missing tiles because a broken pipe had been repaired and the facility would repair the floor in house.

The DON was interviewed on [DATE REDACTED] at approximately 3:30 p.m. The DON said it looked like the ice machine had been moved from where it usually sat

The DD and the NHA were interviewed together on [DATE REDACTED] at 12:00 p.m.

The NHA said he was not sure if the ice machine filter had been assigned to anyone to clean. He said it was possible the ice machine filter should have been cleaned as part of the regular clean performed by their contacted vendor.

E. Facility follow up

On [DATE REDACTED] at 11:32 a.m. the NHA provided documentation that the facility reached out to a local vendor on [DATE REDACTED] for a quote on epoxy chip coating (seamless) the kitchen floor. No further documentation was provided if the local vendor provided the quote.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0847 Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Level of Harm - Minimal harm or 47151 potential for actual harm Based on record review and interviews, the facility failed to ensure the facility's binding arbitration agreement Residents Affected - Some was thoroughly and accurately explained to the residents and or resident representatives before signing the agreement for three (#54, #85 and #96) of four residents out of 36 sample residents.

Specifically, the facility failed to:

-Thoroughly explain the binding arbitration agreement in a form and in a manner to ensure Resident #54, Resident #85 and Resident #96 and/or their representatives understood the agreement before signing the arbitration agreement; and,

-Ensure the facility staff provided evidence Resident #54, Resident #85 and Resident #96 and/or their representatives acknowledged understanding of the components of the agreement.

Findings include:

I. Facility policy and procedure

The Binding Arbitration Agreement policy, November 2023, was provided by the nursing home administrator (NHA) on 3/26/25 at 6:24 p.m. The policy read in pertinent part, Residents (or representatives) are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether to enter into such agreements. Residents (or their representatives) have the right to make informed decisions about the important aspects of their health, welfare and safety.

The terms and conditions of a binding arbitration agreement are explained to the resident (or representative)

in a way that ensures his or her understanding of the agreement, including that the resident may be giving up his or her right to have a dispute decided in a court proceeding. The terms and conditions of a binding arbitration agreement are explained to the resident (or representative) in a form and manager that he or she understands, taking into consideration the resident's (or representative's) language, literacy and stated preference for learning.

After the terms and conditions of the agreement are explained, the resident or representative must acknowledge that he or she understands the agreement before being asked to sign the document. A signature alone is not sufficient acknowledgement of understanding. The resident (or representative) must verbally acknowledge understanding, and the verbal acknowledgement documented by the staff member who explains the agreement.

II. Resident interviews

Resident #54 and Resident #85 were interviewed during a group interview on 3/25/25 at 10:30 a.m. Resident #54 and Resident #85 said they did not know what an arbitration agreement was and did not remember signing an arbitration agreement.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0847 Resident #96 was interviewed on 3/25/25 at 3:00 p.m. Resident #96 said she did not remember signing an arbitration agreement when she signed her paperwork upon admission. Resident #96 said she did not know Level of Harm - Minimal harm or what an arbitration agreement was and that she had no difficulties or disputes with the facility. potential for actual harm IV. Record review Residents Affected - Some

The NHA provided a list of residents who signed arbitration agreements on 3/23/25 at 10:55 a.m.

-The list documented Resident #54 and Resident #85 signed an arbitration agreement. However, the list of residents was created in June 2024 and not updated to include residents that had admitted since.

The admissions coordinator (AC) provided an additional list of residents who signed arbitration agreements

on 3/25/25 at approximately 2:00 p.m. Resident #96 signed the arbitration agreement on 2/13/25

IV. Staff interviews

The AC and the business office manager (BOM) were interviewed together on 3/26/25 at 12:20 p.m. The AC said she reviewed and read aloud to the resident or the responsible party that signed the admission paperwork and the

arbitration agreement.

-However, the facility failed to provide documentation of acknowledgement by the residents or their representatives that they understood the arbitration agreement.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0848 Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Level of Harm - Minimal harm or 47151 potential for actual harm Based on record review and interviews, the facility failed to ensure the facility's binding arbitration agreement Residents Affected - Many contained the required components.

Specifically, the facility failed to:

-Ensure the arbitration agreement presented to residents contained language that provided for the selection of a venue that was convenient to both parties; and,

-Provide for the selection of a neutral arbitrator agreed upon by both parties.

Findings include:

I. Facility policy and procedure

The Binding Arbitration Agreement policy, dated November 2023, was provided by the nursing home administrator (NHA) on 3/26/25 at 6:24 p.m. The policy read in pertinent part, Residents (or representatives) are informed of the nature and implications of any proposed binding arbitration agreements so as to make informed decisions on whether to enter into such agreements. Residents (or their representatives) have the right to make informed decisions about the important aspects of their health, welfare and safety.

Arbitration agreements provide for the selection of a neutral arbitrator, which is agreed upon by both parties.

A neutral arbitrator is an impartial, unbiased party decision maker, without the appearance of any conflicts of interest, contracted with and agreed to by both parties to resolve their dispute. Residents (or representatives) are given the opportunity to suggest an arbitrator and venue. If the facility disagrees with the resident's suggested arbitrator(s) and/or venue, the facility will document the reason and provide that documentation to

the resident (or representative).

Arbitration agreements provide for the selection of a venue that is both convenient to and suitably meets the needs of both parties. The venue will be agreed upon by both parties. When selecting a venue for consideration, ' convenience' for the resident (or representative) may be determined by his or her ability to get to the venue.

II. Facility's binding arbitration agreement

A copy of the facility's binding arbitration agreement was provided by the NHA on 3/23/55 at 10:55 a.m. The agreement read in pertinent part, The arbitration shall be administered and conducted by a contracted provider in accordance with its comprehensive arbitrations rules and procedures. Within 15 days after a claim for arbitration is made, the demand shall be filed by the contracted provider (dispute resolution specialist) and a single arbitrator will be selected from a list provided by the named provider pursuant to its rules to conduct the arbitrations. The arbitrator shall have the jurisdiction to decide whether the claims may be arbitrated pursuant to this agreement. The hearing arising under this voluntary arbitration agreement shall be held in the county where the facility is located.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0848 -The facility's binding arbitration agreement failed to include the selection of a neutral arbitrator agreed upon by both parties and failed to contain language that provided for the selection of a venue that was convenient Level of Harm - Minimal harm or to both parties. potential for actual harm III. Staff interviews Residents Affected - Many

The admission coordinator (AC) was interviewed on 3/26/25 at 12:20 p.m. The AC said the facility's arbitration agreement did not include information indicating a resident could speak with federal, state, local, surveyors or ombudsman. She said the information was included in the facility's admission agreement (a separate document) instead. The AC said there was no language in the facility's arbitration agreement regarding a selection of venue by both parties.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50219

Residents Affected - Few Based on record review and interviews, the facility failed to meet all the requirements for the provision of hospice care for one (#26) of five residents out of 36 sample residents.

Specifically, the facility failed to ensure the hospice agency notes regarding Resident #26's care were easily accessible to the facility staff in an attempt to effectively coordinate care with the hospice agency.

Findings include:

I. Facility-Hospice contract

The contract between the facility and the hospice services company, dated 7/10/23, was provided by the nursing home administrator (NHA) on 3/25/25 at 3:08 p.m. It read in pertinent part, The hospice and nursing facility shall each prepare and maintain complete and detailed clinical records concerning each residential hospice patient receiving services under this agreement. Each clinical record shall completely, promptly, and accurately document all services provided to, and events concerning, each hospice patient. The hospice and

the nursing facility shall each retain such records. Each such record shall be readily available and systematically organized to facilitate retrieval by either party.

II. Resident #26

A. Resident status

Resident #26, age 83, was admitted on [DATE REDACTED]. According to the March 2025 computerized physician orders (CPO), diagnoses included respiratory failure, vascular dementia and adult failure to thrive.

The 12/31/24 minimum data set (MDS) assessment documented the resident had both short-term and long-term memory impairments and had severely impaired daily decision-making skills, per staff assessment.

The resident was dependent on staff for most activities of daily living (ADL).

The MDS assessment indicated the resident was receiving hospice services.

B. Record review

The March 2025 CPO revealed a physician's order for Resident #26 indicating the resident was admitted to hospice services on 9/25/24.

The end of life care plan, revised 10/15/24, revealed Resident #26 required hospice care and was at risk for rapid decline in ADLs. Pertinent interventions included coordinating Resident #26's needs with hospice staff.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0849 A hospice notebook was provided by licensed practical nurse (LPN) #1 on 3/25/25 at 4:09 p.m. Review of the notebook revealed three visits from the hospice social worker dated 1/13/25, 2/12/25 and 3/14/25. Level of Harm - Minimal harm or potential for actual harm -However, the notebook did not reveal any documentation from the hospice nursing staff regarding their visits and the care they provided. Residents Affected - Few -Review of Resident #26's electronic medical record (EMR) failed to reveal any progress notes from the hospice services provider.

Hospice nursing notes, dated 12/23/24 through 3/26/25, were provided by the director of nursing (DON) on 3/26/25 at 6:06 p.m. The hospice notes documented the care that was provided to Resident #1 at each hospice visit.

-However, the hospice nursing notes were not in the hospice binder accessible to the facility staff.

III. Staff interviews

LPN #1 was interviewed on 3/25/25 at 4:12 p.m. LPN #1 said when the hospice staff visited residents, their notes should be placed in the hospice notebook. LPN #1 said the hospice documents did not get uploaded anywhere into the residents' EMRs. LPN #1 said hospice certified nurse aides (CNAs) visited Resident #26 two to three days per week.

LPN #1 was interviewed again on 3/26/25 on 10:34 a.m. LPN #1 verified there were no notes from any hospice CNA visits in Resident #26's hospice binder. LPN #1 said there should be notes from each visit from

the hospice staff in the resident's hospice binder.

-However, there were no notes documented from the hospice CNAs in Resident #26's hospice notebook (see record review above).

CNA #5 was interviewed on 3/26/25 at 9:30 a.m. CNA #5 said the hospice staff reported to the CNA or nurse

on duty after each visit to let them know what care they performed with Resident #26. CNA #5 said this information was also written down in the hospice binder. CNA #5 said the hospice staff communicated what care they performed so the facility's nursing staff could chart it in the resident's EMR, or attend to the resident if they needed medications or were not feeling well.

CNA #2 was interviewed on 3/26/25 at 10:13 a.m. CNA #2 said some of the hospice CNAs did not tell the facility staff what care they provided for Resident #26 during their visits or if his incontinence brief needed to be changed. CNA #2 said the facility had a binder in which the hospice staff recorded everything they did when they came to assist Resident #26. CNA #2 said the hospice staff communicated with the facility staff to note any changes with Resident #26, ensure he was not left soiled and to make sure he got the care he needed.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0849 The DON and the regional clinical resource (RCR) were interviewed together on 3/26/25 at 4:40 p.m. The DON said the hospice staff emailed the facility recommendations after each visit. The DON said the hospice Level of Harm - Minimal harm or CNA visits and documentation were the social services department's responsibility. The DON said the potential for actual harm hospice binders for each resident should contain the resident's plan of care and nursing recommendations from hospice. Residents Affected - Few

The RCR said the hospice binders for each resident should also contain visit summaries, chaplain notes and

the hospice CNA visits.

-However, Resident #26's hospice binder did not contain the plan of care, CNA visits or any documentation aside from the hospice social worker visits (see record review above).

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50690 potential for actual harm Based on observations, interviews and record review, the facility failed to maintain an infection control Residents Affected - Some program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of disease on three of three units.

Specifically, the facility failed to:

-Ensure housekeeping staff followed appropriate hand hygiene processes when cleaning resident rooms;

-Ensure high touch surfaces in residents' rooms were cleaned;

-Ensure housekeeping staff followed proper cleaning techniques when cleaning residents' bathrooms; and,

-Ensure enhanced barrier precautions (EBP) were followed for Resident #1, who had a peripherally inserted central catheter (PICC).

Findings include:

I. Housekeeping failures

A. Professional references

According to the Centers for Disease Control and Prevention (CDC), CDC Clinical Safety, Hand Hygiene for Healthcare Worker (2/17/24), retrieved on 4/1/25 from https://www.cdc.gov/clean-hands/hcp/clinical-safety,

Know when to clean your hands: immediately before touching a patient, before performing an aseptic task such as placing an indwelling device or handling invasive medical devices, before moving from work on a soiled body site to a clean body site on the same patient, after touching a patient or patient's surroundings,

after contact with blood, body fluids or contaminated surfaces and immediately after glove removal.

According to Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, retrieved on 3/21/25 from

https://www.journalofhospitalinfection.com/article/S0195-6701(21)00105-5/fulltext,

High-touch surfaces are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0880 Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive Level of Harm - Minimal harm or approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection potential for actual harm of surfaces and clinical equipment.

Residents Affected - Some B. Observations

During a continuous observation on 3/26/25, beginning at 9:40 a.m. and ending at 10:27 a.m., the following was observed:

The housekeeper (HK) sanitized her hands and donned (put on) gloves. The HK took her keys out of her pocket and opened the top of the supply cart. She grabbed a spray bottle of sanitizer and entered the bathroom in room [ROOM NUMBER], a double-occupancy room. She sprayed the surfaces of the toilet and sink.

-The HK contaminated her clean gloves by touching her keys.

-The HK failed to lift up the toilet seat and spray the rim of the toilet bowl with sanitizer.

The HK cleaned the surfaces of the furniture on side B of the bedroom, changing gloves before each new cloth was used. She swept side B, changed gloves, then swept side A. She mopped half of side A, changed gloves, and cleaned the surfaces and handles of the dresser, bedside table and the door handles. She entered the bathroom and wiped down the vanity and fixtures with a clean towel.

-The HK failed to sanitize her hands in between glove changes.

At 9:58 a.m. the HK took a bucket with a scrub brush from underneath the supply cart. She poured sanitizer into the toilet bowl and flushed it. She scrubbed the inside of the toilet bowl with the brush. She then used the brush to scrub the top and outsides of the toilet bowl and finished by scrubbing the inside of the toilet again.

-The HK failed to use proper cleaning technique by cleaning from a dirty area to a clean area and back to a dirty area.

After cleaning the toilet, the HK put the scrub brush back into the bucket and returned it to the cart. She donned new gloves and mopped the bathroom floor. She changed gloves again and mopped the rest of side A, turned off the bedroom lights and exited the room.

-The HK failed to sanitize her hands in between glove changes.

-The HK failed to clean and sanitize the high touch areas in room [ROOM NUMBER], including door knobs, light switches and call lights.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0880 At 10:08 a.m., the HK entered the bathroom of the adjacent room, room [ROOM NUMBER]. She followed the same procedure, spraying the surfaces in the bathroom, then cleaning side B and side A separately, Level of Harm - Minimal harm or changing gloves in between each step. At 10:21 a.m, she took the same bucket and scrub brush from potential for actual harm underneath the supply cart. She poured sanitizer into the toilet bowl and flushed it, using the same technique to clean the toilet. She scrubbed the inside of the toilet bowl with the brush. She then used the brush to scrub Residents Affected - Some the top and outsides of the toilet bowl and finished by scrubbing the inside of the toilet bowl again. After cleaning the toilet, she put the scrub brush back into the bucket and returned it to the cart.

-The HK failed to sanitize her hands in between glove changes.

-The HK again failed to use proper cleaning technique by cleaning from a dirty area to a clean area and back to a dirty area.

-The HK failed to clean and sanitize the high touch areas in room [ROOM NUMBER], including door knobs, light switches and call lights, and used the same scrub brush for multiple residents' toilets.

C. Staff interviews

The HK was interviewed in Spanish on 3/26/25 at 10:27 a.m. The HK said she used the same toilet scrub brush for all the rooms in the hallway.

The housekeeping supervisor (HKS) was interviewed on 3/26/25 at 12:46 p.m. The HKS said she started her position a month ago and she had scheduled a meeting for the following day (3/27/25) to discuss policies, procedures and expectations. She said she told staff that when they were in doubt, they should change them out (their gloves). The HKS said every time gloves were taken off, the hands should be sanitized.

The HKS said high touch surfaces should be cleaned daily as part of the regular cleaning procedures. She said toilet scrub brushes were only used for the inner toilet bowl and cleaning cloths should be used on the outside of the toilet bowl. She said currently, there was only one toilet scrub brush per unit. The HKS said

she wanted each room to have their own separate toilet brush/plunger combination.

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II. Failure to identify and follow EBP

A. Professional reference

The Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), was retrieved on 4/2/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part,

Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0880 EBP may be indicated (when contact precautions do not otherwise apply) for residents with wounds or indwelling medical devices, regardless of MDRO colonization status. Level of Harm - Minimal harm or potential for actual harm B. Observations

Residents Affected - Some On 3/24/25 at 9:22 a.m. restorative aide (RA) #1 was sitting on Resident #1's bed while Resident #1 was doing a physical therapy exercise in her chair. Resident #1 had a peripherally-inserted central catheter (PICC) line hanging from her right arm. RA #1 removed a gait belt from around her waist and put the gait belt around Resident #1. RA #1 grabbed the gait belt and assisted Resident #1 to a standing position from her recliner so the resident was standing in front of her walker. RA #1 grabbed Resident #1's arm at her PICC site to support the resident as she walked. RA #1 quickly let go of the resident's arm but continued holding onto the gait belt around the resident's waist.

-RA #1 failed to wear a gown or gloves when she was working with Resident #1.

-Additionally, there was no PPE observed in Resident #1's room or outside the resident's room for staff to put

on when providing high contact care with the resident.

C. Staff interviews

Certified nurse aide (CNA) #2 was interviewed on 3/26/25 at 10:13 a.m. CNA #2 said residents that needed EBP had a bag containing PPE on their door and a sign indicating what precautions they were on. CNA #2 said nursing staff needed to wear a gown and gloves when entering the room of any residents on EBP. CNA #2 said residents were on EBP when they had a urinary catheter or needed tube feeding. CNA #2 said she was not sure if Resident #1 needed EBP, but she said no one told her about the resident needing any precautions.

Licensed practical nurse (LPN) #1 was interviewed on 3/26/25 at 10:34 a.m. LPN #1 said EBP were used for residents with urinary catheters, tube feedings and PICC lines. LPN #1 said nursing staff needed to wear a mask, gown and gloves when working with residents who needed EBP.

RA #1 was interviewed on 3/26/25 at 2:36 p.m. RA #1 said she needed to wear a gown and gloves when working with residents on EBP and disinfect her hands between working with each resident. RA #1 was not sure what the reasons were which caused a resident to require EBP.

The infection preventionist (IP) was interviewed on 3/26/25 at 5:53 p.m. The IP said that EBP should be used with any resident that had an indwelling device, such as a PICC line, gastrostomy tube or urinary catheter.

She said EBP should additionally be used for residents with wounds or multi-drug resistant organisms (MDROs) in their urine. She said every shift the nurse was required to document that EBP was in place for their residents who were on EBP. The IP said she put in the initial physician's order for EBP for residents, which consisted of wearing a gown and gloves any time staff performed direct care with a resident, such as when they changed dressings, performed incontinence care or bathed a resident. She said EBP was to prevent transmission of infectious organisms. The IP said she did not think that Resident #1 had a PICC line anymore.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 65 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0880 The director of nursing (DON) was interviewed on 3/26/25 at 7:11 p.m. The DON said Resident #1 had EBP

in place when the facility was accessing her PICC line to administer antibiotics, but she said the resident had Level of Harm - Minimal harm or not had EBP in place since the resident completed her antibiotics and the staff were no longer administering potential for actual harm medications through the PICC line. The DON said Resident #1 still needed EBP during dressing changes for

the PICC line. Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 66 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0921 Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50690

Residents Affected - Some Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public.

Specifically, the facility failed to ensure resident rooms, bathrooms, dining room furniture and hallways received necessary maintenance repairs.

Findings include:

I. Facility policy and procedure

The Safe and Homelike Environment policy, undated, was provided by the nursing home administrator (NHA) on 3/25/25 at 1:53 p.m. The policy read in pertinent part, The facility will provide a safe, clean, and comfortable homelike environment. This ensures that the resident can receive care and services safely and that the physical layout maximizes resident independence and does not pose a safety risk. Environment refers to any location in the facility that is frequented by residents. A homelike environment is one that de-emphasizes the institutional character of the setting. Housekeeping and maintenance services will be provided as necessary to maintain a sanitary, orderly, and comfortable living environment. Furniture in disrepair will be reported to maintenance promptly.

II. Aspen common/dining area

On 3/23/25 at 9:15 a.m. the following observations were made of the Aspen common area:

-Nine dining room chairs had seat cushions that were ripped and peeling; and,

-Four of the six dining room tables had scratched and peeling surfaces and the underlying particle board was exposed.

III. Ceiling and door frame in the Mountain View hallway

On 3/23/25 at 9:30 a.m. the following observations were made in the Mountain View hallway:

-There was rotted wood along the bottom of the double doorway frame in the hallway; and,

-The ceiling near the exit sign above the double doorway had water spots and was bowing downward.

IV. Resident rooms and bathrooms

A. Observations

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 67 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0921 On 3/24/25 at 9:46 a.m. room [ROOM NUMBER] was observed. One of the residents who resided in the room was lying in bed. There were four raised and rough patches on the wall next to his bed, approximately Level of Harm - Minimal harm or three inches in diameter. There was a pink spot on the wall approximately 18 inches long and three inches potential for actual harm high next to a vertical wall light approximately the same size. There were two round quarter inch holes in the wall and multiple scuff marks. There was a health shake container on the floor and two wet wipes next to a Residents Affected - Some small trash can on the floor under a tray table.

On 3/24/25 at 9:55 a.m. room [ROOM NUMBER] was observed. The walls on the opposite side of one of the residents' beds had multiple lines where a light brown liquid had spilled down and dried on the walls. There were seven spots of a yellow chunky substance splattered on the corner of the wall directly adjacent to the dried spill.

On 3/24/25 at 2:37 p.m. room [ROOM NUMBER] was observed. There was a hole in the wall approximately four inches long by one inch tall, surrounded by peeling paint and broken plaster.

On 3/25/25 at 5:36 p.m. room [ROOM NUMBER]'s bathroom was observed. There was hard water staining covering several square inches of the floor to the left of and behind the toilet. The baseboard was separating from the wall and had approximately a one centimeter gap between the baseboard and the wall. The area where the water inlet for the toilet met the wall had several inches of corrosion and hard water buildup, and

the wall showed signs of water damage where several inches of paint were peeling away from the wall.

On 3/25/25 at 5:42 p.m. room [ROOM NUMBER]'s bathroom was observed. There was a towel folded up and placed over a section of the floor to the left of the toilet. The flooring around the towel had areas of hard water buildup and several gnats were flying in the area of the towel.

On 3/25/25 at 5:52 p.m. the maintenance director (MTD) lifted the towel on the floor in room [ROOM NUMBER]'s bathroom to examine the flooring underneath. Approximately 15 to 20 gnats flew out from between the floor and the towel.

On 3/26/25 at 8:57 a.m. room [ROOM NUMBER] was observed. The room had no curtains on the windows. There were three large brown stains on the tile floor near bed A. The heating vent along the far wall was broken with brown stains and portions of the metal covering were falling off.

On 3/26/25 at 10:10 a.m., the lid to the toilet tank in room [ROOM NUMBER] was observed. The toilet tank lid did not fit and was the wrong shape for the tank. It was half-off, leaving an opening into the tank. The wall next to the toilet had an area approximately three feet long with peeling paint and cracks. The wall under the sink had a large horizontal crack extending from the toilet tank to the plumbing. There were large yellow/brown water stains on the wall under the sink. Yellow caulking lined the top of the white vanity and wall, partially covering cracks in the paint.

B. Resident interviews

One of the residents who resided in room [ROOM NUMBER] was interviewed on 3/24/25 at 9:46 a.m. The resident said he was unable to see his trash basket and so he dropped his trash on the floor.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 68 of 69 065378 Department of Health & Human Services Printed: 09/03/2025 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 065378 B. Wing 03/26/2025

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

Riverdale Post Acute 2311 E Bridge St Brighton, CO 80601

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 0921 The resident who resided in room [ROOM NUMBER] was interviewed on 3/24/25 at 9:55 a.m. The resident said he was unable to see the wall in his room that had drips on it. He said he had asked for a dead [NAME] Level of Harm - Minimal harm or moth to be removed from the overhead light in his room and it never happened. potential for actual harm One of the residents who resided in room [ROOM NUMBER] was interviewed on 3/26/25 at 9:00 a.m. The Residents Affected - Some resident said she used to have curtains on her windows, but she said the facility had taken them off a while ago and never replaced them. She said the room was always cold and the curtains might have helped keep

it warmer. She said the heat vent looked like it was broken and unused, but she said it worked.

V. Staff interviews

The NHA was interviewed on 3/25/25 at approximately 3:40 p.m. The NHA said housekeeping could clean spills on the walls as well as other staff, such as a certified nurse aide (CNA), if they were in a resident's room. The NHA said he was not aware of the maintenance concerns items and holes in the walls in rooms #46, #47 and #54.

The MTD was interviewed on 3/25/25 at 5:52 p.m. The MTD said he had not been made aware of any issues with the bathroom in room [ROOM NUMBER]. The MTD said he had not gone into the room since he started at the facility, as he had not received any work orders for that room or otherwise been invited into the room by the residents.

The MTD said there was not any standing water under the towel in room [ROOM NUMBER] but there was a definite issue with the toilet leaking.

The MTD was interviewed again on 3/26/25 at 1:29 p.m. The MTD said there was no standing water near the toilet in room [ROOM NUMBER] but that the area had significant staining. The MTD said room [ROOM NUMBER]'s bathroom was being decontaminated by the housekeeping staff.

The MTD was interviewed a third time on 3/26/25 at 5:00 p.m. The MTD said he knew about all of the maintenance repair issues in room [ROOM NUMBER], room [ROOM NUMBER], in the Mountain View hallway and the furniture in the Aspen unit dining room. He said the building was old and every time he started to fix one issue, another major and more important issue arose.

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47151

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 69 of 69 065378