South Platte Rehabilitation And Nursing Llc

F-F600 for failure to protect residents from abuse.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 26 065170 Department of Health & Human Services Printed: 09/11/2025 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 065170 B. Wing 01/07/2025

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

South Platte Rehabilitation and Nursing LLC 2200 Edison St Brush, CO 80723

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 0742 The comprehensive care plan addressed psychosocial areas of mood related to her admission and current situation (initiated 10/1/24) and challenges adjusting to her admission (initiated 10/1/24). Level of Harm - Actual harm -The mood care plan was updated on 1/6/25 (during survey) to add Resident #5 was involved in a physical Residents Affected - Few altercation with another resident related to physical aggression towards her.

-The care plan revision documented the mood care plan was initiated on 10/21/24, however it was not part of

the comprehensive care plan reviewed on 1/6/25 at 9:35 a.m.

A risk for depression care plan, initiated 12/22/24, related to her recent decline in health, change in living situation, and financial situation. Interventions included observing for signs or symptoms of depression and contacting the provider if the depression screen was positive.

-However, the care plan was initiated two months after the mood interview/depression assessment indicated Resident #5 had increased signs of depression and there was no documentation the provider was notified (see Resident Mood Interview assessments below).

The trauma informed care plan, revised 12/23/24, revealed the resident had fearfulness from an event that occurred at the facility when another resident exhibited aggressive behavior towards her. Interventions (all initiated 12/23/24) included offering her another room on the opposite hall (which she declined), offering to escort her to desired locations in the facility (declined due to personal choice), arranging for services with a mental health provider, encouraging her to share her feelings and concerns with staff, identifying items that lessen the effect of the trauma and monitoring her whereabouts and emotional state.

-The trauma informed care plan was initiated over two months after the traumatic incident with Resident #4 occurred.

The 12/23/24 trauma interview revealed Resident #5 had experienced trauma related to being a victim of physical aggression. The interview documented Resident #5 experienced anxiety, feeling of detachment and fearfulness related to the incident. Resident #5 indicated counseling would help her to deal with the trauma.

The 7/23/24 Resident Mood Interview assessment (prior to the incident), revealed Resident #5 scored a zero

on the mood interview, indicating she did not have any symptoms of depression. Resident #5 answered the question regarding social isolation as she never felt lonely or socially isolated.

The 10/23/24 Resident Mood Interview assessment (after the incident), revealed Resident #5 scored a six on

the mood interview, indicating she felt down, depressed or hopeless more than half of the time, had trouble falling or staying asleep or was sleeping too much more than half of the time, and felt tired or had little energy more than half of the time over the past two weeks. Resident #5 answered the question regarding social isolation as she sometimes felt lonely or socially isolated.

-There was no social service progress note regarding these mood changes for Resident #5.

-There were no changes to the plan of care related to these changes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 26 065170 Department of Health & Human Services Printed: 09/11/2025 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 065170 B. Wing 01/07/2025

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

South Platte Rehabilitation and Nursing LLC 2200 Edison St Brush, CO 80723

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 0742 -There was no documentation that the physician or behavioral health services were notified of these changes.

Level of Harm - Actual harm E. Staff interviews

Residents Affected - Few The activity director (AD) was interviewed on 1/6/25 at 4:35 p.m. The AD said Resident #5 liked to come to social activities, especially if there was food. The AD said Resident #5 was coming out of her room less often for the past month and had been sleeping in later in the mornings.

The SSD was interviewed on 1/7/25 at 10:30 a.m. The SSD said she typically made a progress note if there was a change on a residents' MDS assessment. The SSD said she did not know why she did not make a progress note for Resident #5. The SSD said she should have made a quarterly progress note for Resident #5 in October 2024. The SSD verified there was not a social service progress note for Resident #5 in October 2024 after she completed the resident's mood interview assessment.

The SSD said she sent an email to behavior health services requesting a visit for Resident #5 but did not document this in the medical record. The SSD said Resident #5 was experiencing stress about her finances and wanting to move to another facility. The SSD said a trauma care plan was added to Resident #5's plan of care on 12/23/24 because that was when the resident expressed she was still having fear from the incident with Resident #4. The SSD said they offered Resident #5 an alternate location for her puzzles and a room change but she declined. The SSD said she had sent several referrals to other facilities and Resident #5 had been accepted at a couple of them in another town, but Resident #5 was not interested in moving to those facilities.

-Documentation of the behavioral health services referral and visit were requested at the time of survey but not received from the facility by the end of the survey on 1/7/25.

The NHA was interviewed on 1/7/25 at 11:32 a.m. The NHA said the social services staff should have, at a minimum, a quarterly progress note for each resident, and more if there were resident changes. The NHA said if there was a change in a resident's mood or on the MDS assessment, there should be a social services note addressing the change.

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F-F742 for failure to provide treatment/services for mental/psychosocial concerns.

D. Staff interviews

LPN #1 was interviewed on 1/6/25 at 9:56 a.m. LPN #1 said she did not witness the occurrence between Resident #4 and Resident #5 but she knew one of the residents was coming in from smoking and the other was going out. LPN #1 said Resident #5 told her Resident #4 rammed his wheelchair into her knees. LPN #1 said Resident #5 did not have any visible marks (however, the occurrence investigation revealed she had an abrasion on her arm and redness to her knee) but later Resident #5 said she got whiplash. LPN #1 said Resident #4 told her people should get out of his way. LPN #1 said they tried to watch for Resident #5 when

she came out into the hall or went to smoke. LPN #1 said if Resident #4 was out in the hallway, Resident #5 went back to her room and did not go out to smoke. LPN #1 said frequent checks meant staff laid eyes on

the resident every 15 minutes for 72 hours. LPN #1 said the staff documented these checks on paper.

CNA #1 was interviewed on 1/6/25 at 11:33 a.m. CNA #1 said on the day of the incident (10/21/24) she saw Resident #4 close to Resident #5 and asked him what he was doing. She said Resident #4 backed away and wheeled down the hall but she did not see him run into Resident #5. CNA #1 said Resident #5 told her Resident #4 took hold of her wheelchair and rammed her into the wall. She said the residents were face to face in their wheelchairs. CNA #1 said the facility did not do 15-minute frequent checks on Resident #4 after

the incident. CNA #1 she was not aware of any interventions in place for Resident #4's aggressive behaviors. She said staff were just told to intervene if the residents got too close to each other.

The social service director (SSD) was interviewed on 1/7/25 at 10:30 a.m. The SSD said she did not know if there was a physical aggression behavior care plan for Resident #4 prior to the incident on 10/21/24 or when

it may have been resolved. The SSD said the facility was using a different EMR program now and she was not able to access the old care plans.

The nursing home administrator (NHA), director of nursing (DON) and the RDQC were interviewed together

on 1/7/25 at 11:32 a.m. The DON said frequent checks for Resident #4 were implemented following the incident with Resident #5. The DON said frequent checks meant checking on the resident every 15 minutes for 72 hours. The DON said the staff documented on paper and the documentation was uploaded into the EMR.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 26 065170 Department of Health & Human Services Printed: 09/11/2025 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 065170 B. Wing 01/07/2025

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

South Platte Rehabilitation and Nursing LLC 2200 Edison St Brush, CO 80723

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 -However, there was no documentation provided to indicate frequent checks were completed for Resident #4 following the incident (see record review above). Level of Harm - Actual harm

The NHA said Resident #4 had a brain injury and was triggered by other people not using common sense. Residents Affected - Few The NHA said people knocking on his door agitated him if he was sitting right there and could see them. He was protective of his personal belongings. The RDQC said the facility would be implementing further interventions for Resident #4's behavior care plan.

48458

III. Incident of physical abuse of Resident #6 by Resident #4 on 11/21/24

A. Facility investigation

The 11/21/24 facility abuse investigation documented the incident occurred on 11/21/24 at 10:01 a.m. The investigation documented Resident #4 stood up from his wheelchair and grabbed Resident #6 by the shirt collar. Resident #6 responded by pushing Resident #4 who then fell and hit his head on the wall. The residents were immediately separated and placed on frequent checks.

The investigation documented two facility staff members witnessed the resident-to-resident altercation. It documented Resident #6 was an at-risk adult. The police, residents' families, the ombudsman and the physician were notified of the resident-to-resident altercation.

The investigation revealed there was no evidence of injury to Resident #6.

The investigation documented the NHA interviewed Resident #6 following the incident. The investigation documented Resident #6 said he was walking down the hall with a maintenance staff member when Resident #4 said stop acting tough in front of me. Resident #6 said Resident #4 then stood up and grabbed Resident #6's shirt and pushed Resident #6 and then Resident #6 pushed Resident #4 away. Resident #6 said Resident #4 stumbled backwards and hit his head. Resident #6 said he was not fearful of Resident #4

after the incident.

The investigation documented Resident #4 was interviewed by the NHA on 11/21/24 at approximately 1:00 p. m. Resident #4 said Resident #6 was outside of Resident #4's room acting like a tough guy. Resident #4 said he told Resident #6 he would slap him around a little bit and then Resident #4 said he stood up and lost his balance and hit his head on a door frame.

The investigation documented the following interviews with witnesses to the incident:

-An interview with housekeeper (HK) #1 on 11/21/24 at 1:05 p.m. by the NHA. The interview documented HK #1 said Resident #4 stood up and pushed Resident #6 in the chest and then Resident #6 responded by pushing Resident #4 back.

-An undated interview with CNA #4, who was also a member of the maintenance staff, was conducted by the NHA. The interview documented CNA #4 was walking down the hallway with Resident #6 when Resident #4 began yelling at Resident #6. Resident #6 approached Resident #4 to listen to Resident #4 and then Resident #4 stood up and grabbed Resident #6 by the shirt collar. Resident #6 pushed Resident #4 and Resident #4 stumbled back and hit his head.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 26 065170 Department of Health & Human Services Printed: 09/11/2025 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 065170 B. Wing 01/07/2025

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

South Platte Rehabilitation and Nursing LLC 2200 Edison St Brush, CO 80723

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 The investigation documented Resident #6 was placed on frequent checks, follow-up with mental health services and monitoring for psychosocial abnormalities for the following 72 hours. The care plan for Resident Level of Harm - Actual harm #6 was updated to redirect Resident #6 from wandering in front of rooms or doorways of those who had the potential to be upset by the increased presence. Residents Affected - Few

The investigation documented increased supervision and medication change were actions taken for Resident #4 to help prevent a recurrence.

The investigation documented Resident #4 had been involved in previous altercations within the past 12 months.

The investigation concluded the abuse was substantiated.

B. Resident #4 (assailant)

1. Record review

A nursing progress note, dated 11/21/24 at 12:55 p.m., documented the nurse heard Resident #4 raising his voice and telling someone don't be stupid in front of my door. When the nurse got up to walk out to hallway to see what was going on, Resident #4 stood up and grabbed Resident #6 by the front of his shirt and Resident #6 shoved him away and Resident #4 struck his head on the doorway and fell to his right side. The SSD immediately intervened and attempted to redirect Resident #6 away from Resident #4 as Resident #4 was attempting to get up and go back at Resident #6.

-Review of Resident #4's behavior care plans revealed the care plans were not updated following the incident on 11/21/24 with Resident #6.

-Review of Resident #4's comprehensive care plan revealed a care plan focus for physical aggression was not initiated until 12/23/24, one month after the incident with Resident #6 and two months after a previous incident on 10/21/24 with Resident #5 (see above).

C. Resident #6 (victim)

1. Resident status

Resident #6, age less than 65, was admitted on [DATE REDACTED]. According to the January 2025 CPO, diagnoses included drug induced dyskinesia (uncontrolled involuntary muscle movement), dysphagia (difficulty swallowing) and dementia.

The 11/27/24 MDS assessment revealed the resident had a severe cognitive impairment with a BIMS score of five out of 15. The resident ate and walked independently and he required set-up assistance with showering.

The MDS assessment did not reveal any behaviors displayed by the resident toward others.

2. Resident observation and interview

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 26 065170 Department of Health & Human Services Printed: 09/11/2025 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 065170 B. Wing 01/07/2025

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

South Platte Rehabilitation and Nursing LLC 2200 Edison St Brush, CO 80723

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 #6 was interviewed on 1/6/25 at 1:36 p.m. Resident #6 was standing in his room. He was calm and cooperative during the interview. Resident #6 said there was an incident a while back, but it was over and Level of Harm - Actual harm done and the resident could not remember the specific details of the incident between him and Resident #4. Resident #6 said he did not fear Resident #4. Residents Affected - Few 3. Record review

Resident #6's behavioral care plan, revised 5/7/24, revealed a behavior challenge related to Resident #6 being sexually inappropriate with staff and Resident #6 had taken items from staff in a playful manner.

-Resident #6's care plan did not reveal any behavioral issues with other residents.

A nursing progress note, dated 11/21/24 at 12:55 p.m., documented the nurse heard Resident #4 raising his voice and telling someone don't be stupid in front of my door. When the nurse got up to walk out to hallway to see what was going on, Resident #4 stood up and grabbed Resident #6 by the front of his shirt and Resident #6 shoved him away and Resident #4 struck his head on the doorway and fell to his right side. The SSD immediately intervened and attempted to redirect Resident #6 away from Resident #4 as Resident #4 was attempting to get up and go back at Resident #6.

D. Staff interviews

Registered nurse (RN) #1 was interviewed on 1/6/25 at 10:15 a.m. RN #1 said a CNA told her she was needed for assessment of the residents after the incident involving Resident #4 and Resident #6 on 11/21/24. RN #1 said she received a report that Resident #4 stood up and grabbed Resident #6 by the collar, Resident #6 defensively pushed Resident #4 away and Resident #4 hit the doorframe and slid to the floor. RN #1 said she did a physical assessment of Resident #6 and found no injuries. RN #1 said she completed a physical assessment of Resident #4 and found an abrasion on his head, which had stopped bleeding, and some scratches on his shoulder. RN #1 said Resident #4 was transferred to the hospital as a precaution for further assessment as he had a history of metal plates in his head. RN #1 said Resident #4 returned to the facility the same day without further concerns.

HK #1 was interviewed on 1/6/25 at 10:35 a.m. HK #1 said she witnessed the incident between Resident #4 and Resident #6 on 11/21/24. HK #1 said the incident happened outside of Resident #4's room. She said Resident #4 said something to Resident #6 and then Resident #6 moved closer to Resident #4 to ask what

he said. She said Resident #4 stood up from his wheelchair and pushed Resident #6's chest. HK #1 said Resident #6 stumbled back and pushed Resident #4 back. HK #1 said Resident #4's head bumped the door jam and the resident went down to his knees. HK #1 said Resident #6 was upset and shaking after the incident.

The minimum data set coordinator (MDSC) was interviewed on 1/6/25 at 10:54 a.m. The MDSC said she witnessed the incident between Resident #4 and Resident #6 on 11/21/24. The MDSC said she was in her office and overheard Resident #4 talking loudly in the hallway. The MDSC said she entered the hallway and observed Resident #4 as he stood up and tried to hit Resident #6. She said Resident #6 then pushed Resident #4 back into the doorway. The MDSC said the SSD updated the care plans and she did not know if there was an IDT meeting after the incident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 26 065170 Department of Health & Human Services Printed: 09/11/2025 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 065170 B. Wing 01/07/2025

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

South Platte Rehabilitation and Nursing LLC 2200 Edison St Brush, CO 80723

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 The SSD was interviewed on 1/6/25 at 11:26 a.m. The SSD said she had just spoken with Resident #6 prior to the incident with Resident #4 on 11/21/24. The SSD said she was in the hallway during the incident. he Level of Harm - Actual harm said she heard a loud male voice, turned around and saw Resident #4 shove Resident #6. She said Resident #6 shoved back and Resident #4 lost his balance and fell into the door. She said it appeared Residents Affected - Few Resident #6 was being defensive when he pushed back at Resident #4. The SSD said since the incident,

she had directed other residents to not pace in front of Resident #4's doorway. She said Resident #4 had some medication changes after the 11/21/24 incident.

The SSD said she updated care plans related to residents' behaviors. The SSD said Resident #4 was the aggressor during the 11/21/24 incident and was also the aggressor during a previous incident on 10/21/24 (see above). The SSD said the IDT met after the incident on 10/21/24.

The SSD said she did not see an addition to Resident #4's care plan for behavior monitoring after it was referenced in the IDT progress note on 10/23/24. The SSD said she could not find any notes about an IDT meeting after the 11/21/24 incident. The SSD said she did not see evidence that Resident #4's care plan was updated for behaviors to include his physically aggressive behavior until 12/23/24, four weeks after the 11/21/24 incident.

The SSD said Resident #4 had prior physical aggression incidents more than a year ago. The SSD said she thought the care plan related to aggressive behaviors had been resolved since there had not been further incidents until recently. The SSD said Resident #4's triggers for his behaviors were added on 12/23/24.

LPN #1 was interviewed on 1/6/25 at 2:00 p.m. LPN #1 said Resident #4 liked to have his way and was very particular about many things. LPN #1 said she was unaware Resident #4 and Resident #6 had an altercation

on 11/21/24.

CNA #4 was interviewed on 1/6/25 at 2:15 p.m. CNA #4 said he witnessed the altercation between Resident #4 and Resident #6 on 11/21/24. CNA #4 said he was talking with Resident #6 in the hallway outside of Resident #4's room. CNA #4 said Resident #4 became annoyed and stood up from his wheelchair. CNA #4 said Resident #4 grabbed Resident #6's shirt and then Resident #6 pushed him back. CNA #4 said Resident #4 had yelled at other residents before.

CNA #2 was interviewed on 1/6/25 at 3:15 p.m. CNA #2 said she was not aware of any resident-to-resident altercations involving Resident #4 and she was not aware of any triggers that would make him upset.

The SSD, the NHA and the RDQC were interviewed together on 1/6/25 at 3:21 p.m. The RDQC said she was trying to determine if Resident #4's care plan information had been lost due to technical issues.

The SSD and the NHA said there should have been more information added to Resident #4's care plan related to his behaviors after the 10/21/24 altercation with Resident #5.

The RDQC said a medication review for Resident #4 was requested on 11/21/24, as there was concern a medication change might have contributed to his behavior issues.

The NHA said residents' behavior care plan should be updated within a week of a resident-to-resident incident.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 26 065170 Department of Health & Human Services Printed: 09/11/2025 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 065170 B. Wing 01/07/2025

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

South Platte Rehabilitation and Nursing LLC 2200 Edison St Brush, CO 80723

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 -However, the care plan for Resident #4's physically aggressive behavior was not initiated until 12/23/24 (see above). Level of Harm - Actual harm CNA #3 was interviewed on 1/7/25 at 10:34 a.m. CNA #3 said Resident #4 was triggered for behaviors if Residents Affected - Few other residents made comments to him. CNA #3 said she was aware of recent altercations between Resident #4 and other residents. She said Resident #4 was told to watch what he said to other residents, but

she said she was not aware of any other behavioral interventions initiated for Resident #4. She said one of

the residents was told to be aware of the scheduled times for supervised smoker breaks (as Resident #4 was

a smoker) to avoid Resident #4.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 11 of 26 065170 Department of Health & Human Services Printed: 09/11/2025 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 065170 B. Wing 01/07/2025

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

South Platte Rehabilitation and Nursing LLC 2200 Edison St Brush, CO 80723

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 0659 Provide care by qualified persons according to each resident's written plan of care.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 19262 potential for actual harm Based on observations, record review and interviews, the facility failed to ensure resident assessments were Residents Affected - Some provided by qualified persons for three (#8, #3 and #5) of eight residents out of eight sample residents.

Specifically, the facility failed to:

-Ensure Resident #8 and Resident #3, who experienced unwitnessed falls, were assessed by a registered nurse (RN) before they were assisted from the floor; and,

-Ensure Resident #5, who was the victim of resident-to-resident physical abuse, was assessed by a RN following the resident-to-resident altercation.

Findings include:

I. Failed to have a RN assess Resident #8 and Resident #3 after unwitnessed falls, prior to assisting the residents from the floor

A. Facility policy and procedure

The Falls - Clinical Protocol policy, revised 10/2012, was provided by the regional director of quality and compliance (RDQC) on 1/6/25 at 11:59 a.m. The policy revealed as part of the initial assessment, nursing staff would identify individuals with a history of falls and risk factors for subsequent falling. Staff would ask

the resident or resident's representative about a history of falling. While many falls were isolated individual incidents, a significant proportion occurred among a few residents. Those individuals might have a treatable medical disorder or functional disturbance as the underlying cause.

The staff would document risk factors for falling in the resident's record and address the resident's fall risk factors with appropriate interventions in the resident's plan of care. The staff would evaluate and document falls that occurred on an incident report form, for example, when/where they happened, and any

observations of the events. Staff should categorize falls as unwitnessed, witnessed, or assisted.

For an individual who had fallen, the interdisciplinary team (IDT) would complete an evaluation to identify the root cause and recommend appropriate new interventions to address risk factors of falling. Causes referred to factors that were associated with or that directly resulted in a fall, for example, a balance problem caused by an old or recent stroke. Multiple factors in varying degrees might contribute to a falling problem. If the cause of a fall was unclear, if the fall might have a significant medical cause such as a stroke or an adverse drug reaction (ADR), or if the individual continued to fall despite attempted interventions, it might be appropriate to ask the attending physician to review the situation and help identify contributing causes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 12 of 26 065170 Department of Health & Human Services Printed: 09/11/2025 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 065170 B. Wing 01/07/2025

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

South Platte Rehabilitation and Nursing LLC 2200 Edison St Brush, CO 80723

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 0659 Nursing staff should initiate post-fall assessments after a fall occurred. Staff should complete an assessment to look for new injuries, changes in range of motion, complaints of pain or other adverse clinical changes Level of Harm - Minimal harm or related to the fall. potential for actual harm For unwitnessed falls or falls wherein the resident hit their head, staff should complete neurological and vital Residents Affected - Some sign checks according to the facility's neurological assessment flowsheet. Staff should initiate alert charting

on each nursing shift for 72 hours or longer as indicated, wherein each nurse evaluates for adverse changes related to the fall and the efficacy of current fall interventions.

-However, the policy did not specify that a RN should do an assessment of the resident before the resident was moved from off the floor for unwitnessed falls.

B. Resident #8

1. Resident status

Resident #8, age greater than 65, was admitted on [DATE REDACTED] and readmitted on [DATE REDACTED]. According to the January 2025 computerized physician orders (CPO), diagnoses included displaced intertrochanteric fracture of the left femur, subsequent encounter for a closed fracture with routine healing, fracture of the right femur, fracture of the head/neck of the right femur, anxiety and chronic diastolic (congestive) heart failure.

The 12/27/24 minimum data set (MDS) assessment revealed Resident #8 had a moderate cognitive impairment with a brief interview for mental status (BIMS) score of 12 out of 15. The resident used a walker and/or a wheelchair.

The resident had impairment on one side of the lower extremities (hip, knee, ankle or foot). The resident required substantial/maximal staff assistance for sit to stand (the ability to come to a standing position from a sitting position for a chair, wheelchair or on the side of the bed.

2. Record review

The fall risk assessment dated [DATE REDACTED] at 2:02 p.m., revealed a score of 16, which indicated the resident was

a high fall risk

Resident #8's care plan for being at risk for falls due to a history of falls, a fall with a fracture, cognition impaired safety awareness, and medication side effects was initiated on 4/3/24 and revised on 1/2/25. Interventions included to ensure the resident's call light was within reach, encourage the resident to use the call light for assistance as needed, ensure the resident's high/low bed was in the lowest position while in bed, ensure the resident was wearing appropriate footwear when ambulating and the resident had been provided

a walkie talkie for use in the dining room to contact staff (this was the location the resident spent most of her day and a call light was not available in this area). Staff were to review information on past falls and attempt to determine the cause of the falls, document the possible root causes, alter/remove any potential causes, if possible and educate the resident/family/caregivers/ and the interdisciplinary team as to the causes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 26 065170 Department of Health & Human Services Printed: 09/11/2025 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 065170 B. Wing 01/07/2025

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

South Platte Rehabilitation and Nursing LLC 2200 Edison St Brush, CO 80723

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 0659 An incident report, dated 12/20/24 at 8:20 p.m., for an unwitnessed fall, was written by licensed practical nurse (LPN) #3 .The report revealed a call light went off in Resident #8's room. A certified nurse aide (CNA) Level of Harm - Minimal harm or went down to see what the resident needed and found the resident on the floor. The CNA went to go get a potential for actual harm nurse. A nurse asked the resident how she ended up on the floor. The resident said everything slipped. The nurse asked a second time how the resident ended up on the floor and the resident asked if she had broken Residents Affected - Some her back. A RN was called from the other side of the facility to do an assessment. LPN #3 and the CNA got Resident #8 from off the floor and into her chair and the resident had no complaints.

After LPN #3 and the CNA had assisted Resident #8 back into her chair, the RN walked into the room. The resident started to say it hurts and she was not going to therapy the next day. Resident #8 had a skin tear to

the left elbow and the RN was unable to determine the left hip trochanter (hip) condition. The resident was sent to the emergency department to be evaluated.

The county hospital near the facility admitted Resident #8 on 12/20/24 at 8:24 p.m., with a chief complaint of falling out of a wheelchair to the ground and a complaint of left hip pain. The resident apparently had a low mechanism fall out of a wheelchair and had acute pain in the left hip and femur regions. The diagnosis was a left hip fracture and the resident would be transferred to another hospital with a higher level of care. The resident was discharged to the second hospital on 12/21/24 at 12:54 a.m.

A situation, background, assessment, recommendation (SBAR) note, dated 12/20/24 at 8:56 p.m., revealed

the resident had a change in condition related to a fall. The nursing observations, evaluation and recommendations revealed the resident fell with no injury and was sent to the emergency department because the resident started complaining of pain.

A nurse note, dated 12/20/24 at 11:58 p.m., revealed the nurse spoke with the hospital and the resident broke her hip and was being transferred to another hospital for treatment.

The second hospital admitted the resident on 12/21/24 at 2:13 a.m. The chief complaint was left hip pain from a fall. Resident #8 was transferred to the second hospital from the previous hospital secondary to a left intertrochanteric hip fracture. The resident said she was helping her roommate in the bathroom when she fell

on her left side. The resident said she was unable to get up from off the floor due to sharp pain that was constant, which was at least an 8 or 9 out of 10 on a 1-10 pain scale. The musculoskeletal assessment revealed good muscle mass, tone, strength, normal range of motion, except for the left hip, which had pain

on ranges of motion.

An IDT event review, dated 12/23/24 at 10:28 a.m., revealed Resident #8 had a fall on 12/20/24 due to weakness and poor gait. The resident was sent to the emergency department for an evaluation and treatment.

A skilled charting note, dated 12/24/24 at 2:24 p.m., revealed Resident #8 returned from hospital. The resident was confused at times, which appeared to be related to post surgical effects. The resident was able to make her needs known.

A nurse note, dated 12/2024 at 8:52 p.m. and written by a LPN, revealed Resident #8 fell on to the floor on her left side, had a skin tear on her left elbow and was at the emergency department getting x-rays done to make sure nothing was broken.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 26 065170 Department of Health & Human Services Printed: 09/11/2025 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 065170 B. Wing 01/07/2025

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

South Platte Rehabilitation and Nursing LLC 2200 Edison St Brush, CO 80723

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 0659 -Review of Resident #8's electronic medical record (EMR) did not reveal that a RN assessed the resident

after the unwitnessed fall on 12/20/24 at 8:20 p.m., prior to the resident being assisted by staff from off the Level of Harm - Minimal harm or floor to a chair. The resident sustained a left hip fracture from the fall. potential for actual harm 3. Staff interviews Residents Affected - Some LPN #1 was interviewed on 1/7/25 at 10:10 a.m. LPN #1 said a RN should perform an assessment on a resident for an unwitnessed fall, before the resident was moved from off the floor. She said the assessment was out of the scope of practice of a LPN.

LPN #2 was interviewed on 1/7/25 at 11:06 a.m. LPN #2 said a RN must assess a resident who had an unwitnessed fall before the resident was moved from off the floor. She said the complete resident assessment was not in the scope of practice of an LPN.

RN #1 was interviewed on 1/7/25 at 11:27 a.m. RN #1 said a RN should do an assessment of a resident that had an unwitnessed fall before the resident was moved from off the floor. She said the complete resident assessment was not in the scope of practice of an LPN.

The nursing home administrator (NHA), the director of nursing (DON), the assistant director of nursing (ADON) and the RDQC were interviewed on 1/7/24 at 1:04 p.m. The NHA, the DON, the ADON and the RDQC said Resident #8 had an unwitnessed fall on 12/20/24 at 8:20 p.m. and was sent to the emergency department for evaluation and treatment. The NHA, the DON, the ADON and the RDQC said the resident received a diagnosis of a left hip fracture.

The NHA, the DON, the ADON and the RDQC said LPN #3 and a CNA moved Resident #8 off the floor,

before a RN did an assessment of the resident. The NHA, the DON, the ADON and the RDQC said a RN should do an assessment of a resident with an unwitnessed fall, prior to the resident being moved from off

the floor.

The DON said it was not in the LPN's scope of practice to conduct an assessment of a resident after an unwitnessed fall. She said LPN #3, who moved the resident off the floor, received an in-service on falls on 12/23/24.

C. Resident #3

1. Resident status

Resident #3, age greater than 65, was admitted on [DATE REDACTED] and discharged home on 11/13 24. According to

the November 2024, CPO, diagnoses included stable burst fracture of T9-T10 (thoracic) vertebra, subsequent encounter for fracture with routine healing, mechanical complication of internal fixation device of vertebrae, protein-calorie malnutrition and pneumonia.

The 11/13/24 MDS assessment revealed Resident #3 was cognitively intact with a BIMS score of 15 out of 15. The resident used a manual wheelchair. The resident had no impairments in either the upper or the lower extremities. The resident required substantial/maximal staff assistance for sit to stand (the ability to come to

a standing position from a sitting position for a chair, wheelchair or on the side of the bed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 26 065170 Department of Health & Human Services Printed: 09/11/2025 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 065170 B. Wing 01/07/2025

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

South Platte Rehabilitation and Nursing LLC 2200 Edison St Brush, CO 80723

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 0659 2. Record review

Level of Harm - Minimal harm or The baseline admission care plan, dated 11/10/24, revealed the resident was at risk for falls. The resident potential for actual harm did not have any falls within the last two to six months prior to admission to the facility. The interventions included anticipating/meeting the resident's needs, keeping frequently used items within reach, Residents Affected - Some educating/encouraging the resident to wear appropriate footwear, such as non-skid socks or shoes when ambulating, educating the resident/family/caregiver regarding safety reminders and what to do if a fall occurred, following the facility policy if a fall occurred, orienting the resident to the call light, keeping the resident's call light within reach, encouraging the resident to use the call light and referring the resident to therapy for evaluation/treatment as indicated to address the resident's fall risk.

A care plan for the resident being at risk for fall related to an actual fall, impaired mobility and recent surgery was initiated on 11/12/24. Interventions included for staff to anticipate and meet the resident's needs, keep frequently used items within reach, keep the resident's call light within reach and encourage the resident to use it for assistance as needed, educate and encourage the resident to wear appropriate footwear, such as non-skid socks or shoes, when ambulating/mobilizing, educate the resident/family/caregivers about safety reminders and what to do if a fall occurs and follow facility fall protocol if a fall occurred and offer the resident

a bedside commode.

The incident report, dated 11/11/24 at 10:48 p.m. and written by LPN #3 for an unwitnessed fall, revealed LPN #3 went down to Resident #3's room because her call light went off and the CNA was working in another room. LPN #3 opened the door and the resident was on the floor. LPN #3 asked Resident #3 if anything hurt. The resident said no, but she hit her elbow. LPN #3 looked at the resident's elbow and there was no bleeding, however there was a small bruise. LPN #3 and a CNA helped the resident from the floor and back into bed. The nurse observed a skin tear on the resident's right knee. The skin tear was washed and a one centimeter (cm) by one cm bandage was placed on the skin tear.

A RN came and assessed Resident #3 after the resident was assisted from the floor by LPN #3 and the CNA.

The fall occurred when Resident #3 went to the bathroom and slipped on the floor. The resident wore socks with sticky pads on the bottom of the socks. The resident said that she went to the bathroom after pressing her call light and no staff came. The resident was oriented to person, place, situation and time.

A weekly skin check assessment, dated 11/11/24 at 11:04 p.m., revealed Resident #3 had a skin tear to the right knee, a bruise to the right elbow and symptoms of a wound to the lower back area measuring approximately one foot long.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 26 065170 Department of Health & Human Services Printed: 09/11/2025 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 065170 B. Wing 01/07/2025

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

South Platte Rehabilitation and Nursing LLC 2200 Edison St Brush, CO 80723

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 0659 A nurse note, dated 11/11/24 at 10:30 p.m., revealed this nurse (LPN #3) was notified of Resident #3's fall at 10:25 p.m. LPN #3 went into the resident's room to assess the resident. The resident was alert/orientated Level of Harm - Minimal harm or times four and appeared to be at baseline in mental status. The resident said she did not want to wait for potential for actual harm assistance and got up to go to the restroom on her own. The resident said she had to grab onto the sink to keep from falling onto the floor. The resident said she landed on the right side of her body. Observations Residents Affected - Some revealed old and new bruising to the right elbow. A bandaid was observed to the resident's right lower leg.

The resident said she had a small cut from a fall and a nurse had placed a bandaid over the area. The resident complained of neck pain and lower back pain that was normal due to spinal fashion. The resident had no other apparent injuries observed.

A nurse note, dated 11/11/24 at 11:01 p.m., revealed Resident #3 fell on to the floor. The resident had a skin tear to right leg and a bruise to right elbow. The DON, a RN and the physician were notified.

The IDT event review note, dated 11/12/24 at 9:51 a.m., revealed Resident #3 had an unwitnessed fall on 11/11/24 related to poor safety awareness. The facility treated the skin tear and started neurological assessments. An intervention put in place was an in-room commode. There were no new physician orders.

-Review of Resident #3's EMR did not reveal that a RN assessed the resident after the unwitnessed fall on 11/11/24 at 10:25 p.m., prior to the resident being assisted by staff from off the floor.

3. Staff interviews

The NHA, the DON, the ADON and the RDQC were interviewed on 1/7/24 at 1:25 p.m. The NHA, the DON,

the ADON and the RDQC said Resident #3 had an unwitnessed fall on 11/11/24 at 10:25 p.m. The NHA, the DON, the ADON and the RDQC said LPN #3 and a CNA moved the resident off the floor before a RN assessed the resident.

The DON said a RN should have completed an assessment before Resident #3 was moved off the floor. The DON said the resident was not sent to the hospital after the fall.

50853

II. Failed to ensure a RN assessed Resident #5 following a resident-to-resident altercation

A. Resident #5

1. Resident status

Resident #5, age less than 65, was admitted on [DATE REDACTED]. According to the January 2025 CPO, diagnoses included acute infarction of the spinal cord (spinal cord stroke causing pain or loss of sensation in the back down to legs), occipital neuralgia (pain or loss of sensation in the back of the head and neck), anxiety disorder, hypertension (high blood pressure) and type 2 diabetes mellitus.

The 10/23/24 MDS assessment revealed the resident was cognitively intact with a BIMS score of 15 out of 15. She was independent with personal hygiene, dressing and transfers. She did not walk but was independent with mobility using a wheelchair.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 26 065170 Department of Health & Human Services Printed: 09/11/2025 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 065170 B. Wing 01/07/2025

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

South Platte Rehabilitation and Nursing LLC 2200 Edison St Brush, CO 80723

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 0659 2. Resident interview

Level of Harm - Minimal harm or Resident #5 was interviewed on 1/6/25 at 9:06 a.m. Resident #5 said another resident rammed into her potential for actual harm wheelchair in the hallway in October 2024. Resident #5 said she believed she had whiplash from the incident when she was jolted back in her wheelchair. She said she had a tight knot in the back of her neck for a while Residents Affected - Some afterwards and had to have physical therapy to relieve the tightness.

3. Record review

The 10/21/24 incident report was provided by the RDQC on 1/7/25 9:14 a.m. The report documented LPN #1 was informed another resident purposely collided into Resident #5 while both residents were seated in their wheelchairs. Resident #5 reported her right arm was jarred and LPN #1 documented a 0.5 centimeter (cm) by 0.5 cm abrasion on her right forearm where the top layer of skin had come off. Resident #5 reported her left lower leg above the ankle hit the wheel of her wheelchair. LPN #1 documented redness to the skin above

the resident's left ankle.

The abuse investigation report, dated 10/21/24 at approximately 2:37 p.m., documented another resident ran into Resident #5 who was in the hallway seated in her wheelchair. CNA #1 separated the residents and called LPN #1 for assistance. Resident #5 was assessed by LPN #1 and did have physical injuries, including redness to the left lower leg above the ankle and an abrasion to her right forearm where the top layer of skin had come off. The abuse investigation included an interview with Resident #5. She said another resident wheeled right into her with his legs hitting hers. Resident #5 said the impact threw her back in her wheelchair causing right shoulder and leg pain.

Cross-reference