South Platte Rehabilitation And Nursing Llc

F 0659

NP #2, as this was not within her scope of practice. The DON said LPN #1 should have been communicating with NP #2 and receiving the physician's orders.

Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

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 0690 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

record review and interviews, the facility failed to provide catheter care in accordance with standards of professional practice for one (#3) of three residents out of 12 sample residents.Specifically, the facility failed to ensure the urinary catheter was changed timely for Resident #3. Findings include:I. Facility policy and procedureThe Catheter Care policy, dated 4/11/25, was provided by the chief nursing officer on 10/14/25 at 11:44 a.m. It read in pertinent part, It is the policy of this facility to ensure that residents with indwelling catheters receive appropriate catheter care and maintain their dignity and privacy when indwelling catheters are in use.II. Resident #3A.Resident statusResident #3, age greater than 65, was admitted on [DATE REDACTED]. According to the October 2025 computerized physician orders (CPO), the diagnoses included dementia and bladder neck distention (the bladder is enlarged due to the opening where the bladder connects to the urethra being blocked).The 9/25/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief interview for mental status (BIMS) score of 12 out of 15. He required set-up assistance with eating and partial/moderate assistance with oral hygiene. He was dependent on staff for activities of daily living (ADLs) including dressing, showering, toileting and mobility.

The 9/25/25 MDS assessment revealed the resident used an indwelling catheter.B. Record reviewResident #3's catheter care plan, initiated on 5/30/24 and revised on 9/5/25, revealed the resident had a suprapubic catheter. Pertinent interventions included documenting urinary output each shift, monitoring/recording/reporting to the physician any signs or symptoms of urinary tract infection (UTI), ensuring the catheter tubing was securely anchored to prevent accidental removal of the catheter and providing dressing changes to the suprapubic catheter site per the physician's orders.Review of Resident #3's October 2025 CPO revealed a physician's order for the following:Change the suprapubic catheter every month at the facility using an 18-French catheter, every night shift starting on the second and ending

on the second of every month, ordered 9/2/25 at 1:36 p.m. and revised on 10/2/25 at 6:00 p.m.Review of Resident #3's electronic medical record (EMR) revealed the suprapubic catheter was last changed by overnight staff on 9/2/25 per physician's order.A nursing progress note, dated 10/3/25, revealed the resident's catheter did not get changed during shift. The staff reached out to an on-call provider and received authorization to place a one time order for a suprapubic catheter change on the overnight shift for 10/3/25 to 10/4/25.-However, review of Resident #3's EMR did not reveal documentation indicating the resident's catheter had been changed since 9/2/25.III. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 10/13/25 at 1:48 p.m. LPN #1 said an indwelling catheter should be changed every 30 days. She said she knew that Resident #3's suprapubic catheter had been placed by urology in August

1. 2025. LPN #1 spent a few minutes searching the resident's EMR to find the date the suprapubic catheter

was last changed. She said she did not know when the urinary catheter was last changed.The director of nursing (DON) was interviewed on 10/15/25 at 1:12 p.m. The DON said she was aware Resident #3 had physician's orders for suprapubic catheter care and for the catheter to be changed monthly. She said the urinary catheter was supposed to be changed on the second, but she saw a note that said the nightshift staff member received a one time order for dayshift to change it. The DON said based on what she saw documented on the task administration record (TAR), she did not think the catheter change had been completed yet. She said if the urinary catheter was left indwelling for too long, there could be a chance of infection or the catheter might not work properly. The DON said the urinary catheter should not be placed and then never replaced or removed.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

10/15/2025

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 0695 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Few

FORM CMS-2567 (02/99) Previous Versions Obsolete

with Resident #2 was at 4:45 p.m. on [DATE REDACTED], when she checked the resident's blood pressure and talked about dinner. She said during that time, Resident #2 was not cyanotic or gasping at that time. LPN #1 said

she guessed it probably would have been her responsibility to switch Resident #2 from the portable canister to the oxygen concentrator. CNA #3 was interviewed on [DATE REDACTED] at 12:22 p.m. CNA #3 said she was working dayshift on [DATE REDACTED], but she only went into Resident #2's room for breakfast that morning. She said Resident #2 did not complain of any pain or shortness of breath at that time and the resident was really good at using her call light to let staff know if she needed something. CNA #3 said it was not routine to regularly round on residents who were on portable oxygen canisters. She said she did not know who should have been responsible for switching Resident #2 back to her oxygen concentrator when power was restored.The DON was interviewed again on [DATE REDACTED] at 1:12 p.m. The DON said someone should have checked on the portable oxygen canister. She said the portable oxygen canister was full when the SSD put Resident #2 on the portable oxygen tank, but nurses or CNAs should have been monitoring to ensure the canister did not run out of oxygen.

Event ID:

Facility ID:

If continuation sheet