Heritage Park Care Center

F-F550 dignity: The facility failed to ensure care for residents in a manner and in an environment that maintains or enhances each resident's dignity and respect.

Cross-reference

F-F645 Preadmission Screening and Resident Review (PASRR) Level I: The facility failed to ensure a PASRR Level I screening was completed within thirty days of admission.

Cross-reference

F-F655 baseline care plans: The facility failed to develop and implement acute/baseline care plans.

Cross-reference

F-F677 activities of daily living for dependent residents: The facility failed to provide appropriate treatment and services to maintain or improve residents' ability to perform activities of daily living.

Cross-reference

F-F684 quality of care: The facility failed to ensure that residents received treatment and care

in accordance with professional standards of practice.

Cross-reference

F-F685 treatment or devices to maintain hearing and vision: The facility failed to ensure proper treatment and services to maintain hearing.

Cross-reference

F-F688 range of motion: The facility failed to ensure residents with limited mobility reviewed for range of motion (ROM) received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 58 065237 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 065237 B. Wing 08/29/2024

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

Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623

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 0867 Cross-reference

F-F692 nutrition and hydration: The facility failed to ensure effective interventions were in place to address weight loss timely. Level of Harm - Minimal harm or potential for actual harm Cross-reference

F-F695 respiratory: The facility failed to ensure residents received proper respiratory treatment and care. Residents Affected - Many Cross-reference

F-F758 unnecessary psychotropic medications: The facility failed to ensure residents were as free from unnecessary psychotropic drugs as possible.

Cross-reference

F-F804 palatable food: The facility failed to ensure residents were provided with food cooked and served in a manner that conserved nutritive value, flavor, appearance, texture and at an appetizing temperature.

Cross-reference

F-F812 kitchen sanitation: The facility failed to prepare and serve food in a sanitary manner.

III. Staff interviews

The nursing home administrator (NHA) and regional vice president (RVP) were interviewed together on 8/29/24 at 7:43 p.m.

The NHA said the facility did not invite floor staff, residents or family members to their QAPI meetings or for feedback but the facility wanted to. She said the facility had not accomplished getting others involved in the QAPI meetings.

The NHA said dignity, baseline care plans, positioning residents, restorative services, weight loss, oxygen canisters, as-needed psychotropic medications, PASRR Level I screens, palatable food and kitchen sanitation were not identified by the QAPI team as areas for improvement.

The NHA said hand hygiene and infection control were always watched as an area for improvement but resident hand hygiene and appropriate cleaning of resident rooms were not identified as an area for improvement until the annual recertification survey.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 58 065237 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 065237 B. Wing 08/29/2024

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

Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623

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 0867 The NHA said the QAPI team needed to create a performance improvement plan (PIP) and complete audits to better identify areas for improvement. The NHA said the facility completed random spot checks with staff Level of Harm - Minimal harm or and she wanted to increase spot checks. She said the facility needed more eyes on the floor to identify areas potential for actual harm for improvement. She said the facility focused on bigger areas of concern for improvement and the little areas were missed. The NHA said there was a lot of turnover in leadership which caused a breakdown in the Residents Affected - Many system. She said the QAPI system worked but the QAPI team needed to re-evaluate, not just focusing on

the bigger areas of concern but all areas that could affect the care the facility provided the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 58 065237 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 065237 B. Wing 08/29/2024

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

Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623

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** 50314 potential for actual harm Based on observations, record review and interviews, 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 possible development and transmission of infectious diseases.

Specifically, the facility failed to:

-Ensure housekeeping staff cleaned high touch areas in residents' rooms; and,

-Ensure staff followed appropriate hand hygiene practices.

Findings include:

I. Housekeeping failures

A. Professional reference

The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (3/19/24) was retrieved on 9/5/24 from https://www.cdc. gov/healthcare-associated-infections/hcp/cleaning-global/appendix-c.html. It read in pertinent part,

High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility.

Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs.

Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms. Examples include: during terminal cleaning, clean low-touch surfaces before high-touch surfaces, clean patient areas (patient zones)

before patient toilets, within a specified patient room, terminal cleaning should start with shared equipment and common surfaces, then proceed to surfaces and items touched during patient care that are outside of

the patient zone, and finally to surfaces and items directly touched by the patient inside the patient zone. In other words, high-touch surfaces outside the patient zone should be cleaned before the high-touch surfaces inside the patient zone and clean general patient areas not under transmission-based precautions before those areas under transmission-based precautions.

B. Facility policy

The Daily Room Cleaning policy, reviewed 6/12/24, was received from the regional director of clinical services (RDCS) #1 on 8/29/24 at 2:10 p.m. It read in pertinent part, The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 58 065237 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 065237 B. Wing 08/29/2024

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

Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623

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 policy did not specify that high touch surface areas should be cleaned

Level of Harm - Minimal harm or C. Observations potential for actual harm

On 8/27/24 at 8:37 a.m. housekeeper (HSKP) #1 was observed cleaning room [ROOM NUMBER]. Residents Affected - Some -The call light cords in the resident's room and the resident's bathroom were not cleaned by HSKP #1 during

the room cleaning process.

-the door handles to the resident's room and the resident's bathroom were not cleaned by HSKP #1 during

the room cleaning process.

On 8/29/24 at 9:14 a.m. HSKP #2 was observed cleaning room [ROOM NUMBER].

-The call light cords in the resident's room and the resident's bathroom were not cleaned by HSKP #2 during

the room cleaning process.

-The door handles to the resident's room and the resident's bathroom were not cleaned by HSKP #2 during

the room cleaning process.

D. Staff interviews

HSKP #1 was interviewed on 8/27/24 at 8:55 a.m. HSKP #1 said call light cords and door handles should be cleaned daily because they were high touch surfaces. HSKP #1 said she cleaned the call light cords during

the room cleaning she completed in room [ROOM NUMBER].

-However, HSKP #1 failed to clean either residents' call light, the bathroom call light or the door handles to

the room or the bathroom in room [ROOM NUMBER] (see observation above).

-Additionally, the director of housekeeping (DHK) said HSKP #1 reported to her she had not cleaned the resident call lights during the room cleaning in room [ROOM NUMBER] on 8/27/24 (see DHK interview below).

HSKP #2 was interviewed on 8/29/24 at 9:35 a.m., utilizing a spanish-speaking interpreter. HSKP #2 said

she did not clean the residents' call lights , the call light in the bathroom or the room and bathroom door knobs in room [ROOM NUMBER].

The DHK was interviewed on 8/29/24 at 12:40 p.m. The DHK said call light cords, door handles, drawer handles and cabinet handles were high-touch surface areas that should be cleaned everyday. The DHK said

she had previously spoken to housekeeping staff about the importance of cleaning high-touch surfaces as part of the daily cleaning. The DHK said HSKP #1 told her she did not clean the resident's call light cords or

the call light cord in the bathroom during the room cleaning observation that occurred on 8/27/24 in room [ROOM NUMBER].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 58 065237 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 065237 B. Wing 08/29/2024

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

Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623

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 infection preventionist (IP) and the director of nursing (DON) were interviewed together on 8/29/24 at 3:19 p.m. The IP said the resident call lights and door handles should be cleaned because they were Level of Harm - Minimal harm or considered high touch surfaces that could transmit infections. The IP said resident call light cords and door potential for actual harm handles should be cleaned every day. The DON said call lights and door handles should be cleaned daily.

Residents Affected - Some II. Hand hygiene failures

A. Professional reference

The CDC Clinical Safety: Hand Hygiene for Healthcare Workers, (2/27/24) was retrieved on 9/5/24 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html. It read in pertinent part,

Hand hygiene protects both healthcare personnel and patients. Hand hygiene means cleaning your hands by handwashing with water and soap (plain soap or with an antiseptic), using an antiseptic hand rub (alcohol-based foam or gel hand sanitizer), or performing surgical hand antisepsis.

Cleaning your hands reduces the potential spread of deadly germs to patients, the spread of germs, including those resistant to antibiotics, and the risk of healthcare personnel colonization or infection caused by germs received from the patient.

Some healthcare personnel may need to clean their hands as often as 100 times during a work shift to keep themselves, patients and staff safe.

B. Facility policy

The Hand Hygiene policy, reviewed 8/19/24, was received from the regional vice president (RVP) on 8/29/24 at 6:49 p.m. It read in pertinent part, Hand hygiene using an alcohol-based hand rub is appropriate before direct patient contact and after contact with inanimate objects in the patient's environment.

C. Observations

On 8/28/24 at 9:49 a.m, registered nurse (RN) #1 entered room [ROOM NUMBER]. RN #1 knocked on the door, opened the door and touched the resident's call light in the room. RN #1 left the room and began to prepare medications for another resident at the medication cart.

-RN #1 failed to perform hand hygiene before entering room [ROOM NUMBER].

-RN #1 failed to perform hand hygiene after interacting with the resident's environment in room [ROOM NUMBER].

On 8/28/24 at 10:45 a.m., certified nurse aide (CNA) #1 was observed assisting Resident #33 to the restroom.

-CNA #1 failed to offer Resident #33 hand hygiene after assisting her in the bathroom.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 58 065237 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 065237 B. Wing 08/29/2024

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

Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623

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 On 8/29/24 at 10:31 a.m., CNA #2 was passing clean water cups to residents in their rooms. CNA #2 entered several residents' rooms and replaced the residents' used water cups with clean cups. CNA #2 performed Level of Harm - Minimal harm or hand hygiene after passing clean water to several rooms. potential for actual harm -However, CNA #2 failed to perform hand hygiene before entering and after exiting each residents' rooms. Residents Affected - Some -CNA #2 failed to perform hand hygiene after her hands became contaminated by touching used resident water cups.

D. Staff interviews

The IP and the DON were interviewed together a second time on 8/29/24 at 3:19 p.m. The IP said staff should perform hand hygiene before entering a resident's room, when they were leaving a resident's room and in between cares in the resident's room as appropriate. The IP said staff should offer to wash a resident's hands after assisting the resident to the bathroom. The IP said staff should wash their hands after interacting with a resident's environment in their room.

The DON said nursing staff should offer hand hygiene to residents after they were assisted to the bathroom for toileting.

The IP said it was important to promote hand hygiene to prevent the spread of infection in the facility.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 58 065237 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 065237 B. Wing 08/29/2024

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

Heritage Park Care Center 1200 Village Rd Carbondale, CO 81623

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 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Level of Harm - Minimal harm or potential for actual harm 50314

Residents Affected - Few Based on interviews and record review, the facility failed to ensure certified nurse aides (CNA) received at least 12 hours of annual in-service training that also included dementia management training and resident abuse prevention training to ensure continued competence for two out of five certified nurse aides (CNA) reviewed.

Specifically, the facility failed to ensure CNA #2 and CNA #3 received 12 hours of continuing education annually.

Findings include:

I. Training record review

Five randomly selected CNA training records were reviewed on 8/27/24. Of the five CNAs reviewed, CNA #2 and CNA #3 did not receive 12 hours of annual training.

A. CNA #2

-CNA #2, hired on 6/22/22, had participated in 10 hours and 30 minutes of training during the annual training year.

B. CNA #3

-CNA #3, hired on 6/11/14, had participated in 10 hours and 30 minutes of training during the annual training year.

II. Staff interviews

The nursing home administrator (NHA) was interviewed on 8/28/24 at 11:27 a.m. The NHA said she kept the records for the annual staff training and verified that all of the staff members received appropriate training in

the facility. The NHA said she had recorded 10.5 hours of CNA training for CNA #2 and CNA #3, which also included dementia and abuse training. The NHA said it was important for CNAs to complete their annual training to stay updated on current bedside skills and education. The NHA said she would conduct an audit in

the facility to ensure all staff had completed training appropriately moving forward.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 58 065237

F-F880 infection control: The facility failed to maintain an infection control program designed to provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection.

Cross-reference