Silver Heights Skilled Nursing And Rehabilitation

F-F758 for failure to ensure there was adequate justification prior to the prescription and administration of a psychotropic medication for Resident #259.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 31 065285 Department of Health & Human Services Printed: 08/31/2025 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 065285 B. Wing 04/03/2025

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

Silver Heights Skilled Nursing and Rehabilitation 4001 Home St Castle Rock, CO 80108

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 3/12/25 physician's progress note documented the physician saw Resident #259 in the hallway and he was confused and pleasant, ambulatory and seemed fairly steady. However the resident had a fall with some Level of Harm - Minimal harm or skin tears the night before last. It indicated the staff were not reporting any other issues. potential for actual harm

The 3/13/25 progress note, documented at 6:04 p.m., revealed Resident #259 was found in the hallway, Residents Affected - Few lying down on the floor. The resident was not able to state what happened. A hematoma (bruise) was observed on the left side of his forehead and he had small skin tears on both hands. The facility contacted Resident #259's physician to evaluate medications for restlessness and agitation.

The 3/13/25 IDT review documented Resident #259 had an unwitnessed fall and was found in the hallway, lying down. The resident was unable to give a statement about what happened. The intervention included the physician was to review all medications for restlessness and agitation.

-However, a review of the resident's EMR did not indicate episodes of restlessness or agitation until after the falls occurred.

The 3/14/25 nurse practitioner progress note documented Resident #259 had a fall on the evening of 3/13/25 resulting in a large hematoma to his left forehead and eye. Hospice suggested Seroquel nightly.

The 3/16/25 nursing progress note, documented at 11:55 p.m., revealed Resident #259 was observed in the hallway, lying on the floor beside his wheelchair. The resident reported a skin tear to his right forearm and was assisted back to the wheelchair by two staff members. The resident was taken to the nursing station to watch television and be supervised by staff.

The 3/20/25 IDT review documented the resident sustained two falls. The recommendation was for hospice to come and evaluate the resident for noted increased restlessness and agitation. Hospice started the resident on Seroquel 50 milligram (mg) at night.

-However, a review of the resident's EMR did not indicate episodes of restlessness or agitation until after the falls occurred.

-A review of the resident's EMR on 4/2/25 did not reveal documentation that the facility had identified the root cause of Resident #259's restlessness, there were not any non-pharmacological interventions put into place by the facility and there was no documentation or care plan to indicate the resident had any hallucinations or behavioral concerns to justify the immediate use of the Seroquel following Resident #259's falls.

III. Staff interviews

Certified nurse aide (CNA) #1 was interviewed on 4/3/25 at 1:45 p.m. CNA #1 said Resident #259 required maximum assistance with transfers because he was unable to hold his balance. CNA #1 said Resident #259 was unable to get up by himself most of the time, but a few times he was able to get up without assistance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 31 065285 Department of Health & Human Services Printed: 08/31/2025 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 065285 B. Wing 04/03/2025

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

Silver Heights Skilled Nursing and Rehabilitation 4001 Home St Castle Rock, CO 80108

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 #1 said he thought Resident #259 had sustained recent falls because he wanted and needed to move.

He said the facility staff kept the door open to Resident #259's room as much as possible to keep an eye on Level of Harm - Minimal harm or him. potential for actual harm Registered nurse (RN) #1 was interviewed on 4/3/25 at 2:31 p.m. RN #1 said she was unaware Resident Residents Affected - Few #259 had sustained any recent falls. She said she was an agency nurse. She said she had not been informed Resident #259 was a fall risk.

RN #1 said Resident #259 had dementia, but she never witnessed the resident having any hallucinations or behaviors. She said she was unaware of the fall interventions for Resident #259.

The NHA and the director of nursing (DON) were interviewed together on 4/3/25 at 4:18 p.m. The DON said

she was not aware of Resident #259 having any hallucinations or psychosis prior to or after the recent falls.

She said she was unable to find documentation of non-pharmacological interventions that were put in place following the falls and prior to the ordering and administration of Seroquel, an anti-psychotic medication. She said she was not sure why Resident #259 was up early in the morning or late at night, but she would have guessed it was because of the progression of his disease. She said she was unable to find documentation that the facility had determined the root cause of the resident's restlessness of getting up without assistance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 16 of 31 065285 Department of Health & Human Services Printed: 08/31/2025 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 065285 B. Wing 04/03/2025

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

Silver Heights Skilled Nursing and Rehabilitation 4001 Home St Castle Rock, CO 80108

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 0761 Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately Level of Harm - Minimal harm or locked, compartments for controlled drugs. potential for actual harm 47350 Residents Affected - Some Based on observations and interviews, the facility failed to ensure all drugs and biologicals were properly stored and labeled in accordance with professional standards in one of one medication storage rooms.

Specifically, the facility failed to ensure Tubersol (tuberculin purified protein derivative), Hepatitis B vaccine, Prevnar (pneumococcal vaccine), Fluzone (influenza vaccine), Spikevax (COVID-19 vaccine) and Basaglar insulin pens were stored within the appropriate medication storage refrigerator temperature guidelines.

Findings include:

I. Professional reference

According to The Centers for Disease Control and Prevention (CDC) (3/29/24) Vaccine Storage and Handling Toolkit, retrieved on 4/8/25 from https://www.cdc. gov/vaccines/hcp/downloads/storage-handling-toolkit.pdf,

If the cold chain is not properly maintained, vaccine potency may be lost, resulting in an unusable vaccine supply.

According to the Sanofi Pasteur (2020) package insert for Tuberculin Purified Protein Derivative (Mantoux): Tubersol Food and Drug Administration (FDA), retrieved on 4/8/25 from www.fda.gov/media/74866/download,

Store at 35 to 46 degrees Fahrenheit (F).

According to the Merck Vaccine (2024) Storage and Handling of Recombivax B (Hepatitis B) guidelines, retrieved on 4/8/25 from https://www.merckvaccines.com/recombivax-hb/storage-handling/#:~:text=Storage% 20and%20Handling%20for%20RECOMBIVAX%20HB%C2%AE%20[Hepatitis, DO%20NOT%20FREEZE%20since%20freezing%20destroys%20potency,

Store vaccine vials and syringes at 36 to 46 degrees Fahrenheit; storage above or below the recommended temperature may reduce potency.

According to the Moderna (2025) Spikevax (Covid 19) vaccine storage and handling guidelines, retrieved on 4/8/25 from https://products.modernatx.com/spikevaxpro/dosing-and-administration,

Store frozen between -50 degrees F to 5 degrees F.

Storage after thawing, store refrigerated between 36 degrees F to 46 degrees F for up to 60 days prior to use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 17 of 31 065285 Department of Health & Human Services Printed: 08/31/2025 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 065285 B. Wing 04/03/2025

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

Silver Heights Skilled Nursing and Rehabilitation 4001 Home St Castle Rock, CO 80108

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 0761 According to the Pfizer (January 2025) Prevnar 20 Storage and Handling Guidelines, retrieved on 4/8/25 from https://prevnar20adult.pfizerpro.com/administration, Level of Harm - Minimal harm or potential for actual harm Store refrigerated at 36 to 46 degrees F.

Residents Affected - Some According to the Sanofi Pasteur (July 2022) Fluzone Quadrivalent Influenza Vaccine Storage and Handling Guidelines, retrieved on 4/8/25 from https://www.fda.gov/media/119856/download,

Store at 35 to 46 degrees F.

According to Lilly (2024) Basaglar Insulin Pen Storage Guidelines, retrieved on 4/8/25 from https://insulins. lilly.com/basaglar,

Before insulin use: When you get your unused pens, your insulin should be refrigerated at 36 degrees F to 46 degrees F.

II. Facility policy and procedure

The Medication Labeling and Storage policy and procedure, revised February 2023, was provided by the nursing home administrator (NHA) on 4/3/25 at 7:18 p.m. It read in pertinent part,

If the facility has discontinued, outdated or deteriorated medications or biologicals, the dispensing pharmacy is contacted for instructions regarding returning or destroying these items.

III. Observations

On 4/3/25 at 1:25 p.m. the unit medication storage refrigerator was observed with the director of nursing (DON), who was also the facility's infection preventionist (IP). The medication storage refrigerator temperature was at 50 degrees F.

-The medication storage refrigerator was not within the safe refrigerated medication storage temperature range of 36 degrees F to 46 degrees F

The following items were found inside the medication storage refrigerator:

-A vial of Tubersol;

-A hepatitis B vaccine vial;

-A Prevnar 20 vaccine vial;

-A Fluzone influenza vaccine syringe;

-A Spikevax vaccine syringe; and,

-A Basaglar insulin pen.

IV. Staff interview

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 31 065285 Department of Health & Human Services Printed: 08/31/2025 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 065285 B. Wing 04/03/2025

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

Silver Heights Skilled Nursing and Rehabilitation 4001 Home St Castle Rock, CO 80108

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 0761 The DON was interviewed on 4/3/25 at 1:30 p.m. The DON said the medication storage refrigerator should be between 36 degrees F and 46 degrees F. She said the night shift nurses should check the refrigerator but Level of Harm - Minimal harm or there was no documentation that this was done. She said the facility did not have a refrigerator temperature potential for actual harm log. She said she did not know how long the refrigerator had been above the safe storage temperature range. She said she would have the maintenance director (MTD) look at the refrigerator. Residents Affected - Some

The DON was interviewed a second time on 4/3/25 at 4:20 p.m. The DON said the MTD was going to order a new medication storage refrigerator, since the current refrigerator did not seem to be holding the correct temperature.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 31 065285 Department of Health & Human Services Printed: 08/31/2025 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 065285 B. Wing 04/03/2025

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

Silver Heights Skilled Nursing and Rehabilitation 4001 Home St Castle Rock, CO 80108

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 0791 Provide or obtain dental services for each resident.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 51915 potential for actual harm Based on record review and interviews, the facility failed to assist residents to obtain routine or emergency Residents Affected - Few dental services, as needed, for one (#12) of one resident reviewed for ancillary services out of 30 sample residents.

Specifically, the facility failed to ensure a dental referral was followed upon timely for Resident #12.

Findings include:

I. Facility policy and procedure

The Resident Dental Services policy and procedure, dated December 2016, was provided by the nursing home administrator (NHA) on 4/3/25 at 4:30 p.m. It revealed in pertinent part, Routine and emergency dental services are available to meet the resident's oral health services in accordance with the resident's assessment and plan of care. Routine and 24-hour emergency dental services are provided to our residents through a contract agreement with a licensed dentist that comes to the facility monthly, referral to the resident's personal dentist, referral to community dentists, or referral to other health care organizations that provide dental services.

Social services representatives will assist residents with appointments, transportation, arrangements, and for reimbursement of dental services under the state plan, if eligible. Direct care staff will assist residents with denture care, including removing, cleaning, and storing dentures. If dentures are damaged or lost, residents will be referred for dental services within three days. If the referral is not made within three days, documentation will be provided regarding what is being done to ensure that the resident is able to eat and drink adequately while awaiting the dental services and the reason for the delay.

II. Resident #12

A. Resident status

Resident #12, age 66, was admitted on [DATE REDACTED] and readmitted on [DATE REDACTED]. According to the April 2025 computerized physician orders (CPO), diagnoses included bipolar disorder, left hemiplegia (paralysis on one side of the body) following cerebral infarction, major depressive disorder and post-traumatic stress disorder.

The 2/20/25 minimum data set (MDS) assessment revealed the resident was cognitively intact with a brief

interview for mental status (BIMS) score of 15 out of 15. She required maximum assistance with transfers and bed mobility and moderate assistance for bathing, toileting, dressing and personal hygiene.

B. Resident interview

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 31 065285 Department of Health & Human Services Printed: 08/31/2025 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 065285 B. Wing 04/03/2025

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

Silver Heights Skilled Nursing and Rehabilitation 4001 Home St Castle Rock, CO 80108

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 0791 Resident #12 was interviewed on 4/1/25 at 9:55 a.m. Resident #12 said she had had pain in her bottom jaw for a long time now. She said she saw the dentist at the facility quite a few months prior and was still waiting Level of Harm - Minimal harm or for another appointment. She said she had not received any communication from the facility on when her potential for actual harm dental appointment would be.

Residents Affected - Few Resident #12 said she was having pain, but was still able to eat.

C. Record review

The 4/24/24 dental progress note revealed Resident #12 presented with soreness in the lower jaw.

The 11/13/24 dental progress note revealed Resident#12 was seen for treatment due to soreness in the lower jaw and indicated the resident experienced tenderness to the lower ridge. The dentist documented a referral for the resident to have an alveoloplasty (a surgical procedure where the jawbone is reshaped and smoothed, particularly after tooth extraction, to prepare for dentures or dental implants) of her lower ridge (alveolar ridge located just below the bottom teeth).

A review of Resident #12's electronic medical record (EMR) did not reveal documentation the facility had followed up on the dental referral from 11/13/24.

III. Staff interviews

The NHA was interviewed on 4/3/25 at 1:42 p.m. The NHA said the social services department was responsible for the coordination of all ancillary services, including dental care. She said the facility was currently in the process of hiring social services staff.

The NHA said she was unable to find documentation that the dental referral had been made for Resident #12, based on the dentist's recommendation from November 2024. She said she would contact the dentist to determine where Resident #12 should be sent for the procedure.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 31 065285 Department of Health & Human Services Printed: 08/31/2025 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 065285 B. Wing 04/03/2025

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

Silver Heights Skilled Nursing and Rehabilitation 4001 Home St Castle Rock, CO 80108

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** 47350 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 development and transmission of disease on three of three units.

Specifically, the facility failed to:

-Ensure hand hygiene was performed during wound care;

-Ensure clean technique was followed during wound care;

-Ensure residents' rooms were cleaned in a sanitary manner;

-Ensure laundry was sorted in a sanitary manner;

-Ensure laundry was washed in a different cycle for residents in isolation; and,

-Ensure residents' personal items were labeled and stored in a sanitary manner.

Findings include:

I. Facility policy and procedure

The Infection Prevention and Control Program (IPCP) and Plan, revised October 2018, was provided by the nursing home administrator (NHA) on 3/31/25 at 1:10 p.m. It revealed in pertinent part,

An IPCP is established and maintained to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of communicable diseases and infections.

The program is based on accepted national infection prevention and control standards.

II. Failed to ensure hand hygiene and clean technique was followed during wound care

A. Professional references

According to the Centers for Disease Control and Prevention (CDC) Hand Hygiene for Healthcare Workers, updated 2/27/24, retrieved on 4/8/25 from https://www.cdc.gov/clean-hands/hcp/clinical-safety/index.html,

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.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 22 of 31 065285 Department of Health & Human Services Printed: 08/31/2025 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 065285 B. Wing 04/03/2025

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

Silver Heights Skilled Nursing and Rehabilitation 4001 Home St Castle Rock, CO 80108

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 Gloves are not a substitute for hand hygiene. If your task requires gloves, perform hand hygiene before donning gloves and touching the patient or the patient's surroundings, always clean your hands after Level of Harm - Minimal harm or removing gloves, remember to remove gloves carefully to prevent hand contamination as dirty gloves can potential for actual harm soil your hands.

Residents Affected - Some B. Observations

On 4/2/25 at 1:15 p.m. the director of nursing (DON), who was also the facility's infection preventionist (IP), and the wound care physician entered Resident #40's room to perform wound care for the resident on his left foot. The following observations were made:

The DON performed hand hygiene and donned a gown and a pair gloves upon entering the resident's room.

The DON brought in wound dressing supplies and placed them on the resident's bedside table. The DON then removed the heel boot on Resident #40's left foot. The DON removed the old dressing on Resident #40's left lateral foot. The DON placed the old dressing on the bed. The DON placed a disposable underpad

on the bed under the resident's left foot, on top of the old dressing. The DON then used a clean gauze and

an individual saline solution vial to wipe the wound. The DON disposed of the gauze and saline solution. The DON opened the resident's clean dressing from the bedside table and applied the dressing.

-Throughout the wound care process, the DON failed to establish and maintain a clean field for the resident's clean wound supplies.

-Additionally, the DON failed to perform hand hygiene and change gloves after touching the old soiled wound dressing and before touching the clean wound supplies and applying a new dressing to the resident's left foot wound.

On 4/2/25 at 1:30 p.m. the DON and the wound care physician entered Resident #33's room to perform wound care for the resident. The following observations were made:

The DON removed clean dressing supplies from the wound care cart. The DON donned gloves and a gown.

The DON placed the clean wound care supplies on Resident 33's wheelchair at the end of the bed. The DON removed the resident's left heel boot. The DON picked up the betadine pain stick and painted the resident's left heel with betadine. The DON then obtained saline and clean gauze and removed the soiled dressing from the resident's sacral wound. She cleaned the sacral wound and applied a clean dressing. The DON then removed her gown and gloves and disposed of the soiled dressing supplies in the trash.

-Throughout the wound care process, the DON failed to establish and maintain a clean field for the resident's clean wound supplies.

-The DON failed to perform hand hygiene before donning gloves and a gown.

-Additionally, the DON failed to perform hand hygiene and change gloves after cleaning the resident's left heel wound and before proceeding to the resident's sacral wound.

-The DON failed to change her gloves and perform hand hygiene after removing Resident #33's soiled sacral wound dressing and before cleaning the wound and applying a new dressing.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 23 of 31 065285 Department of Health & Human Services Printed: 08/31/2025 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 065285 B. Wing 04/03/2025

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

Silver Heights Skilled Nursing and Rehabilitation 4001 Home St Castle Rock, CO 80108

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 4/2/25 at 1:45 p.m. the DON and the wound care physician entered Resident #20's room to perform wound care for the resident. The following observations were made: Level of Harm - Minimal harm or potential for actual harm The DON removed clean dressing supplies from the wound cart. The DON donned gloves and a gown. The DON pulled back the resident's incontinence briefs and removed the old soiled dressing from the resident's Residents Affected - Some sacral wound.

The DON opened clean wound care supplies and applied silver alginate (an antibacterial wound treatment) and a border dressing. The DON removed her gown and gloves and disposed of everything in the trash.

-Throughout the wound care process, the DON failed to establish and maintain a clean field for the resident's clean wound supplies.

-The DON failed to perform hand hygiene before donning gloves and a gown.

-Additionally, the DON failed to perform hand hygiene and change gloves after removing the resident's old wound dressing and before touching the resident's clean dressing supplies.

C. Staff interviews

The DON was interviewed on 4/2/25 at 2:52 p.m. The DON said before performing wound care, a clean field should be established. She said a bedside table or designated surface should be wiped down with the Super Sani Cloth germicidal and disinfectant wipes. She said this should be done before placing any clean dressing supplies on top of the surface. She said hand hygiene should be done before putting on gloves and a gown.

She said hand hygiene should be performed and gloves should be changed after touching a dirty area and

before touching clean wound supplies.

III. Failed to ensure resident's rooms were cleaned in a sanitary manner

A. Professional reference

The Centers for Disease Control (CDC) Environment Cleaning Procedures (3/19/24), was retrieved on 4/8/25 from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/procedures.html. It read in pertinent part,

Proceed from cleaner to dirtier areas to avoid spreading dirt and microorganisms.

Clean resident areas before cleaning resident toilets.

Include identified high touch surfaces and items in checklists and other job aids to facilitate completing cleaning procedures.

Proceed in a systematic manner to avoid missing areas. In a multi-bed area, clean each resident zone in the same manner.

For higher risk areas, change cleaning cloths between each resident zone (use a new cleaning cloth for each resident bed).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 31 065285 Department of Health & Human Services Printed: 08/31/2025 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 065285 B. Wing 04/03/2025

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

Silver Heights Skilled Nursing and Rehabilitation 4001 Home St Castle Rock, CO 80108

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 B. Facility policy and procedure

Level of Harm - Minimal harm or The Daily Room Cleaning Procedures policy and procedure, undated, was provided by the NHA on 4/3/25 at potential for actual harm 7:18 p.m. It revealed in pertinent part,

Residents Affected - Some Always start with cleaning the resident's restroom.

Disinfect toilet bowls and urinals.

C. Manufacturer's recommendations

The Diffense Cleaner and Disinfectant manufacturer guidelines, 2025, was retrieved on 4/8/25 from https://www.sfreedman.com/products/1024-spartan-rtu-diffense-clnr-quart/525039070/?srsltid=AfmBOoo7j5w qpwdbMMjm1Fj0oNYH2ChUBkqNjJgQ6mERSEMaPhUfyA2Z. It read in pertinent part,

Effective against a comprehensive range of harmful bacteria and viruses and less than one minute disinfection.

D. Observations

On 4/3/25 at 8:53 a.m. housekeeper (HK) #1 was observed cleaning a shared room [ROOM NUMBER].

HK #1 put on gloves and obtained a disinfectant-saturated rag from the housekeeping cart and wiped the bedside table on the A side of the room. She then wiped down the window sill and the bedside table on the B side of the room.

After wiping both residents' bedside tables and the windowsill with the same rag, she disposed of the rag.

She then mopped the entire room, starting from the far side of room (the B side), mopping under both beds and mopped her way to the door. After finishing the mopping, HK #1 disposed of the mop head and swept up

the debris.

-HK #1 failed to clean the resident's area on the B side of the room separately from the resident's area on the

A side of the room.

-HK #1 failed to change gloves, perform hand hygiene or change rags before proceeding from the A side to

the B side of the room.

-HK #1 failed to change mop heads after mopping the B side of the room before mopping the A side of the room.

-HK #1 failed to clean the high touch areas in the room, including light switches and door knobs.

E. Staff interview

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 31 065285 Department of Health & Human Services Printed: 08/31/2025 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 065285 B. Wing 04/03/2025

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

Silver Heights Skilled Nursing and Rehabilitation 4001 Home St Castle Rock, CO 80108

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 maintenance director (MTD), who was also the housekeeping supervisor, was interviewed on 4/3/25 at 9:20 a.m. The MTD said HK #1 should not be interviewed because she was new to the position and because Level of Harm - Minimal harm or of the language barrier. He said the cleaner/disinfectant the facility used had a one-minute disinfection time. potential for actual harm He said residents' rooms were cleaned starting from high areas to low areas. He said high touch areas, such as light switches and door handles should be included when the rooms were cleaned. Residents Affected - Some IV. Failed to ensure laundry was sorted in a sanitary manner and laundry was washed in a different cycle for residents on isolation precautions

A. Professional reference

According to the CDC's Appendix D-Linen and Laundry Management (3/19/24), retrieved on 4/9/25 at 2:04 p. m. from https://www.cdc.gov/healthcare-associated-infections/hcp/cleaning-global/appendix-d.html,

Use hot water 70 degrees Celsius (C) to 80 degrees C for 10 minutes or 158 degrees Fahrenheit (F) to 176

degrees F and an approved laundry detergent.

Use disinfectant on a case by case basis, depending on the origin of the soiled linen (for example, linens from an area on contact precautions).

B. Facility policy and procedure

The Departmental (Environmental Service) Laundry and Linen policy and procedure, revised January 2014, was provided by the NHA on 4/3/25 at 7:50. It read in pertinent part,

Consider all soiled linen to be potentially infectious and handle with standard precautions.

Laundry for high temperature processing, wash linen in water that is at least 160 degrees F for a minimum of 25 minutes.

C. Observations and staff interview

On 4/3/25 at 9:42 a.m. the laundry area was observed with the MTD, the NHA and the laundry aide (LA).

The laundry area was entered through the clean sorting room. The MTD explained the laundry process. The door opening where the laundry carts were sent for dirty laundry had a door leading to the soiled laundry sorting room.

Upon entering the sorting room, the LA said she put on a gown first prior to sorting the laundry.

Multiple cloth long sleeve gowns were observed hanging on hooks behind the laundry sorting room door.

The reusable gowns were overlaying each other and touching other gowns.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 31 065285 Department of Health & Human Services Printed: 08/31/2025 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 065285 B. Wing 04/03/2025

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

Silver Heights Skilled Nursing and Rehabilitation 4001 Home St Castle Rock, CO 80108

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 LA said she washed the reusable protective gowns maybe once a week, but not after each use. The LA said she did not know of any potential infection control issues with that practice. Level of Harm - Minimal harm or potential for actual harm The MTD said not washing the gowns after each use created the potential for cross contamination. The MTD said he would get the laundry staff more gowns to use and dispose of after each time they sorted the soiled Residents Affected - Some laundry items.

The LA said she would put on gloves and use a tie to close the sleeves of the gown at her wrist because the gown sleeves were too long. The LA pointed to three black hair ties hanging on the wall with a thumb tack.

The LA said she used the hair ties all of the time and did not clean them after use.

The NHA said the hair ties were not cleanable and should not be used.

The MTD said it was possible for the debris from the soiled clothing and linen to be transferred to the hair ties.

V. Failed to ensure residents' personal items were labeled and stored in a sanitary manner

A. Observations

On 3/31/25 the following observations were made:

-At 1:45 p.m. room [ROOM NUMBER], a shared room, had on the vanity below the mirror two unlabeled toothbrushes, one unlabeled container of Listerine and one unlabeled deodorant; and,

-At 1:52 p.m. room [ROOM NUMBER], a shared room, had on the vanity below the mirror two unlabeled toothbrushes.

On 4/1/25 the following observations were made:

-At 9:21 a.m. room [ROOM NUMBER], a shared room, had on the vanity below the mirror two unlabeled toothbrushes;

-At 11:00 a.m. room [ROOM NUMBER], a shared room, had on the vanity one unlabeled toothbrush;

-At 11:02 a.m. room [ROOM NUMBER], a shared room, had two unlabeled toothbrushes on the vanity;

-At 11:03 a.m. room [ROOM NUMBER], a shared room, had a cup with one unlabeled toothbrush sitting on

the vanity; and,

-At 11:05 a.m. room [ROOM NUMBER], a shared room, had a cup which contained two unlabeled toothbrushes.

B. Staff interview

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 31 065285 Department of Health & Human Services Printed: 08/31/2025 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 065285 B. Wing 04/03/2025

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

Silver Heights Skilled Nursing and Rehabilitation 4001 Home St Castle Rock, CO 80108

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 DON and the NHA were interviewed together on 4/3/25 at 4:15 p.m. The DON said she was responsible for ensuring that residents' toothbrushes were labeled and stored in a sanitary manner. She said in the past, Level of Harm - Minimal harm or the facility had used special covers for the toothbrushes and had labeled them. She said over time, the potential for actual harm special toothbrush covers had been thrown away. She said she would get new covers for the toothbrushes and ensure they were labeled for each specific resident. Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 31 065285 Department of Health & Human Services Printed: 08/31/2025 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 065285 B. Wing 04/03/2025

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

Silver Heights Skilled Nursing and Rehabilitation 4001 Home St Castle Rock, CO 80108

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 0883 Develop and implement policies and procedures for flu and pneumonia vaccinations.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47350 potential for actual harm Based on record review and interviews, the facility failed to implement policies and procedures related to Residents Affected - Few influenza and pneumococcal vaccines for two (#26 and #43) of five residents reviewed for immunizations out of 30 sample residents.

Specifically, the facility failed to:

-Document the influenza vaccine was offered annually for Resident #26 and #43;

-Document the pneumonia vaccine was reoffered for Resident #26; and,

-Administer the pneumococcal vaccination after consent was provided for Resident #43.

Findings include:

I. Professional reference

According to the Centers for Disease Control and Prevention (CDC), updated 2025, Recommended Immunization Schedule for Adults Aged [AGE] years or Older, retrieved on 4/10/25 from https://www.cdc. gov/vaccines/hcp/imz-schedules/downloads/adult/adult-combined-schedule.pdf,

Pneumococcal vaccination-Routine vaccination-Age [AGE] years or older who have not previously received

a dose of PCV13 (pneumococcal conjugate vaccine), PCV15, PC20, OR PCV21 or whose previous vaccination history is unknown: one dose PCV15 or PCV20 or one dose PCV21. If PCV15 is used, administer one dose PPSV23 at least one year after the PCV15 dose (may use a minimum interval of eight weeks for adults with an immunocompromising condition, cochlear implant, or cerebrospinal fluid leak).

Previously received only PCV7: follow the recommendation above.

Previously received only PCV13: one dose PCV20 or one dose PCV21 at least one year after the last PCV13 dose.

Previously received only PPSV23: one dose PCV15 or one dose PCV20 or one dose PCV21, at least one year after the last PPSV23 dose. If PCV15 is used, no additional PPSV23 doses are recommended.

Previously received both PCV13 and PPSV23 but no PPSV23 was received at age [AGE] years or older; one dose PCV20 or one dose PCV21 at least five years after the last pneumococcal vaccine dose.

Previously received both PCV13 and PPSV23, and PPSV23 was received at age [AGE] years or older: Based on shared clinical decision making, one dose of PCV20 or one dose of PCV21 at least five years after

the last pneumococcal vaccine dose.

II. Facility policy and procedure

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 31 065285 Department of Health & Human Services Printed: 08/31/2025 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 065285 B. Wing 04/03/2025

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

Silver Heights Skilled Nursing and Rehabilitation 4001 Home St Castle Rock, CO 80108

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 0883 The Seasonal Influenza, Prevention and Control policy and procedure, revised March 2022, was provided by

the nursing home administrator (NHA) on 4/3/25 at 7:18 p.m. It read in pertinent part, Level of Harm - Minimal harm or potential for actual harm All residents and staff are offered the vaccine prior to the onset of the influenza season.

Residents Affected - Few All residents and staff are encouraged to receive the vaccine unless there is a medical contraindication.

The Vaccination of Resident policy and procedure, revised October 2019, was provided by the NHA on 4/3/25 at 7:18 p.m. It read in pertinent part,

All residents will be offered vaccines that aid in preventing infectious diseases unless the vaccine is medically contraindicated or the resident has already been vaccinated.

All new residents shall be assessed for current vaccination status upon admission.

If the resident receives a vaccine, at least the following information shall be documented in the resident's medical record: site of administration, date of administration, lot number of the vaccine, expiration date and name of person administering the vaccine.

III. Resident #26

A. Resident status

Resident #26, age 75, was admitted on [DATE REDACTED] readmitted on [DATE REDACTED]. According to the April 2025 computerized physician orders (CPO), the diagnoses included pneumonia, type 2 diabetes mellitus (DM), chronic obstructive pulmonary disease (COPD) and vascular dementia.

The 1/15/25 minimum data set (MDS) assessment revealed the resident had severe cognitive impairments with a brief interview for mental status (BIMS) score of five out of 15. She required substantial/maximal assistance with toileting, personal hygiene. She required partial/moderate assistance with bed mobility and was independent with eating.

The assessment indicated the resident had been offered and she had declined the influenza vaccine for the years' influenza season.

The assessment indicated the resident had been offered and she had declined the pneumonia vaccine.

B. Record review

A review of the Resident #26's electronic medical record (EMR) on 4/3/25 revealed a consent form for influenza and pneumonia vaccine. The form indicated the resident declined the influenza and pneumonia vaccine on 4/15/22.

-A review of the EMR on 4/3/25 failed to reveal documentation that the influenza vaccine or the pneumonia vaccine was reoffered annually.

IV. Resident #43

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 31 065285 Department of Health & Human Services Printed: 08/31/2025 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 065285 B. Wing 04/03/2025

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

Silver Heights Skilled Nursing and Rehabilitation 4001 Home St Castle Rock, CO 80108

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 0883 A. Resident status

Level of Harm - Minimal harm or Resident #43, age 74, was admitted on [DATE REDACTED]. According to the April 2025 CPO, the diagnoses included potential for actual harm COPD and stage 4 severe chronic kidney disease (CKD),

Residents Affected - Few The 1/8/25 MDS assessment revealed the resident had moderate cognitive impairments with a BIMS score of 12 out of 15. He was independent with eating, toileting, personal hygiene, bed mobility and transfers.

The assessment indicated the resident had been offered and he had declined the influenza vaccine for the years' influenza season.

The assessment indicated the resident had been offered and he had declined the pneumonia vaccine.

-However, review of Resident #43's consent form revealed the resident indicated he wanted to receive the pneumonia vaccine on 2/17/23 (see record review below).

B. Record review

A review of Resident #43's EMR on 4/3/25 revealed a consent form for the influenza and the pneumonia vaccine that documented the resident declined the influenza vaccine and wished to receive the pneumonia vaccine on 2/17/23.

-A review of the EMR on 4/3/25 failed to reveal documentation of the influenza vaccine being reoffered annually.

-A review of the EMR on 4/3/25 failed to reveal documentation that the pneumonia vaccine was administered

after the resident signed the consent form for permission to receive the vaccine.

V. Staff interviews

The director of nursing (DON) was interviewed on 4/3/25 at 2:26 p.m. The DON said that many of the residents declined immunizations because they did not trust the government. She said the consents for immunizations were completed when a resident was admitted to the facility. She said the form was then uploaded into the residents' EMR. She said the information of vaccines received and refused were documented under the immunization tab in the resident's medical record. She said they offered the vaccines every year and the residents' acknowledgment of education of risk versus benefit was documented on the consent.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 31 065285