Kiowa Hills Rehabilitation And Nursing, Llc

F-F679 for failure to ensure activities meet the interest/needs of each resident.

III. Record review

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

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 0680 The job description for the activities director (AD) was provided by the regional clinical resource (RCR) on 1/16/25 at 1:32 p.m. The job description read in pertinent part, Level of Harm - Minimal harm or potential for actual harm The activities director will collaborate with an activities consultant regarding resident and department issues and implement any recommended changes, including development of monthly activity calendars and Residents Affected - Some development and revision of activity care plans.

Complete all activities related documentation in each residents' medical record, including assessments, progress notes, care plans and activity attendance records.

The initial January 2025 activity calendar (posted prior to 1/14/25) and revised January 2025 activity calendar (posted on 1/14/25) were provided by the nursing home administrator (NHA) on 1/16/25 at 3:00 p. m.

The initial activities calendar contained a daily 9:30 a.m. coffee and news activity which represented 50% of

the activities for the month, or 31 of 62 scheduled activities.

The revised activities calendar had additional activities scheduled and changes to the initially scheduled activities from the initial calendar.

IV. Staff interviews

The AD was interviewed on 1/15/25 at 9:40 a.m. The AD said the administrator in training (AIT) was her supervisor. The AD said she did not have anyone providing activities director training to her and she had no previous experience or qualifications for the activities director position prior to assuming the role on 1/6/25.

The AD said she asked her supervisor if certification was required for her role and was told the facility would get back to her.

The AD said she was told she would have a mentor for her position but had not been provided with the mentor's name or phone number. The AD said she was not aware what the experience or education requirements were for an AD in a nursing facility.

The AD said the previous January 2025 activities calendar was removed and replaced with a calendar she created on 1/14/25. The AD said she did not know who had posted the previous January 2025 calendar. The AD said it was the first activities calendar she had created. The AD said she used an example calendar which was left on her desk to create the January 2025 calendar. The AD said she did not know if Resident #16 had enough or appropriate activities.

The AD said the previous AD had worked in the facility's maintenance department prior to working in the AD role. She said the previous AD was in the role from September 2024 to December 2024.

The AIT and the nursing home administrator (NHA) were interviewed together on 1/15/25 at 10:25 a.m. The AIT said the AD misunderstood and the AIT was not her supervisor.

The NHA said the previous AD who was in the role from September 2024 to December 2024 was not a certified AD. The NHA said the facility had a contract with a certified AD who was a consultant. The NHA said the consultant was the direct supervisor for the previous AD and the current AD. The NHA said the consultant met with the previous AD on 12/18/24.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

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 0680 The NHA said the consultant was at the facility once a month for eight hours and as needed. The NHA said monthly supervision was not sufficient for an AD who did not have experience and needed to learn the role. Level of Harm - Minimal harm or potential for actual harm The AIT said he would ensure the AD had contact information for her mentor (the consultant).

Residents Affected - Some The NHA said the AD did not know what the residents' needs were based on their conditions because she had not had training in the role. The NHA said he did not know if anyone had informed the AD of the requirements for her role. The NHA said the consultant likely was not aware there was a new AD because

the consultant would have contacted the AD to arrange training if the consultant was aware the new AD was hired.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50853 Residents Affected - Few Based on observations, record review and interviews, the facility failed to ensure the residents environment remained as free of accident hazards as possible and ensured residents received adequate supervision and assistance to prevent a fall with major injury for one (#38) of three residents reviewed for accidents/hazards out of 33 sample residents.

Resident #38, who was at high risk for falls and had a history of a fall with a fracture, was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED] after a hospital stay for repair of a right femur fracture. Per the resident's fall care plan, staff were instructed to anticipate and meet the resident's needs, keep the call light within reach and keep personal items within reach.

Resident #38 experienced a witnessed fall on 12/20/24 while trying to walk to her sink to get a drink of water, resulting in a fracture of her right femur. The staff failed to implement new interventions after the resident's fall with major injury.

Observations of Resident #38 during the survey revealed staff were not consistently ensuring Resident #38's call light was within reach when she was in her room.

Findings include:

I. Facility policy and procedure

The Safety and Supervision of Residents policy, dated 12/19/16, was provided by the nursing home administrator (NHA) on 1/15/25 at 5:07p.m. It read in pertinent part,

Our facility strives to make the environment as free from accident hazards as possible. Resident safety and supervision and assistance to prevent accidents are facility-wide priorities.

Implementing interventions to reduce accident risks and hazards shall include the following: communicating specific interventions to all relevant staff via the resident's care plan, assigning responsibility for carrying out interventions, providing training, as necessary, ensuring that interventions are implemented and documenting interventions.

Monitoring the effectiveness of interventions shall include the following: ensuring that interventions are implemented correctly and consistently, evaluating the effectiveness of interventions, modifying or replacing interventions as needed and evaluating the effectiveness of new or revised interventions.

All direct care staff members are responsible to review and follow the resident's individualized care plan for safety and supervision.

II. Resident #38

A. Resident status

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0689 Resident #38, age 80, was admitted on [DATE REDACTED] and readmitted on [DATE REDACTED]. According to the January 2025 computerized physician orders (CPO), diagnoses included fracture of the neck of the right femur, dementia, Level of Harm - Actual harm repeated falls and metabolic encephalopathy (brain disorder caused by a chemical imbalance in the blood).

Residents Affected - Few The 12/28/24 minimum data set (MDS) assessment revealed Resident #38 had moderate cognitive impairments with a brief interview for mental status (BIMS) score of eight out of 15. Resident #38 required supervision or touching assistance with personal hygiene and partial assistance with transfers. She was independent with mobility in a wheelchair.

The assessment documented Resident #38 had clear speech and was always able to make herself understood. She was occasionally incontinent of urine and required partial assistance with getting on and off

the toilet.

B. Observations and interview

On 1/12/25 at 5:30 p.m. Resident #38 was lying in bed. The call light button was on the floor under the head of the bed, out of the resident's sight and reach.

On 1/13/25 at 9:50 a.m. Resident #38 was lying in bed. The call light was on her pillow above her head, out of her sight.

A continuous observation was conducted on 1/13/25, beginning at 2:09 p.m. and ending at 4:09 p.m. The following was observed:

At 2:09 p.m. Resident #38 was lying in bed. The call light button was under the pillow above her head, out of sight and reach.

At 2:35 p.m. an unknown certified nurse aide (CNA) stopped and looked into Resident #38's room, then continued to walk down the hall. The unidentified CNA did not enter the resident's room to ensure the resident's call light was within her reach.

At 2:50 p.m. an unknown CNA delivered ice water to Resident #38's roommate but did not check the call light placement for Resident #38. The call light button was still under the pillow above the resident's head.

At 3:42 p.m. the call light button remained under the pillow above her head.

At 4:09 p.m. the call light button remained under Resident #38's pillow above her head.

On 1/13/25 at 4:32 p.m. registered nurse (RN) #1 observed Resident #38's call light placement. RN #1 said call lights should be placed beside the residents where they could reach them. RN #1 said the cord had a clip so it could be clipped to the resident's shirt. RN #1 moved Resident #38's call light from under the pillow to the top of her comforter.

On 1/14/25 at 8:54 a.m. Resident #38 was lying in bed. The call light cord was clipped to the top corner of

the sheet above Resident #38's head. The call button was on the floor under the head of the bed, out of sight and reach.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

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 #6 was interviewed on 1/14/25 at 9:21 a.m. He said Resident #38's call light should be placed on the bed where she could reach it. He said she could not reach it on the floor where it was currently laying. CNA Level of Harm - Actual harm #6 picked up Resident #38's call light from the floor and placed it on top of the comforter on her chest. CNA #6 said it was important to keep the call lights where the residents could reach them so they could get help Residents Affected - Few when they needed it.

On 1/15/25 at 9:16 a.m. Resident #38 was lying in bed. The call bell cord was clipped to the top corner of the sheet above Resident #38's head. The call button was on the floor under the head of the bed, out of sight and reach of the resident.

C. Record review

The activities of daily living (ADL) care plan, initiated 2/27/24, included an intervention to encourage Resident #38 to use the call bell for assistance. The communication care plan, initiated 2/27/24, included an intervention to keep the call light in reach.

Resident #38's fall care plan, initiated 3/13/24, revealed the resident was at risk for falls. Pertinent interventions included anticipating and meeting the resident's needs, keeping the call light within reach and encouraging the resident to use it, ensuring the resident had shoes or non-skid socks on when walking, ensuring the resident's bed was in the low position when in bed, keeping personal items in reach and keeping the floor free of spills and clutter.

The 8/16/24 fall risk evaluation documented Resident #38 was a high fall risk related to balance problems while standing and walking, gait problems, use of an assistive device, high risk medications and diagnoses.

The 12/20/24 nursing progress note documented Resident #38 was observed trying to walk to her sink to get

a drink of water and fell to the floor.

The 12/20/24 change in condition hospital transport report documented Resident #38 experienced a witnessed fall with a suspected serious injury related to pain in her right leg and hip and inability to bear weight. The facility's physician ordered x-rays which revealed a fracture.

Resident #38 was sent to the hospital where she underwent surgical repair to the right femur and returned to

the facility on [DATE REDACTED].

-Resident #38's fall care plan was not updated with any new interventions after the fall with fracture on 12/20/24.

D. Additional staff interviews

RN #2 was interviewed on 1/12/25 at 6:04 p.m. RN #2 said Resident #38's call light should be placed within her reach.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

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 director of nursing (DON) was interviewed on 1/15/25 at 6:07 p.m. The DON said resident's call lights should be within the residents' reach, clipped on the pillow or blanket if they were in bed. The DON said the Level of Harm - Actual harm call light being clipped on the top corner of the bed would not be within reach of most residents due to their lack of dexterity and range of motion. The DON said Resident #38 was a high fall risk and was not safe to Residents Affected - Few transfer without staff assistance.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

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 50853 Residents Affected - Some Based on observations and interviews, the facility failed to ensure medications and biologicals were properly stored and labeled in accordance with professional standards in two of four medication carts and one of one medication storage room.

Specifically, the facility failed to:

-Ensure expired medications were removed from the medication carts and medication storage room; and,

-Ensure over the counter medications intended for use by a single resident were labeled with the resident's name.

Findings include:

I. Professional reference

The United States Food and Drug Administration (USFDA) (2/8/21) Don't Be Tempted to Use Expired Medicines, was retrieved on 1/22/25 from https://www.fda. gov/drugs/special-features/dont-be-tempted-use-expired-medicines. It read in pertinent part,

Expired medical products can be less effective or risky due to a change in chemical composition or a decrease in strength. Certain expired medications are at risk of bacterial growth and sub-potent antibiotics can fail to treat infections, leading to more serious illnesses and antibiotic resistance. Once the expiration date has passed there is no guarantee that the medicine will be safe and effective. If your medicine has expired, do not use it.

II. Manufacturer's recommendations

The manufacturer's recommendations for latanaprost eye drops were retrieved on 1/22/25 from https://www. accessdata.fda.gov/drugsatfda_docs/label/2012/020597s044lbl.pdf. It read in pertinent part, Latanaprost sterile ophthalmic solution is indicated for the reduction of intraocular pressure in patients with open angle glaucoma. Once a bottle is open for use it may be stored at room temperature for six weeks.

III. Observations

On 1/14/25 at 1:17 p.m. the medication storage room was observed with the director of nursing (DON). The following items were found:

-Seven tubes of activon medical grade honey (a wound treatment) with an expiration date of December 2024; and,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

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 -One box of phos-nak dietary supplement 100 count with an expiration date of April 2024.

Level of Harm - Minimal harm or On 1/14/25 at 9:25 a.m. the medication cart on the 100 hallway was observed with registered nurse (RN) #1. potential for actual harm The following item was found:

Residents Affected - Some -One bottle of cetirizine (allergy medication) 10 milligrams (mg) with an expiration date of December 2024.

On 1/14/25 at 2:06 p.m. the medication cart on the 100 hallway was observed again with RN #1. The following items were found:

-One bottle of latanaprost eye drops opened 10/1/24;

-One bottle of buproprion (antidepressant medication) ER 150 mg with an expiration date of 9/17/24;

-One bottle of amlodipine (medication used to treat high blood pressure) 10 mg with an expiration date of 10/12/24; and,

-One bottle of citalapram (antidepressant medication) 20 mg with an expiration date of 11/30/24.

On 1/15/25 at 10:56 a.m. the medication cart on the 600 hallway was observed with the DON. The following items were found:

-One box of Genteal tears containing two tubes of ointment, opened 1/9/25, with no pharmacy label or resident name on either tube or the box; and,

-One bottle of saline nasal spray opened 1/13/25 with no pharmacy label or resident name on the bottle.

IV. Staff interviews

RN #1 was interviewed on 1/14/25 2:15 p.m. RN #1 said she would dispose of the expired medications in the drug buster (a drug disposal system that breaks down unwanted medications into a non-toxic liquid that can be safely disposed of in the trash). RN #1 said she was not sure how long latanaprost should be used after opening. RN #1 said the risks of giving medication that was expired were unexpected side effects or decreased effectiveness of the medications.

The DON was interviewed on 1/15/25 at 3:25 p.m. The DON said the medication carts and medication storage room should be examined every week by the assistant director of nursing (ADON) or the DON. The DON said she did not know why the bottles of expired medications were left in the medication cart. The DON said it was not advisable to use expired medications because their potency could be reduced.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

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

in accordance with professional standards. Level of Harm - Minimal harm or potential for actual harm 50219

Residents Affected - Many Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the main kitchen, satellite kitchen, and one of two nourishment refrigerators.

Specifically, the facility failed to:

-Ensure ready to eat foods were handled in a sanitary manner to prevent cross contamination in the main kitchen;

-Ensure safe and appropriate storage of food items in the kitchen and nourishment room refrigerators;

-Ensure proper hair restraints were worn in the kitchen;

-Ensure the kitchen and food service areas were kept clean; and,

-Ensure frozen meats were thawed in a safe manner.

Findings include:

I. Failed to ensure ready-to-eat foods were handled in a sanitary manner

A. Professional reference

The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 1/23/25. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment.

If used, single-use gloves shall be used for only one task such as working with ready-to-eat food or with raw animal food, used for no other purpose, and discarded when damaged or soiled, or when interruptions occur

in the operation. (3-301.11)

B. Facility policy and procedure

The Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy and procedure, dated 12/19/16, was received from the nursing home administrator (NHA) on 1/26/25 at 2:38 p.m. It read in pertinent part, Gloves are considered single-use items and must be discarded after completing the task for which they are used.

C. Observations

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 During a continuous observation of the lunch meal service on 1/15/25, beginning at 9:42 a.m. and ending at 12:46 p.m. the following was observed: Level of Harm - Minimal harm or potential for actual harm At 11:00 a.m. dietary aide (DA) #1 washed her hands, donned gloves and left the kitchen. DA #1 returned to

the kitchen with four heads of lettuce and a plastic bag of shredded carrots. With the same gloved hands, DA Residents Affected - Many #1 removed the outer layer of leaves of two lettuce heads, used her gloved hands to touch the faucet head to move it so she could rinse the lettuce and moved the faucet head back. Using the same gloved hands, DA #1 began slicing lettuce for salad. At 11:04 a.m. DA #1 repeated this process for the other two heads of lettuce using the same gloved hands.

At 11:25 a.m. DA #1 donned gloves, used her gloved hands to open the refrigerator and retrieved a bag of shredded cheese wrapped in cling film. Using the same gloved hands, DA #1 unwrapped the bag of cheese shreds and opened it. DA #1 then used the same gloved hands to grab three handfuls of cheese and sprinkled it onto the salad she was preparing.

From 11:59 a.m. to 12:35 p.m. DA #2 wore a pair of gloves. DA #2 used these gloves to handle meal tickets, serving utensils and meal trays. DA #2, using the same gloved hands, picked up cookies and put them onto plates to be served to the residents throughout lunch service.

At 12:22 p.m. DA #3 placed the palm of her gloved hands on the surface of two plates before serving food on them. DA #3 had previously used the same gloved hands to handle serving utensils. DA #3, using the same gloved hands, opened a plastic bag containing hot dog buns, grabbed two buns and separated the halves of

the buns using her gloved hands.

At 12:25 p.m. DA #3 repeated the process of opening the plastic bag of hot dog buns, selecting two buns and separating the halves of the buns using the same gloved hands. DA #3 repeated this process at 12:35 p. m. with the same gloved hands.

D. Staff interview

The dietary manager (DM) was interviewed on 1/16/25 at 9:13 a.m. The DM said ready to eat foods should be handled with gloves. The DM said gloves were single use and single task. He said the dietary staff should remove their gloves and wash their hands between tasks. The DM said the dietary aides should have taken off their gloves and put on fresh gloves between tasks during the lunch service observation.

II. Failure to safely and appropriately store food items

A. Professional reference

The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 1/23/25. It revealed in pertinent part, Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees celsius (41 degrees fahrenheit (F)) or less for a maximum of seven days. The day of preparation shall be counted as day one.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 The day or date marked by the food establishment may not exceed a manufacturer's use-by date if the manufacturer determined the use-by date based on food safety. (3-501.17) Level of Harm - Minimal harm or potential for actual harm B. Observations

Residents Affected - Many During an initial tour of the kitchen on 1/12/25 at 2:38 p.m., the following items were observed in the refrigerators:

-A container of cottage cheese, with an expiration date of 12/27/24;

-A container of hot dogs, with a date of 1/4/25;

-An opened container of sauerkraut, unlabeled and undated;

-A container of fruit salad, unlabeled and undated;

-Five individual containers of diced fruits, unlabeled and undated;

-A block of cheese slices, unlabeled and undated; and,

-Two containers of raw chicken wings, unlabeled and undated.

At 2:38 p.m. in the food preparation area, a container of sugar was observed with no lid on it. The sugar had several dark pieces of debris in it.

On 1/13/25 at 3:35 p.m. observations of the contents of the Glacier Peak neighborhood nourishment refrigerator revealed the following:

-A deli meat sandwich labeled 1/7/25;

-A damp cardboard fast food container in a plastic bag dated 12/5/24 with a resident's name; and,

-Two unlabeled undated containers of sliced fruit.

On 1/15/25 at 9:42 a.m. the lid to the sugar bin in the kitchen was askew and not covering the bin.

C. Staff interview

The DM was interviewed on 1/16/25 at 9:13 a.m. The DM said the dietary staff went through the refrigerators

in the kitchen each day and threw away items that were out of date. The DM said once opened, items in the refrigerator should only be kept for a range of one to seven days, depending on what the item was. He said

the sandwiches should only be held for two to three days. The DM said items in the refrigerators should always be labeled and dated.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 The DM said he did not know the nourishment refrigerators were part of the kitchen's responsibility to maintain. The DM said he checked the nourishment refrigerators in the nurse's stations briefly each day to Level of Harm - Minimal harm or make sure there were enough snacks in them. The DM said the fast food container in the nourishment potential for actual harm refrigerator (see above) was very old and needed to be thrown away.

Residents Affected - Many III. Ensure kitchen staff were wearing appropriate hair restraints while preparing and serving food

A. Professional reference

The Colorado Retail Food Establishment Regulations, effective 3/16/24, were retrieved on 1/23/25. It revealed in pertinent part, Food employees shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed food, clean equipment, utensils, and linens. (2-402.11)

B. Facility policy and procedure

The Preventing Foodborne Illness - Employee Hygiene and Sanitary Practices policy and procedure, dated 12/19/16, was received from the NHA on 1/26/25 at 2:38 p.m. It read in pertinent part, Hair nets or caps/hats and beard restraints (as indicated) must be worn to keep body hair from contacting exposed food, clean equipment, utensils and linens.

C. Observations

On 1/15/25 cook (CK) #1 was observed during a continuous observation of the lunch service, beginning at 9:42 a.m. and ending at 12:46 p.m. CK #1 was preparing food for residents throughout the observation period.

-CK #1 had a goatee and mustache approximately 1.5 inches long and was not wearing a beard net or other facial hair covering throughout the observation period.

D. Staff interview

The DM was interviewed on 1/16/25 at 9:13 a.m. The DM said the facility's kitchen did not have any beard nets available. The DM said he was working on getting beard nets for CK #1.

IV. Failure to ensure kitchen and food service areas were kept clean

A. Professional reference

The Colorado Retail Food Establishment Regulations, effective 3/16/24, were retrieved on 1/23/25. It revealed in pertinent part, Floors, floor coverings, walls and wall coverings shall be designed, constructed, and installed so they are smooth and easily cleanable. (6-201.11)

Non-food-contact surfaces of equipment shall be kept free of an accumulation of dust, dirt, food residue, and other debris. (4-601.11)

B. Facility policy and procedure

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 The Dietary Sanitization policy and procedure, dated 12/19/16, was received from the NHA on 1/26/25 at 2:38 p.m. It read in pertinent part, All kitchens and kitchen areas shall be kept clean, free from litter and Level of Harm - Minimal harm or rubbish and protected from rodents, roaches, flies and other insects. potential for actual harm Kitchen and dining room surfaces not in contact with food shall be cleaned on a regular schedule and Residents Affected - Many frequently enough to prevent accumulation of grime.

C. Observations and staff interviews

An initial tour of the main kitchen was conducted on 1/12/25 at 2:38 p.m. and revealed the following:

-The deli meat slicer that was not actively in use had visible debris along the slicer surface; and,

-The floors throughout the kitchen were soiled with dirt and crumbs.

On 1/13/25 at 3:41 p.m. the floor of the satellite kitchen used for meal service had dirt and debris throughout

the room.

On 1/15/25 at 9:28 a.m. the tile floor of the main kitchen had several cracked tiles and was missing a large patch of tiles approximately three feet by four feet near the food prep island with crumbs and debris stuck in

the cracks of the missing tiles. There was dirt, debris and crumbs throughout the floor in the kitchen.

At 11:59 a.m. in the satellite kitchen there was grime, debris and food crumbs throughout the floor. Seven ants were observed near the trash can in the satellite kitchen near a spill.

At 12:06 p.m. the DM was alerted about the presence of ants in the satellite kitchen and began using a broom to sweep them up. The DM moved the trash can and revealed approximately ten more ants. DA #2 said the ants liked the crumbs in the kitchen.

D. Staff interviews

On 1/13/25 at 3:41 p.m. DA #2 said the kitchen and satellite kitchen were deep cleaned once a month and

the floors were mopped and swept every night.

The DM was interviewed on 1/16/25 at 9:13 a.m. The DM said the facility did not have any issues with pests to his knowledge. The DM said the dietary staff only saw ants in the kitchen when they were not cleaning properly. The DM said the dietary staff should be sweeping and mopping the satellite kitchen after every meal and the main kitchen once a day.

The DM said deep cleaning was performed once a month. The DM said the dietary staff sometimes used a deep cleaning checklist but that they did not have one at the moment. The DM said the dietary staff had checklists for cleaning the satellite kitchen but did not use them.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 The DM said the missing tiles in the kitchen had not been fixed yet because the facility still occasionally had plumbing issues in that area. The DM said the tiles had been missing for several months. The DM said he Level of Harm - Minimal harm or had brought the issue up with the management team and thought they were making progress in getting the potential for actual harm tiles fixed.

Residents Affected - Many V. Failure to ensure frozen meats were thawed in a safe manner

A. Professional reference

The Colorado Retail Food Establishment Regulations, effective 3/16/24, were retrieved on 1/23/25. It revealed in pertinent part: Time/temperature control for safety food shall be thawed completely submerged under running water with sufficient water velocity to agitate and float off loose particles in an overflow. (3-501. 13)

B. Facility policy and procedure

The Food Preparation and Storage policy and procedure, dated 12/16/19, was received from the NHA on 1/16/25 at 2:38 p.m. It read in pertinent part, Thawing procedures include completely submerging the item in cold running water that is running fast enough to agitate and remove loose ice particles.

C. Observations

During a continuous observation of the lunch meal service on 1/15/25, beginning at 9:42 a.m. and ending at 12:46 p.m. the following was observed:

At 10:01 a.m. a container of raw frozen chicken cutlets and a container of raw frozen beef were submerged

in water in metal bins in the kitchen sink under two separate streams of running water. Both the chicken and

the beef were in their original plastic packaging. There was a section approximately twelve inches by five inches of frozen beef which sat above the water and was not under running water.

At 10:26 a.m. the faucet directing water over the frozen chicken was moved to rinse something during food preparation and not replaced until 10:39 a.m.

At 11:15 a.m. the DM adjusted the beef in the metal bin so that the previous section sitting above the water was now submerged, but a new section of beef approximately the same size was above the waterline and not exposed to the running water.

D. Staff interview

The DM was interviewed on 1/16/25 at 9:13 a.m. The DM said frozen raw meat should be thawed under cool running water or in the refrigerator overnight. The DM said the dietary staff tried to keep the frozen raw meat submerged under water during the thawing process as much as possible. The DM said he was aware that

the dietary staff needed to remove the frozen meat from the plastic packaging prior to thawing it in the sink, but said they kept the plastic on because it was too difficult to take it off.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 48458

Residents Affected - Few Based on observations, record review and interviews, the facility failed to ensure the hospice services provided met professional standards and principles that applied to individuals providing services in the facility for one (#17) of two residents reviewed for hospice services out of 33 sample residents.

Specifically, for Resident #17, the facility failed to:

-Obtain a physician's order for hospice care;

-Ensure the hospice agency's notes were easily accessible to the facility staff and had consistent communication and documentation of hospice care visits and updates; and,

-Initiate a hospice care plan timely.

Findings include:

I. Facility policy and procedure

The Hospice Program policy, dated October 2016, was provided by the regional clinical resource (RCR) on 1/16/25 at 3:40 p.m. It read in pertinent part,

When a resident participates in the hospice program, a coordinated plan of care between the facility, hospice agency and resident/family will be developed and shall include directives for managing pain and other comfort symptoms and a delineation of the services that the hospice company is responsible to provide. The care plan shall be revised and updated as necessary to reflect the resident's current status. The director of nursing (DON) of the facility shall serve as the facility's designated hospice liaison.

II. Resident #17

A. Resident status

Resident #17, age less than 65, was admitted on [DATE REDACTED]. According to the January 2025 computerized physician orders (CPO), diagnoses included diabetes, atherosclerosis of arteries of extremities (blood vessels hardened and narrowed in legs), respiratory failure, heart failure, cellulitis (skin infection) lower leg, kidney cancer and right leg above the knee amputation.

The 10/29/24 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. Resident #17 was dependent on staff for hygiene, repositioning in bed and transferring.

The assessment revealed Resident #17 was receiving hospice services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 B. Resident interview

Level of Harm - Minimal harm or Resident #17 was interviewed on 1/16/25 at 11:50 a.m. Resident #17 said she had not seen a hospice nurse potential for actual harm for four or five weeks. Resident #17 said she wanted to continue receiving visits from the hospice nurse.

Residents Affected - Few C. Observation and staff interview

Hospice binders, which contained resident information and communication from hospice visits, were observed at the nurses station with registered nurse (RN) #2 on 1/16/25 at 12:10 p.m.

There were multiple binders labeled with residents' names. The binders represented two different hospice agencies. RN #2 was unable to locate a binder for Resident #17.

RN #2 said she would look for Resident #17's hospice binder. RN #2 said she had not seen a representative from hospice visit Resident #17 this week (week of 1/12/25). RN #2 said she thought a hospice certified nurses aide (CNA) had visited the resident the previous week.

D. Record review

-A review of Resident #17's electronic medical record (EMR) did not reveal a physician's order for hospice care.

Review of Resident #17's hospice care plan, initiated 10/24/24, included information and a hospice plan of care for Resident #17's previous hospice agency.

-Review of Resident #17's EMR revealed the facility failed to initiate a hospice care plan for the current hospice agency, which assumed care of the resident in November 2024.

Documentation of a hospice agency visit with Resident #17 was provided by the RCR on 1/16/25 at 12:45 p. m. The documentation included a hospice nurse practitioner (NP) visit completed on 12/30/24. The RCR said

she had requested documentation from the hospice agency (during the survey) because the facility did not have a hospice binder for Resident #17 that contained documentation of the resident's hospice nurse visits.

-The documentation provided by the RCR did not include documentation of the nurse visits from the hospice agency.

E. Staff interviews

The RCR was interviewed on 1/16/25 at 12:50 p.m. The RCR said Resident #17's hospice care plan had not been updated since a previous hospice agency was managing her care in October 2024. The RCR said the new hospice agency had been providing services since the end of November 2024, however, she said there was not an active physician's order for hospice services in Resident #17's EMR until 1/16/25 (during the survey).The RCR said the facility should have obtained a new hospice care plan and hospice order for Resident #17 when she began receiving services from the new hospice agency in November 2024.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0849 The hospice clinical supervisor (HCS) was interviewed on 1/16/25 at 1:53 p.m. The HCS said Resident #17 was scheduled for RN case manager visits once weekly until this week (week of 1/12/25), when visits were Level of Harm - Minimal harm or changed to twice weekly.The HCS said Resident #17 did not have CNA visits scheduled since she began potential for actual harm receiving these services. The HCS said the RN case manager visits were completed in December 2024 on 12/2/24, 12/9/24, 12/16/24, 12/23/24, 12/30/24, and in January 2025 on 1/9/25 and 1/14/25. The HCS said Residents Affected - Few the hospice social worker visited Resident #17 on 12/6/24, 12/17/24 and 1/8/25.

The HCS said the RN case manager communicated with Resident #17's nurse at each visit and the HCS said the facility was able to reach the hospice agency 24 hours per day. The HCS said there should have been a communication binder at the facility for Resident #17. The HCS said the hospice agency sent documentation of nursing visits to the facility via fax and to the assistant director of nursing's (ADON) email every two weeks. The HCS said if the facility had difficulty with the receipt of fax or email, the hospice company would provide a copy to the facility when the RN case manager was present at visits. The HCS said she was not aware the facility had issues with the receipt of hospice documentation for Resident #17.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

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** 48458 potential for actual harm Based on record review, observations and interviews, the facility failed to maintain an infection control Residents Affected - Many program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious disease.

Specifically, the facility failed to:

-Wear the appropriate personal protective equipment (PPE) when entering transmission based precaution rooms;

-Offer updated COVID-19 vaccinations and document consent or declination for vaccination for Residents #16, #36, #205 and #255;

-Ensure staff followed proper hand hygiene practices during meal delivery;

-Ensure staff followed proper infection prevention practices during wound care for Resident #37; and,

-Ensure resident's glucometers were disinfected after each use.

Findings include:

I. Failure to wear personal protective equipment

A. Professional reference

According to the Centers for Disease Control and Prevention (CDC), Infection Control Guidance: SARS-CoV-2, (6/24/24), retrieved on 1/22/25 from

https://www.cdc.gov/covid/hcp/infection-control/?CDC_AAref_Val=https://www.cdc. gov/coronavirus/2019-ncov/hcp/infection-control-recommendations.html,

HCP (healthcare personnel) who enter the room of a patient with suspected or confirmed SARS-CoV-2 infection should adhere to standard precautions and use a NIOSH (National Institute for Occupational Safety and Health) approved particulate respirator with N95 filters or higher, gown, gloves and eye protection (goggles or a face shield that covers the front and sides of the face).

B. Facility policy and procedure

The Initiating Transmission Based Precautions policy, revised February 2023, was provided by the regional clinical resource (RCR) on 1/14/25 at 2:19 p.m. It read in pertinent part,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

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 When transmission based precautions (TBP) are implemented, the infection preventionist or designee shall ensure that protective equipment (gloves, gowns, masks, etc.) based on the specific type of TBP is Level of Harm - Minimal harm or maintained near the resident's room so that everyone entering the room can access what they need. potential for actual harm C. Observations and staff interviews Residents Affected - Many

On 1/12/25 at 2:49 p.m. an unidentified certified nurse aide (CNA) entered room [ROOM NUMBER], which had a sign on the door indicating droplet precautions should be followed including an N95 mask, eye protection, gown and gloves. The unidentified CNA entered the room without wearing eye protection.

On 1/13/25 at 11:35 a.m. the isolation cart supplies outside of room [ROOM NUMBER] were observed with licensed practical nurse (LPN) #1. The sign on the door revealed droplet precautions should be followed including eye protection (goggles or face shield) prior to entering the room. There were no eye protection supplies present in the isolation cart outside of the room. LPN #1 said she had been in the resident's room earlier that morning and said she had forgotten to wear eye protection.

On 1/13/25 at 11:40 a.m., registered nurse (RN) #1 entered room [ROOM NUMBER] without eye protection.

D. Staff interview

The assistant director of nursing (ADON) was interviewed on 1/13/25 at 3:00 p.m. The ADON said she acted as the infection preventionist (IP). She said the residents in room [ROOM NUMBER] and room [ROOM NUMBER] were on transmission based precautions and were positive for COVID-19, required droplet precautions and staff should use googles or face shields when they entered the resident's rooms.

-However, residents who are positive for COVID-19 require transmission based precautions.

The ADON was interviewed a second time on 1/16/25 at 9:20 a.m. The ADON said in-the-moment training was provided to staff when staff were not wearing face shields as required on 1/12/25 and 1/13/25 (during

the survey). She said she would continue to provide training to all of the staff.

II. Failed to offer updated COVID-19 vaccinations and document consent or declination

A. Professional reference

According to theCDC, Staying Up to Date with COVID-19 Vaccines, revised 1/7/25, retrieved on 1/23/25 from https://www.cdc.gov/covid/vaccines/stay-up-to-date.html,

Everyone ages six months and older should get a 2024-2025 COVID-19 vaccine. The COVID-19 vaccine helps protect you from severe illness, hospitalization , and death. It is especially important to get your 2024-2025 COVID-19 vaccine if you are ages 65 and older, are at high risk for severe COVID-19, or have never received a COVID-19 vaccine. Vaccine protection decreases over time, so it is important to get your 2024-2025 COVID-19 vaccine.

B. Facility policy and procedure

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

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 COVID-19 Vaccine policy, revised 6/5/23, was provided by the RCR on 1/15/25 at 12:49 p.m. It read in pertinent part, Level of Harm - Minimal harm or potential for actual harm The facility shall encourage all staff and residents to remain up-to-date with COVID-19 vaccines, but residents and staff may refuse the COVID-19 vaccine. Residents Affected - Many

The infection preventionist is primarily responsible to securely track and document COVID-19 vaccination status for all staff and residents.

C. Record review

A review of Resident #16's electronic medical record (EMR) immunization tracking section revealed the resident last received the COVID-19 vaccination on 12/28/23.

-The EMR did not include documentation for Resident #16's COVID-19 vaccination status for the 2024-2025 season.

A review of Resident #36's EMR immunization tracking section revealed the resident last received the COVID-19 vaccination on 12/28/23.

-The EMR did not include documentation for Resident #36's COVID-19 vaccination status for the 2024-2025 season.

A review of Resident #205's EMR immunization tracking section revealed the resident last received the COVID-19 vaccination on 1/26/23.

-The EMR did not include documentation for Resident #205's COVID-19 vaccination status for the 2024-2025 season.

A review of Resident #255's EMR immunization tracking section revealed the resident last received the COVID-19 vaccination on 12/28/23.

-The EMR did not include documentation for Resident #255's COVID-19 vaccination status for the 2024-2025 season.

D. Staff interviews

The ADON and the RCR were interviewed together on 1/16/25 at 10:01 a.m. The ADON said she did not know if the COVID-19 vaccinations were offered to residents during the 2024-2025 season. The ADON said

she had not offered COVID-19 to the residents.

The RCR said COVID-19 2024-2025 vaccines were available at the facility and should have been offered to residents. The RCR and ADON said the immunization section in the EMR was not up to date for the residents.

III. Failed to ensure staff followed proper hand hygiene practices during meal delivery

A. Professional reference

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

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 According to the CDC Clinical Safety, Hand Hygiene for Healthcare Worker (2/17/24), retrieved on 1/23/25 from https://www.cdc.gov/clean-hands/hcp/clinical-safety, Level of Harm - Minimal harm or potential for actual harm 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 Residents Affected - Many 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.

B. Observations and staff interview

On 1/12/25 at 5:45 p.m., CNA #4 was delivering meal trays to residents on the 100 hall CNA #4 delivered a tray to room [ROOM NUMBER]. CNA #4 did not perform hand hygiene, went back to the dining room and poured drinks into cups and placed them on a room tray. She pushed the room tray cart down the hall. Without performing hand hygiene, she took a tray and delivered it to room [ROOM NUMBER]. She came out of the room, got another tray from the cart and delivered it to room [ROOM NUMBER] without performing hand hygiene. CNA #4 got another tray from the cart and delivered it to the other resident in room [ROOM NUMBER] without performing hand hygiene. CNA #4 then washed her hands at the sink and dried them with paper towels. She took another tray from the cart, with the paper towels still in her left hand in her hand (and holding the room tray with both hands), and delivered it to room [ROOM NUMBER]. She delivered another tray to room [ROOM NUMBER], did not perform hand hygiene and still had the paper towels in her left hand.

She pushed the room tray cart to the end of the hall and delivered a tray to room [ROOM NUMBER]. She threw the paper towels in the trash can and brought a dirty cup out of room [ROOM NUMBER], then pushed

the cart back to the other end of the hall. She did not perform hand hygiene and delivered the last tray to room [ROOM NUMBER].

On 1/14/25 at 12:52 p.m., CNA #5 was delivering meal trays. CNA #5 delivered a room tray to room [ROOM NUMBER] then pushed the meal tray cart down the hall. She did not perform hand hygiene, obtained the next meal tray and delivered it to room [ROOM NUMBER].

CNA #5 was interviewed on 1/14/25 at 12:56 p.m. She said she forgot to use hand hygiene and she should have performed hand hygiene between passing the two room trays.

On 1/14/25 at 1:02 p.m., CNA #4 was delivering meal trays on the 600 hall. CNA #4 pushed the meal tray cart down the hallway, then delivered a tray to room [ROOM NUMBER]. CNA #4 pushed the cart further down the hall and delivered a tray to room [ROOM NUMBER]. She did not perform hand hygiene and delivered a third tray to room [ROOM NUMBER].

C. Staff interview

The ADON was interviewed on 1/16/25 at 9:20 a.m. The ADON said staff should be using hand hygiene or hand sanitizer before and between each meal delivery and offer hand hygiene to the residents. The ADON said hand hygiene education was provided at least weekly in the dining area by herself and the dining room manager on duty.

IV. Failure to ensure proper infection control practices during wound care

A. Facility policy and procedure

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

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 Wound Care policy, revised 12/19/16, was provided by the RCR on 1/17/25 at 7:13 a.m. It read in pertinent part, Level of Harm - Minimal harm or potential for actual harm -Use disposable barrier to establish clean field on resident's overbed table or other flat surface. -Place all items to be used during procedure on the clean field. Arrange the supplies so they can be easily reached. Residents Affected - Many -Wash and dry your hands thoroughly.

-Position resident. Place a disposable barrier next to resident (under the wound) to serve as a barrier to protect the bed linen and other body sites.

-Put on exam gloves and any other PPE indicated based on wound type (e.g. gown if resident has enhanced barrier precautions in place). Masks and eyewear will only be necessary if splashing of blood or other body fluids into your eyes or mouth is likely.

-Loosen tape and remove dressing if indicated.

-Pull glove over dressing and discard into appropriate receptacle. Wash and dry your hands thoroughly.

-Put on gloves.

-Use no-touch technique. Use sterile tongue blades and applicators to remove ointments and creams from their containers when part of the treatment order.

-Pour liquid solutions directly on gauze sponges on their papers.

-Wear exam gloves for holding gauze to catch irrigation solutions that are poured directly over the wound.

-Consideration should be given to wearing sterile gloves when performing invasive wound care (packing a tunneling wound) or working with heavily exudating wounds as an infection mitigation measure.

-Dress wound in accordance with physician order. [NAME] dressing with initials and date and apply to dressing. Be certain all clean items are on clean field.

-Remove the disposable cloth next to the resident and discard into the designated container.

-Discard disposable items into the designated container. Discard all soiled laundry, linen, towels, and washcloths into the soiled laundry container. Remove disposable gloves and discard into designated container. Wash and dry your hands thoroughly.

B. Record review

Review of Resident #37's January 2025 computerized physician's orders (CPO) revealed the following physician's order for wound care:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

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 -Cleanse right perineal wound and pack with wound cleanser saturated gauze twice daily, ordered on 10/3/24

Level of Harm - Minimal harm or -Clean right buttocks wound with wound cleanser and apply barrier cream to surrounding skin, cover open potential for actual harm areas with skin dressing, change weekly and as needed, ordered on 1/3/25.

Residents Affected - Many C. Observations

RN #1 was performing wound care on Resident #37's wounds on 1/14/25 at 11:18 a.m. RN #1 cleaned the buttocks wound, then removed the soiled packing from the perineal wound and cleaned the perineal wound with gauze and wound cleanser, packed and redressed the perineal wound.

-RN #1 did not change gloves after removing the soiled perineal dressing, nor did she change gloves between wound sites. RN #1 did not place a clean barrier under the resident, and left the resident on a visibly soiled disposable pad.

RN #1 did not change gloves or perform hand hygiene after cleansing the wounds and before packing the perineal wound. RN #1 applied barrier cream to the surrounding skin wearing the same soiled gloves, squirting it directly from the tube to her soiled gloves. RN #1 applied the new dressing over the perineal wound wearing the same gloves. RN #1 then removed the soiled disposable pad under the resident and replaced it with a clean one. RN #1 removed her gloves and applied clean gloves without performing hand hygiene.

D. Staff interview

RN #1 was interviewed on 1/14/25 at 11:40 a.m. RN #1 said she did not know that the wounds should be treated separately and that she should change her gloves between treatments. RN #1 said she thought it was important to avoid cross contamination. RN #1 said she should have changed gloves after cleaning each wound, and before packing the perineal wound and applying the clean dressing. She said it would be important to have a clean disposable pad under the wound so it would not contaminate the wound after it was cleaned.

The ADON was interviewed on 1/16/25 at 10:01 a.m. The ADON said RN #1 should have performed hand hygiene and changed her gloves between the removal of the soiled dressing and the application of the clean one. The ADON said gloves should be changed between wounds if there were multiple wounds. The ADON said the nursing staff received wound care education upon hire, annually and whenever issues arise. The ADON said she was going to provide education to the nursing staff regarding wound dressing change procedures.

V. Failure to disinfect glucometers after use

A. Professional reference

According to the CDC, Consideration for Blood Glucose Monitoring and Insulin Administration (8/7/24) retrieved on 1/23/25 from https://www.cdc.gov/injection-safety/hcp/infection-control/index.html,

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

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 Blood glucose meters are portable devices that measure blood glucose levels and aid in diabetes self-management. Healthcare providers use these types of devices in a variety of clinical settings. Blood Level of Harm - Minimal harm or glucose meters can easily become contaminated during use. When used in healthcare or other group potential for actual harm settings, germs and infections can spread if preventive measures are not in place. Dedicated meters should be cleaned and disinfected per the manufacturer's instructions. Residents Affected - Many B. Observations

On 1/12/25 at 5:08 p.m., RN #2 checked Resident #28's blood sugar. RN #2 removed Resident #28's glucometer from the case in the medication cart. RN #2 then used the glucometer for testing Resident #28's blood and then returned the glucometer to the case.

-RN #2 did not clean the glucometer after use and prior to returning to the case.

On 1/12/25 at 5:20 p.m., RN #2 checked Resident #6's blood sugar. RN #2 removed Resident #6's glucometer from the case in the medication cart. RN #2 then used the glucometer for testing Resident #6's blood and then returned the glucometer to the case.

-RN #2 did not clean the glucometer after use and prior to returning to the case.

C. Staff interviews

RN #2 was interviewed on 1/12/25 at 5:35 p.m. RN #2 said she should have cleaned the glucometers after use and should clean them every time the glucometer was used with sanitizing wipes. RN #2 said each resident had their own glucometer.

The ADON was interviewed on 1/13/25 at 3:00 p.m. The ADON said RN #2 should have cleaned the glucometers with sanitizing wipes after each use.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 51 065175

F-F680 for failure to meet the qualifications of an activity professional.

Level of Harm - Minimal harm or potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 51 065175 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 065175 B. Wing 01/16/2025

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

Kiowa Hills Rehabilitation and Nursing, LLC 924 W Kiowa St Colorado Springs, CO 80905

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 0680 Ensure the activities program is directed by a qualified professional.

Level of Harm - Minimal harm or 48458 potential for actual harm Based on record review and interviews, the facility failed to ensure the activities program was directed by a Residents Affected - Some qualified professional.

Specifically, the facility failed to employ a qualified activities director in order to provide a program of activities for residents requiring activity and recreational support.

Findings include:

I. Professional reference

According to the National Certification Council of Activity Professionals (NCCAP) (2025), retrieved on 1/22/25 from https://www.nccap. org/assets/docs/F-TAG%20680%20QUALIFICATION%20OF%20ACTIVITY%20DIRECTOR.pdf,

The activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist, or an activities professional who is licensed or registered if applicable by the state in which practicing; and,

Is eligible for certification as a therapeutic recreation specialist or as an activities professional by a recognized accrediting body; or,

Has two years of experience in a social or recreational program within the last five years, one of which was full-time in a therapeutic activities program; or,

Is a qualified occupational therapist or occupational therapy assistant; or,

Has completed a training course approved by the State.

An activity director is responsible for directing the development, implementation, supervision and ongoing evaluation of the activities program. This includes completion of the activities component of the comprehensive assessment, contribution to the comprehensive care plan goals and approaches that are individualized to match the skills, abilities and interests/preferences of each resident.

II. Resident interview

Resident #16 was interviewed on 1/12/25 at 4:26 p.m. Resident #16 said he had been sitting in his chair all day with nothing to do. He said the programming on television (TV) was very limited and repetitive. Resident #16 said the facility had very few activities. He said activities mainly consisted of Bingo and there were very few other activities provided to the residents.

Cross-reference