Kiowa Hills Rehabilitation And Nursing, Llc

incident, including CNA #1, who confirmed that Resident #3 approached and grabbed Resident

the incident.

The NHA said the facility’s internal investigation determined that the abuse allegation incident was substantiated. He said CNA #1 directly observed Resident #3 grab Resident #2’s arm. He said no injuries occurred with the incident and skin assessments were performed on Resident #2. He said appropriate interventions, including enhanced supervision and medical work-up were implemented by the facility.

The NHA said during the interview with Resident #3, she was unable to provide a clear or coherent explanation of the incident. He said due to her cognitive impairment, her responses were determined by the facility to be disorganized and did not align with the events that occurred.

The NHA said the facility determined through the interview with Resident #3 that she was not of sound mind and unable to participate in a meaningful interview.

The NHA said the DON met with Resident #3 and Resident #2 on 6/8/25 about the events that occurred. He said Resident #3 was unable to recall any events due to her cognitive impairment. Resident #2 was unable to communicate the events, due to her aphasia and underlying cognitive impairment.

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

requested and providing incontinence care after each incontinence episode, or per an established

on request and as required for incontinence, changing clothing as needed after incontinence episodes

8/26/25 at 1:25 p.m.

Hospice CNA #1 said that the hospice CNAs came to the facility two days a week on Tuesday and Fridays and gave Resident #11 a bed bath.

Hospice CNA #1 said that the staff from the facility was responsible for providing incontinence care and repositioning for Resident #11 when the hospice staff were not there.Hospice CNA #1 was interviewed a second time on 8/26/25 at 1:47 p.m.

Hospice CNA #1 said when removing Resident #11's brief it was saturated with urine and his skin was wet in the perineal area.LPN #1 was interviewed on 8/26/25 at 1:50 p.m. LPN #1 said residents should be repositioned every two hours. LPN #1 said incontinence care should be provided every two hours. LPN #1 said CNAs should be doing a skin check when providing incontinence care.

LPN #1 said Resident #11 was at risk for developing pressure ulcers as he was not mobile. LPN #1 said Resident #11 did not currently have any pressure ulcers.CNA #2 was interviewed on 8/27/25 at 1:19 pm. CNA #2 said residents should be repositioned and provided incontinence care every two hours. CNA #2 said if residents were not repositioned or changed, they could develop a bed sore or pressure ulcers.CNA #2 said she provided repositioning and incontinence care for Resident #11. CNA #2 said she changed Resident #11 on 8/26/25 at 6:00 a.m.

She said after Resident #11 ate his breakfast, she asked him if he wanted to be changed and he said no.

She said she usually changed Resident #11 between 9:30 a.m. and 9:45 a.m., but because he had refused, no care was provided.

She said she had intended to provide incontinence care and repositioning for Resident #11 after lunch but said that the hospice CNAs had already changed Resident #11 and repositioned him so she did not have to.

She said she received reeducation on 8/26/25 on providing timely incontinence care and repositioning.

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

softer, LPN #2 peeled the dressing off in pieces, due to the dressing becoming more slimy when

Once cleansed, the wound bed was pink and red. LPN #2 applied skin prep, placed xeroform gauze and

wound care for Resident #4's left medial ankle wound. had a bordered gauze dressing on it that was slightly saturated and yellow in color.

When LPN #2 removed the bordered gauze dressing, there was no xeroform gauze beneath the outer dressing (see physician's orders below).

The resident's left medial ankle wound bed was pink, rounded and open. LPN #2 cleansed the wound, applied skin prep, placed xeroform gauze and covered the wound with a signed and dated bordered gauze dressing.C.

Record reviewReview of Resident #4's skin integrity care plan revealed the resident had impairment to her skin integrity and required enhanced barrier precautions to prevent the spread of infections.

Interventions included following facility protocols for treatment of injury and keeping the resident's skin clean and dry.Review of Resident #4's August 2025 CPO revealed the following physician's orders: Right dorsal foot: Cleanse with wound cleanser, skin prep periwound, xeroform and cover with bordered gauze.

Change daily and PRN (as needed).

Every night shift for vascular wound care, ordered 8/21/25.-However, Resident #4's right dorsal foot wound did not have xeroform gauze on it during the wound care observation (see observations above).Right medial ankle: Cleanse with wound cleanser, skin prep periwound, xeroform and cover with bordered gauze.

Change daily and PRN.

Every night shift for wound care, ordered 8/21/25.However, Resident #4's right medial ankle wound had calcium alginate covering it instead of xeroform gauze and there was no bordered gauze dressing over the wound during the wound care observation (see interviews below and observations above).Left medial ankle: Cleanse with wound cleanser, skin prep periwound, xeroform and cover with bordered gauze.

Change daily and PRN as needed for wound care, ordered 8/21/25.-However, Resident #4's left medial ankle wound did not have xeroform gauze on it during the wound care observation (see observations above).Review of Resident #4's August 2025 treatment administration record (TAR) revealed the following:-The right dorsal foot wound dressing was documented as changed on 8/25/25 at 9:26 p.m.;-The right medial ankle wound dressing was documented as changed on 8/25/25 at 9:26 p.m.; and,-The left medial ankle wound dressing was documented as changed on 8/25/25 at 9:26 p.m.III.

Staff interviewsLPN #2 was interviewed on 8/26/25 at 10:53 a.m. LPN #2 said she did not see xeroform gauze underneath Resident #4's dressings when she changed them.

She said it was important to check the physician's orders for how to change wound dressings, because Resident #4 usually had new dressing orders each week.

She said the blackish brown material on the resident's right medial ankle wound was calcium alginate build up that needed to be sprayed, softened and removed.-However, the 8/21/25 wound care physician's orders did not indicate calcium alginate was to be used on Resident #4's wounds (see physician's orders above).The wound care physician (WCP) was interviewed on 8/27/25 at 11:38 a.m.

The WCP said the facility was treating Resident #4's vascular ulcers, which came and went because of the vascular issues in her legs. He said the current treatment for the wounds was to use xeroform gauze. He said the purpose of treating the wounds with xeroform gauze was to keep a moist healing environment for the cells and it was a barrier to protect the wound environment. He said prior to 8/21/25, the resident's wounds were being treated with calcium alginate, which was a fibrous material used to collect exudate. He said the calcium alginate got thicker and a little more soggy when exudate leaked from the wound and got absorbed into the alginate material. He said the alginate helped absorb exudate and honey helped to soften hard tissues, so he changed the physician's order to xeroform gauze. -However, Resident #4 did not have xeroform gauze on her wounds during the wound observation (see observations and LPN #2's interview above).

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

menu known as the bistro menu. He said he added more options for the residents to choose from.The

manager RD.

The NHA said not following the recipes could be concerning for allergies, safety

find and print out the recipes.

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

high.The NHA was interviewed on 8/27/25 at 1:41 p.m.

The NHA said the DM gave him some invoices

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

CK was handling only buns, they would not need to change their gloves.

The DM said the unidentified

the unidentified DA should have used tongs.

The DM said he would provide education to the staff on

referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 9/4/25. It revealed in pertinent part, Time/Temperature control for safety food, hot and cold holding at 135 degrees F (Fahrenheit) or higher and 41 degrees F and lower. (Chapter 3)B.

ObservationsDuring a continuous observation during the dinner meal on 8/26/25, beginning at 5:05 p.m. and ending at 6:00 p.m., the following was observed:At 5:11 p.m. an unidentified DA took the temperature of the potato salad and it was 49 degrees F.

The potato salad was stored on a cart and was not on ice during the meal service.

C.

Staff interviewsThe DM was interviewed on 8/27/25 10:50 a.m.

The DM said hot food should be held at 135 degrees F and cold food at 41 degrees F during meal service.

The DM said the potato salad should not have been 49 degrees F.

The DM said the potato salad should have been placed in smaller pans.

The DM said the satellite kitchen did not have a cooling spot to put cold items in.

The DM said the potato salad should have been placed on ice, but they did not have enough pans.III.

Failure to ensure food was covered during transportation from the kitchen to the residents' roomsA.

Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 9/4/25. It revealed in pertinent part, Food shall be protected from contamination that may result from a factor or source. (Chapter 3).B.

ObservationsOn 8/26/25 at 9:16 a.m. the room trays for the 600 hall were being passed out to the residents.

The cart had four room trays.

The plate had a dome cover over the food.

The oatmeal and apple sauce on the trays were not covered as it was transported down the hallway. C.

Staff interviewsThe DM was interviewed on 8/27/25 at 10:50 a.m.

The DM said when room trays were delivered, the food on the tray should be covered.

The DM said he did not have covers for the bowls and cups. He said he talked to the NHA about not having bowl and cup covers. He said the nursing home administrator (NHA) said they would purchase those items in September 2025. He said he also did not have enough room tray covers. He said there were a lot of residents who ate in their rooms.

The NHA was interviewed on 8/27/25 at 1:41 p.m.

The NHA said the kitchen should have covers for the bowls and cups.

The NHA said he was not aware that the kitchen did not have covers for the bowls and cups.

The NHA said bowls and cups should be covered due to sanitization and temperature control.

The NHA said he was working with the DM about what was needed in the kitchen.The NHA said he would get them ordered as soon as possible. He said he would talk to the DM and see what needed to be ordered.