Crestmoor Care Center

F-F880: failure to follow infection control practices.

C. Record review

A review of the February 2025 CPO revealed the following order:

Indwelling catheter., monitor for placement and function every shift, change the catheter for complications and prior to obtaining a urine sample as needed, provide catheter care and ensure a privacy bag was in place every shift, ensure the catheter was unobstructed, secured, and draining properly every shift. Change

the catheter tubing and bag as needed. Replace graduated cylinder or urinal used for draining catheter bag every Friday night, ordered 2/6/25 at 9:26 a.m. (during the survey process).

-Review of the comprehensive care plan did not reveal any focus or interventions related to the use of the indwelling urinary catheter.

A hospital note, dated 10/13/24 at 2:43 p.m., revealed Resident #52 had a foley (indwelling urinary) catheter which the resident would keep after her discharge back to the facility.

A progress note, dated 10/14/24 at 10:57 p.m., revealed Resident #52 returned to the facility from the hospital at 6:45 p.m. that evening. Resident #52 had an indwelling catheter which was draining clear yellow urine.

A progress note, dated 10/15/24 at 5:53 a.m., revealed Resident #52 had a foley catheter in place and a urine output of 450 cubic centimeters (cc) of urine.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 64 065290 Department of Health & Human Services Printed: 09/09/2025 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 065290 B. Wing 02/06/2025

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

Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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

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

F 0690 A progress note, dated 10/15/24 at 9:16 p.m., revealed Resident #52 had a foley catheter in place and a urine output of 1000 milliliters (ml). Level of Harm - Minimal harm or potential for actual harm A weekly nursing note, dated 11/6/24 at 12:46 p.m., revealed Resident #52 used a foley catheter.

Residents Affected - Few A weekly nursing note, dated 12/23/24 at 9:40 p.m., revealed resident #52 used a foley catheter. Resident #52's urine was clear and yellow, and no odor was noted at that time.

A weekly nursing note, dated 1/6/25 at 9:19 p.m., revealed Resident #52 used a foley catheter. Resident #52's urine was free of odor and yellow in color.

A provider note, dated 1/17/25 at 1:43 p.m., revealed Resident #52 was seen by her provider after recent bloodwork revealed elevated white blood cell counts. Resident #52 denied having a fever but reported having burning urination, an intermittent cough and congestion. A urinalysis and culture were ordered.

A provider note, dated 1/29/25 at 12:00 a.m., revealed Resident #52 was on antibiotics for five days for a UTI. Resident #52 said she was having urinary pain a few days prior which had resolved since starting the antibiotics. Resident #52 had a foley catheter in place which was draining clear yellow urine.

A weekly nursing note, dated 1/31/25 at 8:10 p.m., revealed Resident #52 used a foley catheter.

Review of the bladder elimination task for Resident #52 from 1/7/25 to 2/5/25 revealed the following:

-Continence was not rated due to indwelling catheter was marked 37 times;

-Incontinent was marked 17 times; and,

-Continent was marked 10 times.

D. Staff interviews

Certified nurse aide (CNA) #5 was interviewed on 2/5/25 at 2:21 p.m. CNA #5 said the CNAs emptied the catheter bags, gave the nurses the quantity of urine and the nurses charted the information. CNA #5 said the CNAs emptied the catheter bags every shift.

Registered nurse (RN) #5 was interviewed on 2/5/25 at 3:39 p.m. RN #5 said catheter care was performed every day. RN #5 said the nurses or the CNAs could provide catheter care.

RN #1 was interviewed on 2/5/25 at 4:31 p.m. RN #1 said the CNAs provided catheter care but the nurses could also do so if the CNAs were busy. RN #1 said the nursing staff provided Resident #52 catheter care whenever they changed her incontinence brief.

RN #3 was interviewed on 2/5/25 at 4:55 p.m. RN #3 said catheter care was mostly done by the CNAs. RN #3 said the CNAs documented this in their catheter care task sheet.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 64 065290 Department of Health & Human Services Printed: 09/09/2025 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 065290 B. Wing 02/06/2025

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

Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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

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

F 0690 CNA #1 was interviewed on 2/5/25 at 5:07 p.m. CNA #1 said catheter care was documented in the electronic medical record (EMR) in the associated tasks. CNA #1 said catheter care should be performed and Level of Harm - Minimal harm or documented every shift. potential for actual harm

The CC was interviewed on 2/5/25 at 5:12 p.m. The CC said catheter care should be in the resident's orders, Residents Affected - Few medication administration record (MAR) and the care plan.

LPN #1 was interviewed on 2/6/25 at 8:40 a.m. LPN #1 said she washed her hands and put on gloves before performing catheter care. LPN #1 said she normally put on a gown as well. LPN #1 said when providing catheter care she should wipe from front to back and use a separate washcloth when moving from the perineum to the catheter. LPN #1 said when cleaning the catheter she should start at the perineum and wipe away (down the line toward the catheter bag).

The DON was interviewed on 2/6/25 at 7:47 p.m. The DON said when providing catheter care, the nursing staff should wipe from the urethra down to the catheter bag and work from clean surfaces to dirty surfaces.

The DON said the nursing staff needed to don a gown and gloves when providing catheter care. The DON said catheter care needed to be done every day and as needed, especially for Resident #52. The DON said

the CNAs should empty the catheter bag but not clean it. The DON said the CNAs needed to wear a gown and gloves when emptying the catheter bag. The DON said the physician's order for catheter care was added on 2/6/25 and said it should have been added before then. The DON said there was not a catheter care plan in Resident #52's comprehensive care plan. The DON said the admission nurse missed the order for catheter care and the mistake just carried on. The DON said she had been pairing up with a staff member

in the record-keeping department to try to do audits of residents' medical records.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 64 065290 Department of Health & Human Services Printed: 09/09/2025 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 065290 B. Wing 02/06/2025

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

Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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 50219 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.

Specifically, the facility failed to:

-Ensure expired medications were removed from the medication cart; and,

-Ensure injectable medications were labeled with the date they were opened.

Findings include:

A. Professional references

The United States Food and Drug Administration (USFDA) Don't Be Tempted to Use Expired Medicines (revised 10/31/24), was retrieved on 2/12/25 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.

The Food and Drug Administration (FDA) Insulin Storage and Effectiveness (revised 9/19/17), was retrieved

on 2/12/25 from fda.gov/drugs/emergency-preparedness-drugs/information-regarding-insulin-storage-and-swi tching-between-products-emergency. It read in pertinent part, Insulin products contained in vials or cartridges supplied by the manufacturers (opened or unopened) may be left unrefrigerated at a temperature between 59 (degrees) Fahrenheit (F) and 86 F for up to 28 days and continue to work.

B. Facility policy and procedure

The Storage of Medications policy, revised November 2020, was provided by the clinical consultant (CC) on 2/10/25 at 11:56 a.m. It read in pertinent part, Drugs and biologicals are stored in the packaging, containers or other dispensing systems in which they were received.

The nursing staff is responsible for maintaining medication storage and preparation areas in a clean, safe, and sanitary manner.

Discontinued, outdated, or deteriorated drugs or biologicals are returned to the dispensing pharmacy or destroyed.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 64 065290 Department of Health & Human Services Printed: 09/09/2025 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 065290 B. Wing 02/06/2025

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

Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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 C. Observations

Level of Harm - Minimal harm or On 2/6/25 at 5:07 p.m. the medication cart on the second south hall was observed with registered nurse (RN) potential for actual harm #6. The following items were found:

Residents Affected - Some -A bottle of vitamin C supplements, with an expiration date of December 2024;

-A bottle of vitamin C supplements, with an expiration date of August 2024 ;

-A bottle of fish oil supplements, with an expiration date of August 2024;

-A bottle of vitamin D3 supplements, with an expiration date of January 2025;

-A COVID-19 testing reagent, with an expiration date of December 2023;

-A nicotine lozenge, with an expiration date of July 2024;

-A bottle of calcium acetate, with an expiration date of October 2024;

-A bottle of zinc sulfate, with an expiration date of September 2024;

-A bottle of naproxen sodium, with an expiration date of March 2024;

-Two bisacodyl suppositories, with an expiration date of May 2024;

-A bottle of Prostat, with an expiration date of 10/24/24; and,

-Five insulin injection pens for four different residents which were not labeled with the date they were opened;

-Nine loose pills in the back of the top drawer;

-Multiple loose pills in two other drawers of the medication cart.

On 2/6/25 at 5:34 p.m. the medication cart on the north hall was observed with RN #4. The following items were found:

-A bottle of thiamine supplements, with an expiration date of September 2024;

-A bottle of oyster shell calcium supplements, with an expiration date of August 2024; and,

-A bottle of Latanoprost ophthalmic solution, undated.

IV. Staff interviews

RN #4 was interviewed on 2/6/25 at 5:34 p.m. RN #4 said the night shift nursing staff went through and cleaned the medication carts each week.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 64 065290 Department of Health & Human Services Printed: 09/09/2025 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 065290 B. Wing 02/06/2025

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

Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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 director of nursing (DON) was interviewed on 2/6/25 at 8:01 p.m. The DON said the over-the-counter medications on the medication carts should be reviewed every day. The DON said as soon as a resident was Level of Harm - Minimal harm or discharged , their old medications were discarded. The DON said she and another staff member went potential for actual harm through the medication room to try to discard old medications. She said they had been falling behind with doing so because they were the only two staff members doing this task. The DON said she was trying to get Residents Affected - Some the night shift nursing staff to go through the medication carts each night and discard any expired medications or medications from residents that had discharged . The DON said there should not be any loose pills in the medication carts.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 64 065290 Department of Health & Human Services Printed: 09/09/2025 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 065290 B. Wing 02/06/2025

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

Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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 **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 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, activities room, and two of two nourishment refrigerators.

Specifically, the facility failed to:

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

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

Findings include:

I. Failure to safely and appropriately store food items

A. Professional reference

The Colorado Retail Food Establishment Regulations, ([DATE REDACTED]), were retrieved on [DATE REDACTED]. 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 41 degrees Fahrenheit (F) or less for a maximum of seven days. The day of preparation shall be counted as day one.

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. (,d+[DATE REDACTED].17)

B. Facility policy and procedure

The Food Receiving and Storage policy and procedure, revised [DATE REDACTED], was provided by the clinical consultant (CC) on [DATE REDACTED] at 11:56 a.m. It read in pertinent part, Time/temperature control foods are stored at or below 41 degrees F. Functioning of the refrigeration and food temperatures are monitored daily and at designated intervals throughout the day by the food and nutrition services manager or designee and documented. Refrigerated foods are labeled, dated and monitored so they are used by their' use-by' date, frozen, or discarded. Frozen foods are maintained at a temperature to keep the food frozen solid.

All food items to be kept at or below 41 degrees F are placed in the refrigerator located at the nurse's station and labeled with a use by date. All foods belonging to residents are labeled with the resident's name, the item and the use by date. Refrigerators must have working thermometers and are monitored for temperature according to state-specific guidelines. Other opened containers are dated and sealed or covered during storage.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 64 065290 Department of Health & Human Services Printed: 09/09/2025 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 065290 B. Wing 02/06/2025

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

Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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 C. Observations and record review

Level of Harm - Minimal harm or On [DATE REDACTED] at 10:35 a.m., the following items were observed in the south hall nourishment refrigerator: potential for actual harm -An open bottle of thickened apple juice, with an expiration date of [DATE REDACTED]; Residents Affected - Many -A container of yogurt, with an expiration date of [DATE REDACTED];

-A container of milk, with an expiration date of [DATE REDACTED];

-An unidentified food item rolled in aluminum foil in a plastic bag, dated [DATE REDACTED];

-An open and partially used butter packet, undated; and,

-A medical ice pack.

On [DATE REDACTED] at 9:21 a.m., the following items were observed in the north hall nourishment refrigerator:

-An open container of applesauce, unlabeled and undated; and,

-A nutritional frozen dessert cup which was thawed and easy to squeeze, undated. Instructions on the dessert cup revealed it was to be stored frozen and used within five days of thawing in the refrigerator.

The refrigerator was 56 degrees F.

A refrigerator temperature log for February 2025 was posted on the nourishment refrigerator. The refrigerator temperature was recorded as 58 degrees F each day from [DATE REDACTED] through [DATE REDACTED]. The temperature log had instructions written at the bottom which read in part, refrigerator temperature range is less than 41 degrees F, freezer temperature is less than 20 degrees F. Adjust setting if temperature is out of range. Verify the thermometer every three days.

-There was no documentation on the refrigerator temperature log that indicated the temperature of the refrigerator was addressed when it was noted to be out of acceptable range.

On [DATE REDACTED] at 2:50 p.m., the following items were observed in the south hall nourishment refrigerator:

-The same open bottle of thickened apple juice, with an expiration date of [DATE REDACTED];

-The same container of yogurt, with an expiration date of [DATE REDACTED];

-The same container of milk, with an expiration date of [DATE REDACTED];

-The same unidentified food item rolled in aluminum foil in a plastic bag, dated [DATE REDACTED];

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 64 065290 Department of Health & Human Services Printed: 09/09/2025 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 065290 B. Wing 02/06/2025

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

Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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 same open and partially used butter packet, undated; and,

Level of Harm - Minimal harm or -Several dumplings wrapped together in plastic wrap, unlabeled and undated. potential for actual harm

On [DATE REDACTED] at 4:44 p.m., the following items were observed in the activities room refrigerator: Residents Affected - Many -A bottle of dijon mustard, with an expiration date of [DATE REDACTED];

-A bottle of yellow mustard, with an expiration date of [DATE REDACTED];

-A jar of olives, with an expiration date of [DATE REDACTED]; and,

-A bottle of chocolate syrup, with an expiration date of [DATE REDACTED].

-The activities director (AD) threw away the expired contents of the refrigerator during this observation.

On [DATE REDACTED] at 10:30 a.m., the February 2025 refrigerator temperature log on the south nourishment refrigerator only had one temperature recorded on [DATE REDACTED]. No temperatures were recorded for [DATE REDACTED] through [DATE REDACTED].

D. Staff interviews

Registered nurse (RN) #1 was interviewed on [DATE REDACTED] at 9:16 a.m. RN #1 said the dietary staff or the night shift nurses checked the nourishment refrigerator temperatures. RN #1 said she was not sure who checked through the foods in the nourishment refrigerators or when that task was done.

Certified nurse aide (CNA) #10 was interviewed on [DATE REDACTED] at 10:13 a.m. CNA #10 said the dietary staff filled

the nourishment refrigerators and the night shift nurses checked the refrigerator temperatures. CNA #10 said

the dietary staff checked the nourishment refrigerator contents during the day.

The AD was interviewed on [DATE REDACTED] at 4:44 p.m. The AD said the activities staff and dietary staff shared responsibility for maintaining the contents of the activities refrigerator.

The dietary manager (DM) was interviewed on [DATE REDACTED] at 11:50 a.m. The DM said the north nourishment refrigerator was 53 degrees F. The DM said the unit needed a new refrigerator and she would alert the maintenance staff. The DM said the refrigerator temperature should be checked daily. The DM said the temperature of the refrigerator was above what it needed to be, as it needed to be below 41 degrees F. The DM said cold food needed to be kept below 41 degrees F. The DM said the facility nurses checked the refrigerator daily and should have notified the dietary staff about the temperatures.

The DM said she reviewed the south nourishment refrigerator. She said the bottle of milk and thickened apple juice were expired and she threw them away. The DM said the contents and temperature of the refrigerator should be checked daily. The DM verified the refrigerator had only had its temperature monitored once in February 2025. The DM said she would do an inservice with the staff on recording the dates food items were opened.

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

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 64 065290 Department of Health & Human Services Printed: 09/09/2025 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 065290 B. Wing 02/06/2025

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

Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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 A. Professional reference

Level of Harm - Minimal harm or The Colorado Retail Food Establishment Regulations, ([DATE REDACTED]), were retrieved on [DATE REDACTED]. It revealed in potential for actual harm 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. Residents Affected - Many 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. (,d+[DATE REDACTED].11)

B. Observations

During a continuous observation of the lunch meal service on [DATE REDACTED], beginning at 10:40 a.m. and ending at 12:37 p.m. the following was observed:

At 11:50 a.m. DA #1 donned (put on) a pair of gloves and began preparing two hamburgers. DA #1 retrieved

a bag of hamburger buns, opened the bag and grabbed two hamburger buns with the same gloved hands. With the same gloved hands, DA #1 selected lettuce leaves and placed them on the hamburger buns. DA #1 repeated this process with onion slices using the same gloved hands. DA #1 opened a bag of potato chips and retrieved a handful of chips to put onto the plates with the hamburger buns with his gloved hands. DA #1 retrieved a new bag of potato chips, opened the bag and used the same gloved hands to grab another handful of chips to put on the plate with the hamburger buns.

C. Staff interview

The DM was interviewed on [DATE REDACTED] at 9:51 a.m. The DM said ready-to-eat foods should be handled with clean gloves used only for one task.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 64 065290 Department of Health & Human Services Printed: 09/09/2025 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 065290 B. Wing 02/06/2025

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

Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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 0813 Have a policy regarding use and storage of foods brought to residents by family and other visitors.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50219 potential for actual harm Based on observations, record review and interviews, the facility failed to implement their policy regarding Residents Affected - Some use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption.

Specifically, the facility failed to:

-Ensure the resident's personal refrigerator temperatures were monitored correctly for appropriate temperatures; and,

-Implement the facility policy for food brought by visitors and ensure food that was kept in residents' refrigerators had safe and sanitary storage.

Findings include:

I. Professional reference

The Colorado Retail Food Regulations, ([DATE REDACTED]) were retrieved on [DATE REDACTED]. It read in pertinent part, Except

during preparation, cooking, or cooling, time and temperature control for safety food shall be maintained at 41 degrees Fahrenheit (F) or less. (,d+[DATE REDACTED].16)

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 41 degrees Fahrenheit (F) or less for a maximum of seven days. The day of preparation shall be counted as day one.

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. (,d+[DATE REDACTED].17)

The Food and Drug Administration (FDA) food code ([DATE REDACTED]) were retrieved on [DATE REDACTED] from https://www.fda. gov/food/fda-food-code/food-code-2022 revealed in pertinent part, Bacterial growth and/or toxin production can occur if time/temperature control for safety food remains in the temperature danger zone (41 degrees to 135 degrees F) too long.

II. Facility policy and procedure

The Refrigerators and Freezers procedure and policy, revised [DATE REDACTED], was provided by the clinical consultant (CC) on [DATE REDACTED] at 11:56 a.m. It read in pertinent part, Monthly tracking sheets for all refrigerators and freezers are posted to record temperatures.

Food service supervisors or designated employees check and record refrigerator and freezer temperatures daily.

Supervisors are responsible for ensuring food items in refrigerators are not past use by or expiration dates.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 64 065290 Department of Health & Human Services Printed: 09/09/2025 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 065290 B. Wing 02/06/2025

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

Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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 0813 III. Observations

Level of Harm - Minimal harm or On [DATE REDACTED] at 9:05 a.m., Resident #13's refrigerator contained the following items: potential for actual harm -A container of rice, unlabeled and undated; and, Residents Affected - Some -A bottle of chocolate syrup, dated [DATE REDACTED] and the expiration date was obscured by marker.

The thermometer in the refrigerator read 42 degrees Fahrenheit (F). The February 2025 temperature log on

the refrigerator revealed the temperature had not been recorded on [DATE REDACTED], [DATE REDACTED] and [DATE REDACTED] through [DATE REDACTED]. The temperature recorded on [DATE REDACTED] was 42 degrees F.

-However, there were no indications that the staff member who recorded the temperature attempted to correct the temperature of the refrigerator.

On [DATE REDACTED] at 1:29 p.m., the temperature log on Resident #66's personal refrigerator had temperatures recorded for [DATE REDACTED] through [DATE REDACTED]. On [DATE REDACTED] the refrigerator was recorded at 42 degrees F, on [DATE REDACTED] it was 42 degrees F and on [DATE REDACTED] it was 44 degrees F. The temperature was not recorded on [DATE REDACTED] or [DATE REDACTED]. The temperature was 42 degrees F at that time.

-However, there were no indications that the staff member who recorded the temperature attempted to correct the temperature of the refrigerator.

On [DATE REDACTED] at 10:08 a.m., the temperature log on Resident #68's personal refrigerator did not have temperatures recorded on [DATE REDACTED], [DATE REDACTED] and [DATE REDACTED] through [DATE REDACTED]. The temperature of the refrigerator was 42 degrees F at that time.

-However, there were no indications that the staff member who recorded the temperature attempted to correct the temperature of the refrigerator.

IV. Resident interviews

Resident #13 was interviewed on [DATE REDACTED] at 9:08 a.m. Resident #13 said the facility's maintenance staff checked the temperature of his refrigerator but did not do it every day. Resident #13 said no one came in and checked through his refrigerator to see if things were expired.

Resident #68 was interviewed on [DATE REDACTED] at 10:08 a.m. Resident #68 said the facility's maintenance staff came and checked her refrigerator's temperature but did not do so every day.

V. Staff interviews

The dietary manager (DM) was interviewed on [DATE REDACTED] at 9:51 a.m. The DM said refrigerators should be kept at 41 degrees F or below to keep food out of the danger zone for bacterial growth. The DM said any temperature above 41 degrees F was too warm and the refrigerator needed to be serviced.

The DM said she checked multiple of the resident's refrigerators throughout the facility and found they had not had their temperature checked for several days according to their February 2025 temperature logs. The DM said the housekeeping staff checked the resident's refrigerators daily.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 64 065290 Department of Health & Human Services Printed: 09/09/2025 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 065290 B. Wing 02/06/2025

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

Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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 0813 The environmental services director (ESD) was interviewed on [DATE REDACTED] at 12:08 p.m. The ESD said the housekeeping staff were responsible for checking the temperatures of resident's personal refrigerators daily. Level of Harm - Minimal harm or The ESD said he was only told to have the housekeeping staff check the temperatures, not the refrigerators' potential for actual harm contents. The ESD said it was a grey area which department was responsible for the refrigerators.

Residents Affected - Some

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 55 of 64 065290 Department of Health & Human Services Printed: 09/09/2025 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 065290 B. Wing 02/06/2025

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

Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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** 50219 potential for actual harm Based on observations and interviews, the facility failed to maintain an infection control program designed to Residents Affected - Many provide a safe, sanitary and comfortable environment to help prevent the development and transmission of diseases and infection.

Specifically, the facility failed to:

-Ensure housekeeping staff followed proper cleaning techniques for cleaning and disinfecting resident rooms and high-frequency touched areas (call lights, door handles and handrails);

-Ensure housekeeping staff performed appropriate hand-hygiene;

-Ensure enhanced barrier precautions (EBP) were in place for Resident #52 and Resident #284;

-Follow infection control procedures for catheter care;

-Follow infection control procedures for endotracheal tube care; and,

-Clean equipment between use with residents.

Findings include:

I. Housekeeping failures

A. Professional reference

Assadian O, Harbarth S, Vos M, et al. Practical Recommendations for Routine Cleaning and Disinfection Procedures in Healthcare Institutions: A Narrative Review. The Journal of Hospital Infection, (July 2021) 113:104-114, was retrieved on 2/13/25 from https.//pubmed.ncbi.nlm.nih.gov. It read in pertinent part, High-touch surfaces, on the other hand, are usually close to the patient, are frequently touched by the patient or nursing staff, come into contact with the skin and, due to increased contact, pose a particularly high risk of transmitting pathogens (virus or microorganism that can cause disease). Healthcare-associated infections (HAIs) are the most common adverse outcomes due to delivery of medical care. HAIs increase morbidity and mortality, prolonged hospital stays, and are associated with additional healthcare costs. Contaminated surfaces, particularly those that are touched frequently, act as reservoirs for pathogens and contribute towards pathogen transmission. Therefore, healthcare hygiene requires a comprehensive approach. This approach includes hand hygiene in conjunction with environmental cleaning and disinfection of surfaces and clinical equipment.

The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 2/13/25 from https://www.cdc.gov/healthcare-associated- infections/hcp/cleaning-global/procedures.html?CDC_AAref_Val=https://www.cdc.gov/hai/pre

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 56 of 64 065290 Department of Health & Human Services Printed: 09/09/2025 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 065290 B. Wing 02/06/2025

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

Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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 ent/resource-limited/cleaning-procedures. html#cdc_generic_section_2-4-1-general-environmental-cleaning-techniques. It read in pertinent part, Level of Harm - Minimal harm or High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a potential for actual harm necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility. Residents Affected - Many Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs.

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

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

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

B. Facility policy and procedure

The Cleaning and Disinfecting Residents' Rooms policy and procedure, revised August 2013, was provided by the clinical consultant (CC) on 2/10/25 at 11:56 a.m. It read in pertinent part, Housekeeping surfaces (floors, tabletops) will be cleaned on a regular basis, when spills occur, and when these surfaces are visibly soiled.

Perform hand hygiene after removing gloves.

C. Observations

During a continuous observation on 2/5/25, from 9:43 a.m. to 10:11 a.m., housekeeper (HK) #1 was observed cleaning room [ROOM NUMBER].

HK #1 removed his gloves from a previous room and donned (put on) a new set of gloves without performing hand hygiene. HK #1 entered room [ROOM NUMBER] and began spraying the entire surface of the toilet with Clorox hydrogen peroxide cleaner. HK #1 returned to his cart, removed his gloves and donned a new pair of gloves without performing hand hygiene. HK #1 retrieved a rag from a bin with cleaning solution and began wiping the door handles, light switch, sink area, and sink faucet. HK #1 pulled a chisel from his pants pocket and scraped something on the sink surface before returning it to his pants pocket. HK #1 wiped over

the area he chiseled with the rag. HK #1 did not sanitize the chisel.

HK #1 returned to his cart, removed his gloves and donned a new set of gloves without performing hand hygiene. HK #1 grabbed a new rag and began to wipe down the bedside table on side B of the room. HK #1 retrieved the chisel from his pants pocket, used it to scrape something on the side table, then returned the chisel to his pants pocket. HK #1 used the rag to wipe over the area he had scraped. HK #1 then used the chisel to scrape something on the floor underneath the bedside table before returning the chisel to his pants pocket.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 57 of 64 065290 Department of Health & Human Services Printed: 09/09/2025 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 065290 B. Wing 02/06/2025

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

Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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 -HK #1 did not disinfect high-touch areas such as the resident's call light or remotes.

Level of Harm - Minimal harm or HK #1 returned to his cart, removed his gloves and donned a new set of gloves without performing hand potential for actual harm hygiene. HK #1 took a mop head out of a bin with cleaning solution and put it on the floor in side A. HK #1 then pushed the mop into Side B and began mopping. HK #1 used the chisel from his pocket to scrape the Residents Affected - Many floor in several areas. HK #1 wiped the chisel along the back of the mop head before returning it to his pants pocket. HK #1 used the mop to push crumbs and a pillowcase from side B to side A and into the hallway. HK #1 used the same mop head to mop side A.

-HK #1 failed to mop the two sides of the room separately.

HK #1 returned to his cart, removed his gloves and donned new ones without performing hand hygiene. HK #1 grabbed two new rags from the cleaning solution bin and began to wipe down the sink area, the paper towel holder, the walls in the bathroom, then the bathroom handrail. HK #1 used a new rag to wipe the base of the toilet and the outside of the toilet bowl. HK #1 returned to the cart, removed his gloves and donned a new pair of gloves without performing hand hygiene. HK #1 grabbed a new rag from the cleaning solution bin, removed the raised toilet seat and set it on the bathroom floor, wiped the toilet flusher, the top of the toilet seat, bottom of the toilet seat and the rim of the toilet. HK #1 then began wiping the bottom side of the raised toilet seat before wiping down the top side of the raised toilet seat with the same rag.

-HK #1 did not wipe the handles of the raised toilet seat.

HK #1 removed his gloves, retrieved the Clorox hydrogen peroxide spray and sprayed the inside of the toilet bowl. HK #1 donned a new set of gloves, retrieved the toilet brush from the cart, and began scrubbing the inside of the toilet bowl. HK #1 put the toilet brush back onto the housekeeping cart.

-HK #1 did not disinfect the toilet brush after use.

HK #1 retrieved a new mop head, placed it on the bathroom floor and began mopping the bathroom. HK #1 used the chisel to scrape fecal material off of the bathroom floor. HK #1 wiped the chisel on the top of the mop head several times before wiping the chisel on his pants and placing the chisel back into his pocket. HK #1 then used the mop to sweep pieces of feces from the bathroom through side A of the room and into the hallway. HK #1 said the material he chiseled off the ground was feces.

During a continuous observation on 2/6/25, from 9:22 a.m. to 9:44 a.m., HK #2 was observed cleaning room [ROOM NUMBER].

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 58 of 64 065290 Department of Health & Human Services Printed: 09/09/2025 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 065290 B. Wing 02/06/2025

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

Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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 At 9:22 a.m. HK #2 finished cleaning room [ROOM NUMBER], removed her gloves and donned a new set of gloves without performing hand hygiene. HK #2 entered room [ROOM NUMBER] and began cleaning. HK #2 Level of Harm - Minimal harm or went into the bathroom and collected the trash bag from the trash can, grabbed a paper towel and removed potential for actual harm something from the sink, then used the same gloved hand to move one of the resident's walkers by the handle. HK #2 returned to her cart, removed her gloves and donned a new set without performing hand Residents Affected - Many hygiene. HK #2 grabbed a rag from the bin with cleaning solution and began wiping the dresser for side A and the top of the cart used to hold personal protective equipment (PPE). With the same gloved hands, HK #2 grabbed a new rag and wiped the area around the sink. HK #2 then used the same rag to wipe a small area of the outside portion of the door handle. HK #2 retrieved a new rag with the same gloved hands and began wiping the bedside table in side B of the room. The bedside table was mostly covered with the resident's personal items, which HK #2 did not move but instead wiped the available surface area of the table.

-HK #2 did not disinfect the high-touch surfaces on side A or side B of the room including call lights, light switches and remotes.

HK #2 returned to her cart, removed her gloves and donned new gloves without performing hand hygiene. HK #2 grabbed a toilet brush and a new rag from the bin with cleaning solution. HK #2 hung the toilet brush from the hand rail in the bathroom, squeezed the cleaning solution out of the rag and into the toilet, and used

the same rag to clean the sink area in the bathroom. HK #2 used the toilet brush to scrub the bowl of the toilet, then used the same rag to clean the underside of the seat, the rim of the toilet bowl, then the top of the toilet seat and the toilet basin. HK #2 returned the toilet brush back to her cart without disinfecting it.

-HK #2 did not disinfect high-touch surfaces in the bathroom including the sink faucet, the hand rail in the bathroom, the soap dispenser or the toilet flusher.

HK #2 grabbed a mop pad and put it onto the B side and began to mop that side. HK #2 used the mop to sweep debris including cotton gauze and a rubber band through side A into the hallway. HK #2 then used the same mop pad to mop the A side.

HK #2 retrieved a new mop head and put it on the bathroom floor and mopped the bathroom. HK #2 lifted and carried the mop through the room, removed the mop head, put her equipment onto the cart and removed her gloves. HK #2 knocked on the door to room [ROOM NUMBER] and donned a new pair of gloves without performing hand hygiene. HK #2 then began cleaning room [ROOM NUMBER].

D. Staff interviews

The environmental services director (ESD) was interviewed on 2/6/25 at 12:08 p.m. The ESD said the housekeeping staff should start at the sink in the room and work from dirtiest surfaces to cleanest surfaces.

The ESD said the housekeeping staff should start at the sink, then clean the bathroom, then the B side of the room and the A side last. The ESD said the housekeepers had a specific toilet cleaner they used to clean the bowl of the toilet. The ESD said he did not know the exact steps the housekeepers followed, but said they should wipe the toilet handle, then the seat to prevent transferring bacteria from the seat to the handle. The ESD said the toilet scrub brush should be sanitized between each room.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 59 of 64 065290 Department of Health & Human Services Printed: 09/09/2025 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 065290 B. Wing 02/06/2025

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

Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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 ESD said the housekeeping staff should use one mop head for side A and one mop head for side B. The ESD said the housekeeping staff should use hand sanitizer after removing dirty gloves and before putting on Level of Harm - Minimal harm or clean gloves. potential for actual harm

The ESD said the housekeeping staff should use a disinfectant spray and rag to wipe all high-touch surface Residents Affected - Many areas.

The ESD said he knew HK #2 was using a chisel when cleaning the rooms. He said he assumed HK #2 disinfected the chisel between use.

The CC was interviewed on 2/6/25 at 6:01 p.m. The CC said the housekeeping staff should perform hand hygiene before entering a resident's room and before each glove change and should change their gloves frequently. The CC said it was not an acceptable practice to move from the bathroom to the room with the same mop head. The CC said high-touch surfaces should be cleaned daily with a disinfectant solution.

II. EBP failures

A. Professional reference

The Centers for Disease Control and Prevention (CDC) Implementation of Personal Protective Equipment (PPE) Use in Nursing Homes to Prevent Spread of Multidrug-resistant Organisms (MDROs) (4/2/24), was retrieved on 2/13/25 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part, EBP are an infection control intervention designed to reduce transmission of resistant organisms that employ targeted gown and glove use during high contact resident care activities.

Nursing home residents with wounds and indwelling medical devices are at especially high risk of both acquisition of and colonization with MDROs. The use of gown and gloves for high-contact resident care activities is indicated, when contact precautions do not otherwise apply, for nursing home residents with wounds and/or indwelling medical devices regardless of MDRO colonization as well as for residents with MDRO infection or colonization.

Examples of high-contact resident care activities requiring gown and glove use for Enhanced Barrier Precautions include dressing, bathing/showering, transferring, providing hygiene, changing linens, changing briefs or assisting with toileting, device care or use (central line, urinary catheter, feeding tube, tracheostomy/ventilator) and wound care: any skin opening requiring a dressing.

B. Facility policy and procedure

The Enhanced Barrier Precautions policy, revised March 2024, was provided by the CC on 2/10/25 at 11:56 a.m. It read in pertinent part, EBPs are used as an infection prevention and control intervention to reduce the transmission of MDROs.

Gloves and gown are applied prior to performing high-contact resident care activities.

Signs are posted in the door or wall outside the resident room indicating the type of precautions and PPE required.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 60 of 64 065290 Department of Health & Human Services Printed: 09/09/2025 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 065290 B. Wing 02/06/2025

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

Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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 C. Observations

Level of Harm - Minimal harm or On 2/5/25 at 11:45 a.m. an EBP sign was observed on Resident #284's door. Registered nurse (RN) #2 was potential for actual harm providing tube feeding care for Resident #284. RN #2 entered Resident #284's room performed hand hygiene and donned gloves. He raised the head of Resident #284's bed. RN #2 pulled back Resident #284's Residents Affected - Many gown and opened the gastrostomy tube (G tube) cover. He then connected the tube feeding tubing to the open G tube port and started the tube feeding. He then disposed of supplies in the trash, removed his gloves and performed hand hygiene.

-RN #2 did not don a gown before touching the patient, tube feeding supplies or the G tube port.

On 2/5/25 at 2:21 p.m. certified nurse aide (CNA) #5 was observed as she finished emptying Resident #52's catheter bag. CNA #5 was wearing gloves but was not wearing a gown. There was no sign indicating Resident #52 needed EBP on her door and there was no PPE observed inside or outside of the resident's room (which was indicated in the facility's policy and interviews as the facility's process for identifying residents on EBP - see facility policy above and interviews below).

On 2/6/25 at 8:30 a.m. licensed practical nurse (LPN) #1 was providing catheter care for Resident #52. Resident #52's room did not have an EBP sign on the door. LPN #1 filled a basin with warm water, washed her hands, pulled the privacy curtain and put on gloves. LPN #1 did not don a gown.

-LPN #1 did not don the appropriate PPE to care for Resident #52's indwelling catheter.

D. Staff interviews

RN #2 was interviewed on 2/5/25 at 11:50 a.m. RN #2 said before touching a resident with a tube feeding hand hygiene should be performed and gloves should be donned. He said if there was a risk of blood or body fluids being sprayed a mask should be used. He said he was not aware of the EBP outside of the door.

He said he was not aware that a gown needed to be used for residents on EBP.

CNA #5 was interviewed on 2/5/25 at 2:21 p.m. CNA #5 said the CNAs only wore gloves to empty the resident's catheter bags if the resident did not have anything infectious. She said the CNAs did not wear gowns when providing catheter care.

RN #1 was interviewed on 2/6/25 at 9:16 a.m. RN #1 said EBP was used for residents with wounds or urinary catheters. RN #1 said the EBP signs on the resident's doors indicated the nursing staff needed to wear a gown and gloves. RN #1 said EBP were to protect the workers and other residents in case the resident with EBP had an infection.

CNA #10 was interviewed on 2/6/25 at 10:13 a.m. CNA #10 said EBP was used for residents with catheters. CNA #10 said EBP meant the staff needed to wear gloves only when they were specifically working with the resident's catheter or indwelling line, but not when providing other high-contact care. CNA #10 said the nursing staff only needed to wear gloves and not a gown when providing catheter care.

LPN #1 was interviewed on 2/6/25 at 8:40 a.m. LPN #1 said she normally put on a gown on when providing catheter care.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 61 of 64 065290 Department of Health & Human Services Printed: 09/09/2025 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 065290 B. Wing 02/06/2025

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

Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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 CNA #6 was interviewed on 2/6/25 at 3:10 p.m. CNA #6 said she looked for the EBP signs on resident's doors to see what PPE she needed to put on when working with those residents. Level of Harm - Minimal harm or potential for actual harm The CC was interviewed on 2/6/25 at 6:01 p.m. The CC said EBP were used for any residents with chronic wounds or indwelling devices. The CC said the need for EBP was identified on admission. The CC said the Residents Affected - Many residents that needed EBP had a sign outside their door that indicated they needed EBP and a bin of PPE outside of their room. The CC said anyone that entered the room to provide direct care needed to don a gown and gloves. The CC said EBP should be indicated in the resident's care plan.

III. Catheter care failures

A. Facility policy and procedure

The Urinary Catheter Care policy and procedure, revised August 2022, was received from the CC on 2/10/25 at 11:56 a.m. It read in pertinent part, The purpose of this procedure is to prevent urinary catheter-associated complications, including urinary tract infections.

B. Observations

On 2/6/25 at 8:30 a.m. LPN #1 was providing catheter care for Resident #52. LPN #1 filled a basin with warm water, washed her hands, pulled the privacy curtain and put on gloves. LPN #1 did not don a gown. LPN #1 removed Resident #52's incontinence brief. LPN #1 used a warm wet washcloth and wiped down the front of Resident #52's perineum from front to back and then wiped down her catheter with the same cloth. LPN #1 disposed of the washcloth. LPN #1 obtained a new washcloth and wiped the catheter towards the catheter bag then wiped back up the catheter tubing towards Resident #52's perineum. LPN #1 used the same cloth to wipe Resident #52's perineum and disposed of the washcloth.

-LPN #1 wiped the catheter tubing from the catheter bag to the perineum

-LPN #1 used the same washcloth to wipe Resident #52's perineum before wiping down the catheter tubing.

C. Staff interviews

LPN #1 was interviewed on 2/6/25 at 8:40 a.m. LPN #1 said she washed her hands and put on gloves before performing catheter care. LPN #1 said she normally put on a gown as well. LPN #1 said when providing catheter care she should wipe from front to back and use a separate washcloth when moving from the perineum to the catheter. LPN #1 said when cleaning the catheter she should start at the perineum and wipe away (down the line toward the catheter bag).

The director of nursing (DON) was interviewed on 2/6/25 at 7:47 p.m. The DON said when providing catheter care, the nursing staff should wipe from the urethra down to the catheter bag and work from clean surfaces to dirty surfaces. The DON said the nursing staff needed to don a gown and gloves when providing catheter care.

51163

IV. Tracheostomy failures

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 62 of 64 065290 Department of Health & Human Services Printed: 09/09/2025 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 065290 B. Wing 02/06/2025

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

Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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 A. Professional reference

Level of Harm - Minimal harm or Treas, L.S., [NAME], K.L., & [NAME], M.H. (2022) Basic Nursing, Thinking, Doing and Caring, (Third edition), potential for actual harm chapter 33, page 1437, Performing Tracheostomy or Endotracheal Suctioning. It read in pertinent part [NAME] a nonsterile glove and face shield or goggles. Test the suction equipment by oscillating the Residents Affected - Many connection tubing. Remove and discard gloves. Perform hand hygiene. Open the suction catheter kit. Maintain sterility of the inside of the suction kit. [NAME] gloves, consider your dominant hand clean and your nondominant hand as contaminated. Pour the sterile saline solution into a sterile container. Pick up the suction catheter with your dominant hand and attach it to the connection tubing. Do not touch the connection tubing with your dominant hand.

B. Observations and interviews

On 2/6/25 at 10:12 a.m. RN #2 was observed providing suctioning for Resident #284's tracheostomy.

RN #2 said the procedure could be performed as a clean or sterile procedure and that he tried to be as sterile as possible.

RN #2 laid all of the prepackaged sterile equipment on Resident #284's bedside table without cleaning the table or removing the items that were already on the bedside table. RN #2 did not designate a clean area and dirty area.

RN #2 proceeded to wash his hands for approximately 12 seconds. He dried his hands and opened a trash bag and put it in the trashcan. He then washed his hands again for approximately 10 seconds and opened

the box of gloves and put on a pair of the gloves. He then touched the privacy curtain, touched the bed control, pulled out the pulse oximeter from his pocket, touched the resident's hand, touched the tracheostomy tubing that was still connected to the resident and touched the bedside table. The package of suctioning equipment fell to the floor. He then picked up the package of suctioning equipment from the floor, opened the sterile suctioning equipment, grabbed his pen out of his pocket, raised the head of the bed and removed his gloves. Without performing hand hygiene, he put on his gown, opened and poured the distilled water into the sterile container. He then put on gloves without performing hand hygiene. He treated his left hand as his dirty hand. The tracheostomy tubing and tracheostomy mask fell to the floor. He picked up the tubing from the floor and removed the tracheostomy mask from the end of the tubing with his right hand, which was his sterile hand. He began to suction using both hands. He used his right hand to touch the resident and to check the pulse oximeter. He then grabbed the tracheostomy mask with his right hand, went to the sink and rinsed the tracheostomy mask off using water. He then said that he thought it was clean enough. He used his right hand to dry the mask with a paper towel. He then used his left hand to open and dig through all of Resident #284's bedside table drawers looking for a new tracheostomy mask. He touched

the tracheostomy mask with both hands. He attached the tubing to the mask and put the tracheostomy mask onto Resident #284's tracheostomy. RN #2 then took off his gloves and washed his hands.

D. Staff interview

The CC was interviewed on 2/6/25 at 6:31 p.m. The CC said when the staff were completing tracheostomy suctioning, it was important to establish a clean area. She said the person doing the suctioning should have

a clean hand and a dirty hand. She said that hand hygiene should be done before putting on sterile gloves.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 63 of 64 065290 Department of Health & Human Services Printed: 09/09/2025 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 065290 B. Wing 02/06/2025

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

Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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 V. Failure to clean vital signs equipment between residents

Level of Harm - Minimal harm or A. Professional reference potential for actual harm According to the CDC Recommendations for Disinfection and Sterilization in Healthcare Facilities, (2024), Residents Affected - Many retrieved on 2/13/25 from https://www.cdc. gov/infection-control/hcp/disinfection-sterilization/summary-recommendations. html#:~:text=Ensure%20that%2C%20at%20a%20minimum,once%20daily%20or%20once%20weekly. It read in pertinent part, Clean medical devices as soon as practical after use. Perform either manual cleaning or mechanical cleaning. Perform low-level disinfection for noncritical patient-care surfaces and equipment (blood pressure cuffs) that touch intact skin.

B. Observation

During a continuous observation on 2/4/25, beginning at 3:59 p.m. and ending at 5:32 p.m., the following was observed:

At 3:59 p.m. CNA #7 came out of a resident's room with vital signs equipment (blood pressure cuff, pulse oximeter, thermometer and a vitals clipboard) and went directly into another resident's room. She did not disinfect the equipment between residents. She then left the room and went into another resident's room,

she did not clean the equipment. After taking that resident's vital signs she then put the vital signs equipment away without cleaning it and took a resident outside to smoke.

At 4:19 p.m she returned from the smoke break. She did perform hand hygiene and did not clean the vital signs equipment. She then entered another resident's room and obtained their vital signs.

C. Staff interview

The CC was interviewed on 2/6/25 at 6:01 p.m. The CC said the CNAs were responsible for cleaning the equipment between use and on a routine basis. The CC said the vital sign machine should be cleaned with sanitizing wipes in between residents.

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FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 64 of 64 065290