Crestmoor Care Center

documented that the social services director (SSD) searched the room and could not find the pants in his closet. It documented that his last inventory sheet had four pairs of pants.

The NHA approved purchasing four new pairs of pants for the resident.

The form was signed by Resident #24 and the NHA on 2/3/25, during the survey.

D.

Staff interviews The social services consultant (SSC) was interviewed on 2/6/25 at 1:10 p.m.

The SSC said that grievance forms were at the front of the building and could be filled out by residents or staff members and be submitted anonymously.

The SSC said social services started the grievance process and then forwarded it to the appropriate department to follow up on the concern.

She said grievances were also discussed in the morning meetings and forwarded to the appropriate department for follow up and a resolution to the grievance should be reached with the resident within 72 hours of the date the grievance was filled out.

The NHA was interviewed on 2/6/25 at 1:25 p.m.

The NHA said he had been at the facility for two years and Resident #24 had a pattern of asking the facility to replace his pants since 2017. He said the resident had multiple inventory lists and it had been unclear which inventory list he had been working off of. He said the grievance process for the missing pants had begun in September 2024. He said the facility had not been successful in finding the missing pants and did not come to a successful resolution with Resident #24. He said the issue came up again recently, and this time they were able to successfully resolve the issue with the resident.

The NHA said the facility would be purchasing four new pairs of pants for Resident #24.

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Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

According to the February 2025 CPO, diagnoses included dementia and depression.

The 1/9/25 MDS assessment revealed the resident was severely cognitively impaired with a BIMS score of zero out of 15.

The resident was dependent on staff for most ADLs.

The MDS assessment documented Resident #69 did not have physical and behavioral symptoms directed toward others.

D.

Staff interviews CNA #5 was interviewed on 2/6/25 at 3:03 p.m. CNA #5 said Resident #69 did not have any issues with any other residents. CNA #5 said other residents would hold onto Resident #69 or follow her, but Resident #69 did not initiate contact with them.

The NHA was interviewed on 2/6/25 at 6:48 p.m.

The NHA said Resident #69 and Resident #235 got into a scuffle over seating in the dining room in March 2024.

The NHA said he did not think Resident #235 was trying to hurt Resident #69, but she did hit her in the face.

The NHA said Resident #235 had a history of resisting care.

The NHA said there was a situation in the dining room in which two residents were trying to be friends with a third resident, so they were all trying to sit in one specific seat in the dining room.

The NHA said the facility got rid of the seat in question and that eliminated the issue.

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Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

incontinence and noted the resident was dry.

However, RN #4 did not reposition Resident #53 while he

-

The facility failed to reposition Resident #53 during the four hour continuous observation.

C.

Record review The 1/21/25 ADLs care plan revealed Resident #53 was totally dependent on two staff members to provide baths and showers as necessary.

The care plan indicated the resident was to be turned and repositioned frequently to decrease pressure.

The care plan further indicated staff was to provide the resident with mouth care as per ADL personal hygiene and apply lip balm/ointment to the resident's lips as needed.

A review of Resident #53's electronic medical record (EMR) revealed that the resident received only one bath per week. Resident #53 had her last two baths on 1/31/25 and 1/24/25.

D.

Staff interviews CNA #8 was interviewed on 2/6/25 at 3:26 p.m. CNA #8 said he checked Resident #53 every two hours for incontinence care, repositioned her every two hours and cleaned her mouth two to three times a day, and as needed. He said all CNAs should do the same. CNA #8 said Resident #53 needed two people for assistance.

RN #4 was interviewed on 2/5/25 at 5:20 p.m. RN #4 said the CNAs checked Resident #53 every two hours because she could not move or communicate and staff should assist her with repositioning, toileting, mouth care and grooming.

The DON was interviewed on 2/6/25 at 7:21 p.m.

The DON said the staff should reposition Resident #53 and wash her face and mouth every few hours.

The DON was unaware that Resident #53 had not received a bath in six days.

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was a deep tissue injury over scar tissue and the coccyx wound was a stage two pressure injury.

the resident needed one to assist with wound healing.

CNA #3 was interviewed on 2/6/25 at 2:40 p.m. CNA #3 said Resident #75 was total care and dependent on staff for assistance with ADLs.

She said the resident was incontinent. CNA #3 said dependent residents should be repositioned every two hours.

She said skin protectant creams were supposed to be used every time peri-care was completed and any new skin issues should be reported to the nurse.

CNA #1 was interviewed on 2/6/25 at 3:07 p.m. CNA #1 said Resident #75 was dependent on staff for incontinence care, showering and repositioning.

She said residents should be repositioned every two hours, however, some residents may have different care plans.

She said newly identified skin issues should be reported to the nurse.

She said she had previously seen wound dressings on Resident #75's coccyx, however, she said he no longer needed them because his wound had improved. CNA #1 said barrier cream was applied after incontinent episodes to prevent skin breakdown.

She said the resident's nurse should be notified if a dressing came off or became dislodged.

RN #3 was interviewed on 2/6/25 at 3:16 p.m. RN #3 said dependent residents should be repositioned every two hours to prevent skin breakdown.

She said Resident #75 was admitted to the facility with a stage two pressure wound on his coccyx, a widespread rash and stage two pressure wounds on both heels.

She said there was an order to put zinc cream onto his coccyx for wound prevention, however, she said there was not an order to apply Mepilex to Resident #75's coccyx.

After RN #3 reviewed Resident #75's February 2025 CPO for his coccyx wound orders, she said there was an order for Mepilex dressings, however, she said she had not been applying them because they would not adhere to Resident #75's skin due to the topical zinc cream applied to the wound.

She said she would coat on a lot of zinc to treat the wound and told the CNAs to use a lot of barrier cream with incontinence care.

The DON was interviewed a second time on 2/6/25 at 4:03 p.m.

The DON said residents at high risk for skin breakdown and who were dependent on staff for ADL care should be repositioned at least every two hours.

She said if a change in condition was noted, it should be reported to the resident's nurse or the DON.

She said when Resident #75 was admitted , he had redness on his coccyx, however, she said it resolved with the use of barrier cream.

The DON said she was not informed Resident #75 had new redness and an open wound on his coccyx.

She said she asked RN #3 about his wound and RN #3 told her Resident #75's coccyx appeared red and shiny on 2/5/25, however, no open wounds were observed.

The DON said RN #3 was not following physician's orders by not applying a Mepilex dressing to Resident #75's coccyx wound.

She said she would follow up with RN #3.

She said Resident #75's bed mattress was being switched to an alternative pressure mattress (on 2/6/25).

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to get up to go to the bathroom. He said Resident #54 was not on any fall precautions and he was able

-However, Resident #54's 12/18/24 MDS assessment indicated the resident needed supervision or touching assistance for all of his transfers and ambulating and partial to moderate assistance with toileting (see resident status above).

RN #4 was interviewed on 2/6/25 at 4:20 p.m. RN #4 said Resident #54 was on fall precautions because he had a recent fall. He said when Resident #54 ambulated, he was supposed to be supervised and he was supposed to call for help before he got up. RN #4 said Resident #54's bed should be in the lowest position.

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before performing catheter care. LPN #1 said she normally put on a gown as well. LPN #1 said when

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.

discharged .

The DON said there should not be any loose pills in the medication carts.

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Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

During a continuous observation of the lunch meal service on 2/5/25, 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 2/6/25 at 9:51 a.m.

The DM said ready-to-eat foods should be handled with clean gloves used only for one task.

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Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

temperatures, not the refrigerators' contents.

The ESD said it was a grey area which department was

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Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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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Crestmoor Care Center 895 S Monaco Pkwy Denver, CO 80224

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.

065290

Form Approved OMB

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