Highline Post Acute

F-F947 for failure to ensure CNAs received annual training as required.

III. Staff interviews

The DON was interviewed on 8/15/24 at 11:50 a.m. The DON said she had just recently become the DON at

the facility. She said annual performance reviews had not been completed.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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 0730 The RDCS was interviewed on 8/15/24 at 11:26 a.m. The RDCS said the annual performance evaluations had not been completed as required. She said, during the survey, the facility had put a plan in place to Level of Harm - Minimal harm or ensure annual performance reviews were completed timely. potential for actual harm

Residents Affected - Some

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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 47064 Residents Affected - Few Based on observations and interviews, the facility failed to ensure medications and biologicals were stored and labeled properly according to professional standards in two of three medication carts and one of two medication storage rooms.

Specifically the facility failed to:

-Ensure medications were properly labeled with resident names;

-Ensure medications were stored according to route of administration;

-Ensure food was not stored with medications; and,

-Ensure medications were not stored in a dormitory style.

Findings include:

I. Professional reference

According to the Trulicity package insert, retrieved on 8/19/24 from https://uspl.lilly.com/trulicity/trulicity. html#mg,

Store Trulicity in the refrigerator , do not freeze Trulicity. Do not use trulicity if it has been frozen.

II. Facility policy and procedure

The Storage of Medications policy and procedure, dated November 2020, was received from the regional director of clinical services (RDCS) on 8/15/24 at 1:36 p.m. It revealed in pertinent part, The facility stores all drugs and biologicals in a safe, secure and orderly manner.

Nursing staff are responsible for maintaining medications storage and preparation areas in a clean, safe, and sanitary manner.

Medications requiring refrigeration are stored in refrigerators located in the drug room at the nurse's station or other secured locations. Medications are stored separately from food and are labeled accordingly.

III. Observations and staff interviews

On 8/14/24 at 11:01 a.m. the Cherry Creek long hall medication cart was observed with licensed practical nurse (LPN) #1. The following was observed:

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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

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

F 0761 One vial of glargine insulin (used for blood glucose management) with an open date of 8/6/24.

Level of Harm - Minimal harm or -The vial was not labeled with a resident's name. The vial had house stock written on the bottle. potential for actual harm LPN #1 was interviewed on 8/14/24 at 11:04 a.m. LPN #1 said the glargine insulin vial was the facility's Residents Affected - Few house stock for emergencies, for example when there was a new physician's order and the medication had not been delivered from the pharmacy. LPN #1 said the vial should have had the resident's name on it to identify it belonged to a certain resident as each resident should have their own vial or pen for insulin.

On 8/14/24 at 12:13 p.m. the Capitol Hill medication cart was observed with registered nurse (RN) #1. The following was observed:

-One vial of Lantus insulin was stored next to Latanoprost 0.005% eye drops in the medication cart.

RN #1 was interviewed on 8/14/24 at 12:25 she said medications should be stored according to the route

they were to be administered to prevent infections.

On 8/14/24 at 12:18 p.m. the Capitol Hill medication storage room was observed with RN #1. The following was observed:

-The medication storage refrigerator was unlocked and there were four 237 milliliters (ml) cartons of Boost (supplement drink) on the shelf with Lorazepam (antianxiety controlled medication), liquid cephalexin (antibiotic) and two boxes of Trulicity injectable pens (used for glucose control).

-The medication refrigerator was a dormitory style refrigerator where the freezer compartment was in the main compartment of the refrigerator. The freezer compartment had built up ice around and in the freezer.

RN #1 was interviewed on 8/14/24 at 12:25 p.m. RN #1 said there should not be food or oral nutritional supplements in the refrigerator with medications. RN #1 said the ice build up in the freezer compartment could potentially cause temperature fluctuations and medications needed to be kept within a certain temperature range.

IV. Additional staff interviews

The director of nursing (DON) was interviewed on 8/14/24 at 11:18 a.m. The DON said insulin vials or pens should have the resident's name on them to verify who the medication belonged to. The DON said she would pull the vial of glargine insulin from the medication cart.

The DON was interviewed a second time on 8/15/24 at 12:14 p.m. The DON said the facility had obtained a new vial of glargine insulin to replace the glargine insulin vial that had no name on it from the Cherry Creek long hall medication cart.

The DON said food and nutritional supplements should not be stored with medications in the medication refrigerator in order to prevent contamination. The DON said medications should be stored according to the route they were to be administered in the medication carts to prevent contamination/infection.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 18 of 39 065256 Department of Health & Human Services Printed: 09/13/2025 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 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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

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

F 0761 The DON said dormitory style refrigerators should not be used for medication storage as their temperatures could fluctuate and compromise medications. The DON said she was not aware the facility had any Level of Harm - Minimal harm or dormitory style refrigerators. potential for actual harm

Residents Affected - Few

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 19 of 39 065256 Department of Health & Human Services Printed: 09/13/2025 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 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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 0805 Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. Level of Harm - Minimal harm or potential for actual harm 47151

Residents Affected - Few Based on observations, record review and interviews, the facility failed to ensure residents received food and fluids prepared in a form designed to meet his or her needs.

Specifically, the facility failed to ensure residents who were prescribed mechanically altered diets had food prepared according to their diet orders of puree, level five minced and moist and level six soft and bite sized as indicated on their meal tray cards.

Findings include:

I. Professional reference

The International Dysphagia (difficulty swallowing) Diet Standardization Initiative (IDDSI) (a tool to standardize mechanically altered diets and liquids) (January 2019), retrieved on 8/20/24 from https://iddsi. org/Resources/Patient-Handouts read in pertinent part,

Level four pureed foods have a smooth texture with no lumps.

The level five minced and moist texture: Meat should be served finely minced or chopped to a four millimeter (mm) (slightly larger than one eighth of an inch) lump size served in a thick, smooth, non-pouring sauce or gravy; vegetables should be cooked, finely mashed or blended to finely chop them into four mm lump size pieces. Rice requires a sauce to moisten it and hold it together. Rice should not be sticky or gluey and should not separate into individual grains when cooked and served. The rice may require a thick, smooth, non-pouring sauce to moisten and hold the rice together.

The level six soft and bite-sized texture: Meat should be cooked tender and chopped so pieces are no bigger than one and a half centimeter (cm) by one and a half cm lump size. If the meat cannot be served soft and tender, modify and serve as a level five mince and moist product. Vegetables should be steamed or boiled with final cooked size no bigger than one and a half cm by one and a half cm (approximately one half of an inch). (Stir fried vegetables are too firm and are not suitable). Rice requires a sauce to moisten it and hold it together. Rice should not be sticky or gluey and should not separate into individual grains when cooked and served. The rice may require a thick, smooth, non-pouring sauce to moisten and hold the rice together.

Bread: no regular dry bread, sandwiches or toast of any kind should be served for puree, level five or level six diets. Use IDDSI level five minced and moist sandwich recipe to prepare bread, use pre-gelled 'soaked' breads that are very moist and gelled through the entire thickness.

II. Facility policy and procedure

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 20 of 39 065256 Department of Health & Human Services Printed: 09/13/2025 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 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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 0805 The Therapeutic Diets policy and procedure, revised October 2017, was provided by the nursing home administrator (NHA) on 8/15/24 at 1:30 p.m. The policy read in pertinent part, Diet order should match the Level of Harm - Minimal harm or terminology used by the food and nutrition department. If a mechanically altered diet is ordered, the provider potential for actual harm will specify the texture modification. The dietitian, nursing staff and attending physician will regularly review

the need for, and resident acceptance of, prescribed therapeutic diets. Snacks will be compatible with the Residents Affected - Few therapeutic diet. If the resident or resident's representative declines the recommended therapeutic diet, the

interdisciplinary team will collaborate with the resident or representative to identify possible alternatives.

III. Record review

The menu extensions and modifications for modified texture diets were provided by the consulting registered dietitian (CRD) on 8/15/24 at 3:00 p.m. The menu extensions documented the following modifications for the mechanically altered food items served during lunch meal service on 8/13/24 and breakfast and lunch meal service on 8/14/24:

The modified texture diet menu extensions for the lunch meal on 8/13/24 were documented as follows:

-Puree texture included: Puree roast beef, puree cilantro brown rice, puree carrots and puree banana cake;

-Level five minced and moist texture included: Minced and moist roast beef, cilantro brown rice and minced and moist carrot and minced and moist banana cake; and,

-Level six soft and bite sized texture included: Soft and bite sized roast beef, cilantro brown rice, soft and bite sized carrots and soft and bite sized banana cake.

The modified texture diet menu extensions for the breakfast meal served on 8/14/24 were documented as follows:

-Level six soft and bite sized texture: serve the biscuit and gravy as puree biscuit and gravy.

The modified texture diet menu extensions for the lunch meal on 8/14/24 were documented as follows:

-Puree texture included: Puree hamburger, puree potatoes, puree white roll and vanilla pudding;

-Level five minced and moist: Minced and moist hamburger, minced and moist dice potatoes, white roll and vanilla pudding; and,

-Level six soft and bite sized: Soft and bite sized hamburger, diced potatoes, white roll and vanilla pudding.

III. Meal service observation

During a continuous observation of the lunch meal service in the secure unit on 8/13/24, beginning at 10:16 a. m. and ending at 1:00 p.m., the following was observed:

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 21 of 39 065256 Department of Health & Human Services Printed: 09/13/2025 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 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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 0805 The posted menu in the dining room documented the lunch meal consisted of pot roast, glazed carrots, cilantro brown rice and banana cake. Level of Harm - Minimal harm or potential for actual harm At 11:55 a.m. the meal tray cart arrived in the secure unit.

Residents Affected - Few At 12:14 p.m. a meal tray was delivered to Resident #86 by an unidentified staff member. Resident #86's meal tray card documented she was prescribed a level six soft and bite sized diet. Resident' #86 was served

a meal that included roast beef, rice, and carrots sliced in one to one and a half inch pieces.

-The facility failed to add gravy to Resident #86's rice and failed to cut Resident #86's carrots into pieces no bigger than one and a half by one and a half centimeters according to the IDDSI recommendations for a level six soft and bite sized diet (see professional reference above).

At 12:16 p.m. a meal tray was delivered to Resident #23. Resident #23 received puree food items on a divided plate. The puree rice on Resident #23's plate appeared to have visible pieces of rice that were not blended and smooth. While assisting Resident #23 at meal time, an unidentified staff member asked Resident #23 if she liked the food and Resident #23 replied, No.

At 12:29 p.m. Resident #81's meal tray card documented he was prescribed a level five minced and moist diet. Resident #81 was served a meal that included carrots sliced into one to one and a half inch pieces.

-The facility failed to cut or chop Resident #81's carrots into four mm lump size pieces according to the IDDSI recommendations for a level five minced and moist diet (see professional reference above).

At 12:24 p.m. the nutritional services director (NSD) was interviewed. The NSD was notified the carrots were cut into one inch to one and a half inch pieces. The NSD said she did not yet have full access to her menu program for menu extensions. The NSD said the carrots might be too big based on the IDDSI description and the staff usually cut the vegetables into bite sized pieces.

At 12:29 p.m. Resident #28's meal tray card documented she was prescribed a level six soft and bite sized diet. Resident #28 was served a meal that included roast beef, rice, and carrots sliced in one to one and a half inch pieces.

-The facility failed to add gravy to Resident #86's rice and failed to cut Resident #86's carrots into pieces no bigger than one and a half by one and a half centimeters according to the IDDSI recommendations for a level six soft and bite size diet (see professional reference above).

At approximately 1:00 p.m. at the conclusion of the lunch meal, the puree food items provided to Resident #23 were observed to have small visible lumps in the puree entree, puree carrots and puree rice.

-The facility failed to puree the food items in Resident #23's meal until the food was smooth with no lumps according to the IDDSI recommendations (see professional reference above).

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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 0805 During a continuous observation in the secure unit on 8/14/24, beginning at 9:15 a.m. and ending 1:03 p.m.

the following was observed: Level of Harm - Minimal harm or potential for actual harm The posted menu in the dining room documented the breakfast meal consisted of biscuits and sausage gravy, and the lunch meal consisted of a beef gyro with cottage fries and a dinner roll. Residents Affected - Few At 9:49 a.m. certified nurse aide (CNA) #3 delivered a meal tray to Resident #86 that included scrambled eggs and biscuits and gravy. Resident #86's meal tray card documented she was prescribed a level six soft and bite sized diet. The biscuit was served whole, lightly browned on the edges and dry on the bottom with sausage gravy over the top of the biscuit. CNA #3 cut Resident #86's biscuit into one inch pieces.

-The facility failed to serve Resident #86 the biscuit and gravy as puree biscuit and gravy per Resident #86's level six soft and bite sized diet (see professional reference above).

At 12:15 p.m. activities assistant (AA) #1 delivered a meal tray tray to Resident #81. Resident #81's meal tray card documented he was prescribed a level five minced and moist diet. Resident #81 received a sandwich on a bun with meat in strips approximately one inch long, a dinner roll and cottage fries (french fried potatoes with skin on).

-The facility failed to serve Resident #81's meat finely minced or chopped to a four millimeter size, serve Resident #81's vegetables without skin and finely mashed or blended to finely chop them into four mm lump size pieces and modify his dinner roll so it was not served dry according to the IDDSI recommendations (see professional reference above).

IV. Staff interviews

CNA #2 was interviewed on 8/15/24 at 10:46 a.m. CNA #2 said she had received training on mechanically altered diet textures and how to recognize them. She said if a resident received an item prepared incorrectly according to their prescribed diet, she would inform the kitchen. CNA #2 said she did not see that Resident #81 was served potatoes that were not modified correctly during the 8/14/24 lunch meal.

Dietary aide (DA) #2 was interviewed on 8/15/24 at 1:56 p.m. DA #2 said residents prescribed level five and level six mechanically altered diets should not have toast but were able to have bread with crusts removed. DA #2 said if the menu extension called for diced potatoes, those on puree and level five and level six mechanically altered diets could have mashed potatoes unless the kitchen already had diced potatoes prepared.

Cook (CK) #1 was interviewed on 8/15/24 at 2:13 p.m. CK #1 said he worked as an agency employee but would soon be an employee of the facility. CK #1 said he had not had prior education on mechanically altered textures.

DA #1 was interviewed on 8/15/24 at 2:14 p.m. DA #1 said the previous dietary manager said residents on soft and bite-sized texture diets could be served grilled or toasted buns.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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 0805 -However, according to the IDDSI guidelines, no regular dry bread, sandwiches or toast of any kind should be served for puree, level five or level six diets. IDDSI level five minced and moist sandwich recipes should Level of Harm - Minimal harm or be used to prepare bread or the use of pre-gelled 'soaked' breads that were very moist and gelled through potential for actual harm the entire thickness were appropriate.

Residents Affected - Few The NSD and the CRD were interviewed together on 8/15/24 at 2:36 p.m. The NSD said she had not had any recent training regarding mechanically altered diets but was working on refreshing her knowledge. The NSD said the kitchen staff were not too knowledgeable on what the different diet textures were and what residents on mechanically altered diets could not have.

The CRD said the facility made an error serving potato skins on the french fries on 8/14/24. The CRD said

the issue was that the facility had ordered french fries with potato skin on them. The CRD said toasting buns for residents prescribed the soft and bite-sized diet texture's hamburger buns was a mistake.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 24 of 39 065256 Department of Health & Human Services Printed: 09/13/2025 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 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 47151

Residents Affected - Some Based on observations and interviews, the facility failed to provide food and drinks that accommodate resident allergies, intolerances and preferences for residents in one of two dining rooms and for one (#63) of four residents reviewed for preferences out of 46 sample residents.

Specifically, the facility failed to:

-Ensure residents in the secured unit were offered drinks of choice at meal time; and,

-Ensure Resident #63 received the meal items that he ordered.

Findings include:

I. Facility policy and procedure

The Resident Food Preferences policy, revised July 2017, was provided by the nursing home administrator (NHA) on 8/15/24 at 1:30 p.m. It read in pertinent part, Upon a resident's admission (or within 24 hours after his/her admission) the dietitian or nursing staff will identify a resident's food preferences. When possible, the staff will interview the resident directly to determine current food preferences based on history and life patterns related to food and mealtimes. Nursing staff will document the resident's food and eating preferences in the care plan. The Food Services Department will offer a variety of foods at each scheduled meal, as well as access to nourishing snacks throughout the day and night. The facility's Quality Assessment and Performance Improvement (QAPI) Committee will periodically review issues related to food preferences and meals to identify more widespread concerns about meal offerings, food preparation.

II. Failure to ensure residents in the secured unit were offered drinks of choice at meal time

A. Observations

During a continuous observation of the lunch meal service in the secured unit on 8/12/24, beginning at 11:12 a.m. and ending at 1:00 p.m., the following was observed:

At 11:28 a.m. the lunch meal cart arrived at the secure unit.

At 11:35 a.m. the facility staff served four residents their meal trays. Each of the four residents had a glass of cranberry juice on their meal tray.

At 11:36 a.m. the facility staff served two residents their meal trays. Each of the two meal trays had a glass of cranberry juice on the tray.

At 11:41 a.m. the facility staff served six more residents their meal trays. All six meal trays had a glass of cranberry juice on the tray.

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STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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 0806 -All twelve of the residents eating in the secured unit dining room had a pre-poured glass of cranberry juice sent on the meal tray cart on each resident's meal tray. Level of Harm - Minimal harm or potential for actual harm -No other drinks were on the resident meal tray carts or offered to residents.

Residents Affected - Some During a continuous observation of the lunch meal service in the secured unit on 8/13/24, beginning at 10:16 a.m. and ending at 1:00 p.m., the following was observed:

At 11:55 a.m. the lunch meal cart arrived at the secure unit.

At 12:01 p.m. facility staff began serving residents their meal trays.

At 12:03 p.m. the facility staff served four residents their meal trays. Each of the four residents had a glass of cranberry juice on their meal tray.

At 12:16 p.m. the facility staff served seven more residents their meal trays. Each resident had a glass of cranberry juice on their meal tray.

-A total of eleven residents eating in the secured unit dining room had a pre-poured glass of cranberry juice sent on the meal tray cart on each resident's meal tray.

-No other drinks were on the resident meal tray carts or offered to the residents.

During a continuous observation of the lunch meal service in the secure unit on 8/14/24, beginning at 11:15 a. m. and ending at 2:00 p.m., the following was observed:

At 12:04 p.m. the lunch meal cart arrived at the secure unit.

Between 12:04 p.m. and 12:22 p.m. the facility staff served nine residents seated in the dining room their meal trays and each of the nine residents had a glass of cranberry juice on their meal tray.

-A total of nine residents eating in the dining room had a glass of pre-poured cranberry juice sent on the meal tray cart on each resident's meal tray.

-No other drinks were on the resident meal tray carts or offered to the residents.

B. Staff interviews

Certified nurse aide (CNA) #2 was interviewed on 8/15/24 at 10:46 a.m. CNA #2 said the staff asked the residents for their preferences. She said the residents' dislikes and allergies were listed on their care plans and the meal tickets. CNA #2 said the staff asked residents what their drink preferences were. She said if a resident was unable to choose, the facility sent the resident cranberry juice because it was good for the resident's bladders. CNA #2 said the dietary staff used to send pitchers of different juices and milk to the secure unit for meal time but no longer did so. CNA #2 said the drinks for residents living on the secure unit were poured in the kitchen and sent in the meal tray cart at meal time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 39 065256 Department of Health & Human Services Printed: 09/13/2025 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 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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 0806 -However, staff were not observed asking residents the drink preferences during multiple meal service

observations. Level of Harm - Minimal harm or potential for actual harm The director of nursing (DON) was interviewed on 8/15/24 at 1:30 p.m. The DON said the staff should offer a choice of drinks to residents and if a resident was unable to state their preferences, the staff could ask the Residents Affected - Some resident's family for preferences. The DON said facility staff should be taking orders for the residents' drinks.

The DON said the staff should show the residents a choice between two different beverages if that helped

the resident choose. The DON said she was unsure if the residents in the secure unit all choose cranberry juice as their preferred drink.

47064

III. Failure to ensure Resident #63 received the correct meal items

A. Resident #63

1. Resident status

Resident #63, age less than 65, was admitted on [DATE REDACTED]. According to the August 2024 computerized physician orders (CPO), diagnoses included acute respiratory failure (disrupted oxygen exchange), chronic kidney disease (decrease kidney function), type 2 diabetes (abnormal glucose) and hypertension (high blood pressure).

The 6/3/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of nine out of 15.

The MDS assessment indicated the resident was on a therapeutic diet.

2. Resident interview

Resident #63 was interviewed on 8/12/24 at 10:18 a.m. Resident #63 said he preferred to eat his meals in his room. He said he often received food items on his meal trays that he did not order and he was frequently missing items he did order. Resident #63 said he would order sugar-free options like jello and he would receive regular jello versus sugar-free jello.

Resident #63 was interviewed again on 8/13/24 at 1:34 p.m. Resident #63 said he did not get his mashed potatoes and received rice instead for his lunch on 8/13/24. Resident #63 said nobody wanted to eat rice with pot roast.

Resident #63 said he did not want to eat his food because it was not what he had ordered. Resident #63 said nobody informed him that the rice was being served for lunch instead of mashed potatoes.

3. Observations and staff interviews

On 8/13/24 at 1:34 p.m. Resident #63's lunch tray was delivered. Resident #63's lunch meal ticket indicated Resident #63 had ordered mashed potatoes with gravy, pot roast, milk and a Glucerna (supplement drink). Resident #63's lunch tray had pot roast, rice, milk and a Glucerna.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 39 065256 Department of Health & Human Services Printed: 09/13/2025 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 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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 0806 -Resident #63 received rice on his lunch tray instead of the mashed potatoes he had ordered.

Level of Harm - Minimal harm or CNA #1 was interviewed on 8/13/24 at 1:41 p.m. CNA #1 said Resident #63 did not receive mashed potential for actual harm potatoes on his plate. She said the resident received rice, pot roast, milk and Glucerna.

Residents Affected - Some CNA #1 reviewed Resident #63's meal ticket and said the resident had ordered mashed potatoes.

-CNA #1 did not offer to get resident mashed potatoes or another alternative despite the resident's order being delivered incorrectly.

IV. Resident group interview

Four residents (#47, #68, #79 and #84) who were identified as interviewable by the facility and assessment, were interviewed on 8/13/24 at 2:30 p.m.

The residents said they could circle menu items they wanted on their meal ticket but they did not always receive what they ordered. The residents said the kitchen served all of the residents the same food items.

The group said the kitchen staff gave the residents what the kitchen wanted to serve and did not explain why

the residents did not get what they ordered.

V. Additional staff interviews

The DON and the regional director of clinical services (RDCS) was interviewed on 8/15/24 at 1:30 p.m. The DON said the CNAs needed to notify the nurse or unit manager if a resident refused their meal.

The RDCS said the facility had given education to CNAs about offering alternative menu items to residents and making sure the care plan reflected it.

The DON and the RDCS said they were not aware residents were not receiving the alternative menu items

they had requested. The DON and the RDCS said they were not aware that residents were not receiving the menu items they had requested.

Dietary aide (DA) #2 was interviewed on 8/15/24 at 1:56 p.m. DA #2 said the CNAs took the residents' orders and were responsible for helping the residents fill out their meal tickets. DA #2 said all of the residents received the same meals despite what was written on their meal tickets.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 39 065256 Department of Health & Human Services Printed: 09/13/2025 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 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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

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

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

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

Residents Affected - Some Based on observations, record review and interviews, the facility failed to ensure food was prepared, distributed and served under sanitary conditions in the kitchen.

Specifically, the facility failed to:

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

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

-Ensure safe holding temperatures for food items were maintained.

Findings include:

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

A. Professional reference

The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 8/20/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Food employees may not contact exposed, ready-to-eat food with their bare hands and shall use suitable utensils such as deli tissue, spatulas, tongs, single-use gloves, or dispensing equipment.

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

in the operation.

B. Observations

During a continuous observation of the lunch meal service on 8/13/24, beginning at 10:20 a.m. and ending at 1:40 p.m. the following was observed:

At 10:28 a.m. dietary aide (DA) #1 began preparing sandwiches. DA #1 donned (put on) a pair of gloves and grabbed several slices of bread out of a plastic bag. DA #1 grabbed and opened a jar of mayonnaise. Using

the same gloves, DA #1 held the slices of bread and applied mayonnaise. DA #1 set down the bread and opened the cold table tray lid by grabbing the handle with his gloved hand. With the same gloved hands, DA #1 picked up slices of lettuce and deli meat and set them on the sandwich.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 39 065256 Department of Health & Human Services Printed: 09/13/2025 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 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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 At 10:41 a.m. DA #2 donned a pair of gloves and opened the cold table tray lid by grabbing the handle. Using the same gloves, DA #2 picked up a plastic bread bag, undid the twist tie and pulled out two slices of Level of Harm - Minimal harm or bread. With the same gloved hands, DA #2 set the pieces of bread on the cutting board, grabbed deli meat potential for actual harm and set it on the bread. DA #2 left the station, still wearing the same gloves, and went to retrieve a block of cheese slices out of the main walk-in refrigerator. DA #2 peeled off the plastic wrapper around the block of Residents Affected - Some cheese slices. With the same gloved hands, DA #2 removed the deli slices that were on the bread, placed a cheese slice onto the bread, then replaced the deli meat on top of the cheese slice. DA #2 wiped his nose with his wrist and the back of his gloved hand, then placed the top slice of bread on the sandwich and wrapped it in plastic wrap.

At 11:30 a.m. the lunch tray line began. Throughout the lunch service, the nutritional services director (NSD) moved the pita bread using gloved hands to make room for other items on the plate.

-Between each tray the NSD was handling meal tickets, serving handles and tongs with the same gloved hands.

At 12:12 p.m. cook (CK) #1 opened the steam oven using gloved hands and grabbed a plastic bag of pita bread. Using the same gloved hands, CK #1 took several pieces of pita bread out of the bag and set them on individual plates to be served.

At 12:16 p.m. CK #1 grabbed another plastic bag of pita bread. Using the same gloved hands, CK #1 took

the pita bread out of the bag and put it into the steam table bin to be served.

-CK #1 had handled plate warmers and serving tongs using the same gloved hands prior to grabbing the pita bread bag.

At 12:18 p.m. DA #1 was handling meal tickets using gloved hands. With the same gloved hands, DA #1 took a hotdog bun out of the plastic packaging and set it on the griddle. Using the same gloved hands, DA #1 held the hot dog bun to steady it as she put the hot dog inside. DA #1 used the same gloved hands to handle meal tickets, a serving handle, then the microwave handle. Using the same gloved hands, DA #1 again picked up the hotdog and hotdog bun and set it onto a plate.

At 12:22 p.m. the NSD set a meal ticket on top of a lunch plate. The meal ticket was touching the hotdog bun.

At 12:26 p.m. the NSD took the temperature of a batch of gyro meat that was cooking in the steam oven. The NSD said the temperature was eight degrees below what it needed to be and grabbed a set of tongs from

the container that had cooked gyro meat in it. The NSD used the same tongs to lay the steam oven batch of gyro meat onto the griddle, then put the tongs back into the bin of cooked gyro meat on the steam table.

At 12:59 p.m. DA #2 opened the cold table tray lid with gloved hands. Using the same gloved hands, DA #2 sifted through several pieces of lettuce before selecting a few pieces and putting them on a plate. Using the same gloved hands, DA #2 lifted another cold table tray lid and pulled out two tomato slices before putting them on the same plate.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 39 065256 Department of Health & Human Services Printed: 09/13/2025 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 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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 On 8/15/24 at 1:56 p.m. DA #2 began preparing a sandwich. DA #2 donned gloves and opened the cold table tray lid, the lid for a jar of mayonnaise and the kitchen tool drawer. Using the same gloved hands, DA Level of Harm - Minimal harm or #2 grabbed a slice of cheese and several slices of deli meat before setting them onto a slice of bread. potential for actual harm C. Staff interview Residents Affected - Some

The NSD was interviewed on 8/14/24 at 2:50 p.m. The NSD said ready-to-eat foods should be handled with clean gloves. The NSD said gloves should be changed and hand hygiene should be performed after touching items such as tongs, meal tickets and handles to equipment.

II. Failed to store food items correctly in the refrigerators and the dry storage

A. Professional reference

The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 8/20/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part, Except for containers holding food that can be readily and unmistakably recognized such as dry pasta, working containers holding food or food ingredients that are removed from their original packages for use in the food establishment, such as cooking oils, flour, herbs, potato flakes, salt, spices and sugar shall be identified with the common name of the food.

In a mechanically refrigerated or hot food storage unit, the sensor of a temperature measuring device shall be located to measure the air temperature or a simulated product temperature in the warmest part of a mechanically refrigerated unit and in the coolest part of a hot food storage unit.

Ready-to-eat, time/temperature control for safety food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed on the premises, sold, or discarded when held at a temperature of 5 degrees celsius (41 degrees fahrenheit (f)) or less for a maximum of seven days. The day of preparation shall be counted as day one.

B. Observations

On 8/12/24 at 9:15 a.m. an initial walkthrough of the kitchen was conducted. The following was observed in

the dry food storage area:

-There was an unlabeled undated bin of what appeared to be flour; and,

-There was an unlabeled and undated container that held an open bag of rice. The rice was still in the open bag and the container did not have a lid on it.

On 8/13/24 at 10:25 a.m. the following was observed in the Seasons unit refrigerator:

-A used surgical mask was sitting on a container of popsicles in the freezer;

-An opened and undated bag of lettuce;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 39 065256 Department of Health & Human Services Printed: 09/13/2025 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 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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 -An opened and undated bag of shredded cheese;

Level of Harm - Minimal harm or -An opened and undated bag of tortillas; potential for actual harm -A four ounce container of applesauce that was opened and undated; Residents Affected - Some -Three unlabeled and undated sandwiches;

-A container of store-bought pre-cut cantaloupe was on the refrigerator shelf with a use by date of 8/11/24;

-An insulated lunch bag with no name or label was on the bottom shelf of the refrigerator; and,

-A black backpack was on the top shelf of the refrigerator.

-There was not a thermometer in the freezer at the time of observation.

On 8/14/24 at 10:08 a.m. the following was observed in the main kitchen:

-The walk-in refrigerator contained three bottles of heaving whipping cream with an expiration date of 8/13/24 and

-In a different refrigerator, there was a carton of herbal tea with a use by date of 4/26/24.

-In the main kitchen dry goods storage area, the same container that held an open bag of rice (initially observed on 8/12/24 - see above) was still present. The rice was still in the open bag and the container did not have a lid on it. The rice was not labeled or dated.

On 8/14/24 at 3:05 p.m. the following was observed in the activities department refrigerator: -An open and undated jar of jelly;

-An open and undated jar of mayonnaise; and,

-An opened and undated jar of salsa.

-The daily temperature log was missing entries for 8/10/24 through 8/12/24.

On 8/14/24 at 3:10 p.m. the following was observed in the Seasons unit refrigerator:

-Two opened and undated boxes of donuts;

-An opened and undated bag of lettuce;

-An opened and undated bag of shredded cheese;

-An opened and undated bag of tortillas;

-A container of store-brand pre-cut cantaloupe with a use by date of 8/11/24;

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 39 065256 Department of Health & Human Services Printed: 09/13/2025 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 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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 -An opened and undated container of whipped cream;

Level of Harm - Minimal harm or -An opened and undated bottle of chocolate sauce; and, two undated sandwiches. potential for actual harm -The used surgical mask (see observation from 8/13/24 above) was still sitting on top of the bag of popsicles Residents Affected - Some in the freezer.

-The NSD was unable to find a thermometer in the freezer.

On 8/14/24 at 3:18 p.m. the following was observed in the library refrigerator:

-An open and undated bag of frozen juice and an open and undated pint of ice cream were labeled with residents names, opened, unlabeled, and undated bag of granola was at the bottom of the fridge, an unlabeled and undated squeeze bottle of an unidentified green liquid was found on the shelf of the refrigerator.

-The NSD was unable to find a thermometer in the freezer.

C. Staff interview

The NSD was interviewed on 8/12/24 at 9:30 a.m. The NSD said she had ordered thermometers for all of the refrigerators and freezers at the facility the week prior.

The NSD was interviewed a second time on 8/14/24 at 2:50 p.m. The NSD said she was not sure how often

the facility refrigerators were cleaned out or checked but it was going to be part of her cleaning list and her daily walkthroughs. The NSD said she also wanted to train the facility staff on food labeling and storage.

III. Maintain safe holding temperatures for food items

A. Professional reference

The Colorado Retail Food Establishment Regulations, (3/16/24), were retrieved on 8/20/24 from https://cdphe.colorado.gov/environment/food-regulations. It revealed in pertinent part,

Time/temperature control for safe food cold holding shall be maintained at 5 degrees Celsius (C) (41 degrees Fahrenheit) or less.

Time/temperature control for safety food that is cooked to a temperature and for a time specified under SS 3-401.11 - 3-401.13 and received hot shall be at a temperature of 57 degrees Celsius (135 degrees Fahrenheit) or above.

B. Observations

On 8/14/24 at 11:21 p.m. DA #2 took the temperatures of the food items. A bin of sliced tomatoes was 45 degrees F, a bin of sliced cucumbers was 50 degrees F and a bin of tzatziki sauce (yogurt based condiment) was 52 degrees F.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 39 065256 Department of Health & Human Services Printed: 09/13/2025 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 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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 temperatures of these items were above the safe temperature parameters for cold foods of 41 degrees F or less. Level of Harm - Minimal harm or potential for actual harm At 11:26 a.m. the NSD educated DA #2 on the safe holding temperatures for cold food items and had DA #2 put the containers of tomatoes, cucumbers and tzatziki sauce into larger ice baths. Residents Affected - Some -The temperatures of the tomatoes, cucumbers, and tzatziki sauce were not re-assessed to ensure they had reached appropriate cold-holding temperatures prior to the start of lunch service.

At 1:22 p.m. final temperatures were taken of the foods served during lunch service. The sliced gyro meat measured 116 degrees F.

-The temperature of this item was below the safe holding temperature parameters for hot foods of 135 degrees F or greater.

-At 1:26 p.m. the NSD served a resident a plate of the sliced gyro meat for a resident without reheating it.

C. Staff interviews

DA #2 was interviewed on 8/14/24 at 11:21 p.m. DA #2 said a holding temperature of 45 degrees F for a cold food item was okay because it was over the 41 degree F measurement on their reference sheet.

The NSD was interviewed on 8/14/24 at 2:50 p.m. The NSD said the procedure for time and temperature control for food was heating hot food again to make sure it was a safe temperature prior to serving. She said cold food items should be stored in an ice bath for service to ensure the food maintained the correct temperature. The NSD said the ideal holding temperatures for hot foods was above 135 degrees F and for cold foods was below 36 degrees F. The NSD said she did not think the steam table was holding temperatures well and she would look into ordering new equipment.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 39 065256 Department of Health & Human Services Printed: 09/13/2025 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 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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, record review and interviews, the facility failed to maintain an infection control Residents Affected - Few program designed to provide a safe, sanitary and comfortable environment to help prevent the possible development and transmission of infectious diseases.

Specifically, the facility failed to ensure staff followed proper infection control procedures for a resident on enhanced barrier precautions (EBP).

Findings include:

I. 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 8/21/24 from https://www.cdc.gov/long-term-care-facilities/hcp/prevent-mdro/PPE.html. It read in pertinent part,

Enhanced Barrier Precautions (EBP) are an infection control intervention designed to reduce transmission of resistant organisms that employs targeted gown and glove use during high contact resident care activities.

EBP may be indicated (when contact precautions do not otherwise apply) for residents with wounds or indwelling medical devices, regardless of MDRO colonization status.

II. Facility policy and procedure

The Enhanced Barrier Precautions policy, undated, was received from the nursing home administrator (NHA)

on 8/15/24 at 6:14 p.m. It read in pertinent part, It is the policy of this facility to implement enhanced barrier precautions (EBP) for the prevention of transmission of multidrug-resistant organisms.

The facility will have the discretion on how to communicate to staff which residents require the use of EBP, as long as staff are aware of which residents require the use of EBP prior to providing high-contact care activities.

High-contact resident care activities include device care or use for feeding tubes.

III. Resident #55

A. Resident status

Resident #55, age less than 65, was admitted on [DATE REDACTED]. According to the August 2024 computerized physicians orders (CPO), diagnoses included dysphagia (a swallowing disorder) and severe protein-calorie malnutrition.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 39 065256 Department of Health & Human Services Printed: 09/13/2025 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 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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 7/24/24 minimum data set (MDS) assessment documented the resident was using a feeding tube.

Level of Harm - Minimal harm or B. Observations potential for actual harm

On 8/12/24 at 10:45 a.m. there was no sign indicating Resident #55 needed EBP was observed on his door. Residents Affected - Few -However, according to the resident's care plan and August 2024 CPO, Resident #55 was supposed to have

a sign outside his room to indicate he was on EBP (see record review below).

On 8/15/24 at 10:39 a.m. there was no sign outside Resident #55's room to identify the resident was on EBP. Licensed practical nurse (LPN) #4 entered Resident #55's room, washed her hands, and donned a new pair of gloves.

LPN #4 proceeded to remove the dressing over Resident #55's feeding tube and switched the line providing enteral nutrition. LPN #4 left Resident #55's room to gather more supplies, then came back and washed her hands. LPN #4 donned a new pair of gloves, applied a wound cleansing solution to the feeding tube site and wiped it with gauze. LPN #4 applied a new dressing over Resident #55's feeding tube site, removed her gloves and used alcohol based hand sanitizer to sanitize her hands as she exited the room.

-LPN #4 failed to wear a gown while providing care for Resident #55's feeding tube.

-At 12:07 p.m. an EBP sign was observed on Resident #55's door and drawers containing PPE had been placed outside the resident's room.

C. Record review

The 6/18/24 care plan, revised 6/29/24, revealed Resident #55 required EBP during high-contact resident care activities due to the presence of an indwelling device. Pertinent interventions included utilizing gowns and gloves during high-contact resident care activities (including device and wound care) and placing EBP notification/signage near the resident's room to alert staff and visitors of the precautions.

A review of the August 2024 CPO revealed the following physician's order for EBP:

EBP: full PPE with high contact care or activities due to device/wound. Ensure signage is in place, ordered 6/18/24.

D. Staff interviews

LPN #4 was interviewed on 8/15/24 at 10:49 p.m. LPN #4 said residents with any type of wound or indwelling/invasive line needed EBP. LPN #4 said EBP meant the staff needed to don a gown and gloves

before providing care.

LPN #4 said nursing staff did not have to follow EBP for feeding tubes, as they were considered a non-sterile exchange.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 39 065256 Department of Health & Human Services Printed: 09/13/2025 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 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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 infection preventionist (IP) was interviewed on 8/15/24 at 11:15 a.m. The IP said EBP was for residents with indwelling lines and wounds, including feeding tubes. The IP said the need for EBP was identified on Level of Harm - Minimal harm or admission and the facility also did monthly audits. The IP said a gown and gloves were required when potential for actual harm switching lines and changing dressings for residents who were on EBP. The IP said Resident #55 should be

on EBP. Residents Affected - Few

The director of nursing (DON) was interviewed on 8/15/24 at 12:25 p.m. The DON said nursing staff should wear a gown, gloves and mask when providing care for residents with indwelling lines, feeding tubes, drains and wounds. The DON said a resident with a feeding tube needed EBP.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 39 065256 Department of Health & Human Services Printed: 09/13/2025 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 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Level of Harm - Minimal harm or potential for actual harm 40960

Residents Affected - Some Based on record review and interviews, the facility failed to ensure five (#1, #2, #5, #6 and #7) of five certified nurse aides (CNA) received the required 12 hours of annual in-service training for continued competence.

Specifically, the facility failed to ensure five CNAs (#1, #2, #5, #6 and #7) received 12 hours of annual training.

Findings include:

I. Facility policy and procedure

The In-Service Nurse Aide Training Program policy and procedure, revised December 2016, was provided by the regional director of clinical services (RDCS) on 8/19/24 at 2:08 p.m. It read in pertinent part, All nurse aide personnel shall participate in regularly scheduled in-service training classes.

Annual in-services must:

-Be no less than 12 hours per employment year;

-Address areas of weakness as determined by nurse aide performance reviews;

-Address the special needs of the residents as determined by facility staff;

-Include training that addresses the care of residents with cognitive impairment; and,

-Include training in dementia management and abuse prevention.

II. Training review

Documentation of annual trainings was requested on 8/14/24 at 1:20 p.m for CNAs #1, #2, #5, #6 and #7.

-The facility was unable to provide documentation of the 12 hours of required annual training.

III. Staff Interviews

The nursing home administrator (NHA) was interviewed on 8/15/24 at 11:45 a.m. The NHA said the facility did not have a staff development coordinator (SDC) for a while and recently promoted a floor nurse to be the SDC full time. He said the SDC was responsible for tracking the CNAs annual training. He said the facility used a computer-based program for training for all the facility staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 39 065256 Department of Health & Human Services Printed: 09/13/2025 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 065256 B. Wing 08/15/2024

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

Highline Post Acute 6060 E Iliff Ave Denver, CO 80222

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 0947 The RDCS was interviewed on 8/15/24 at 11:26 a.m. The RDCS said when the computer-based training program was reviewed, it revealed not all CNAs had not been completing their scheduled training. She said Level of Harm - Minimal harm or the facility did not have a tracking system in place to track staff training. She said going forward, the facility potential for actual harm would review the computer-based training in the middle of every month to ensure all required training was being completed. She said newly hired CNAs training would be reviewed before the CNAs began working Residents Affected - Some with the residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 39 065256