Holly Heights Care And Rehabilitation

F 0569

Notify each resident of certain balances and convey resident funds upon discharge, eviction, or death.

Level of Harm - Minimal harm or potential for actual harm

Based on record review and interviews, the facility failed to ensure money from personal funds account was managed accurately one (#110) of five residents reviewed for personal funds accounts out of 41 sample residents. Specifically, the facility failed to reimburse Resident #110's estate within 30 days from the resident's personal funds account after his death. Findings include:I. Resident 110's representative interviewResident #110's representative was interviewed on 8/20/25 at 12:46 p.m. He said he had opened

a resident trust account on 12/20/24 at the facility. He said the resident passed away on 1/13/25, before any of the funds were used. The representative said he had left many voice messages for the facility's admission coordinator and left messages with the receptionist regarding the refund. Resident #110's representative was interviewed again on 8/21/25 at 11:46 a.m. The representative said he did not understand how the facility did not have his contact information since he was in communication with the nursing staff during Resident #110's stay. II. Record reviewThe resident's admission agreement, dated 12/20/24 was signed by the Resident #110's representative. It revealed the resident's representative opened a resident fund on admission. The resident fund management service stated in pertinent part, In

the event of my death, I redirect that any funds owed or advanced to me by the facility prior to my death are to be paid to the facility with any remaining balance in my resident fund account to become part of my estate.Review of Resident's #110's face sheet (form that contains pertinent information) revealed the incorrect phone number for the representative. -However, the admission agreement had the correct phone number and address. The electronic medical record did not reveal any documentation indicating that the facility had attempted to return the funds to the resident's estate or contact the resident's representative regarding the funds after the resident's death. III. Staff interviewThe business office manager (BOM) was interviewed on 8/20/25 at 11:05 a.m. The BOM said a resident's estate was reimbursed with remaining funds from a personal account after a death. He said Resident #110 did not open an account and would need to look into it. The BOM was interviewed on 8/20/25 at 12:00 p.m. The BOM said the resident did open

an account and the facility would send a refund check to Resident #110's representative. The BOM was interviewed 8/21/25 at 1:00 p.m. He said the facility had not been able to get in touch with the representative after Resident #110's death. The BOM said the facility had sent a check to Resident #110's old address in hopes the family submitted a change of address card. The BOM said the check was returned to the facility and there was no further attempt to contact the representative.

Residents Affected - Few

Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date

these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

TITLE

(X6) DATE

FORM CMS-2567 (02/99) Previous Versions Obsolete

Facility ID:

If continuation sheet

Event ID:

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Holly Heights Care and Rehabilitation

6000 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 0584 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

Based on observations and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public in three of four shower rooms. Specifically, the facility failed to ensure shower rooms and tubs were clean and free from debris in order for residents to have a sanitary environment to bathe.Findings include:I. ObservationsOn 8/18/25 at 1:35 p.m. the Summit Ridge unit shower rooms were inspected. The first shower room had empty shampoo and body wash bottles on the floor, along with piles of wet towels. The room had a smell of urine. The inside of the tub contained a bag of wet towels, two empty bottles and there was unidentified black grime and hair inside the tub.On 8/18/25 at 1:45 p.m. the Highline Creek unit shower room was inspected. The shower room had visibly dirty and wet towels on the floor. The inside of the tub contained wet towels, empty bottles and unidentified trash inside the tub. On 8/18/25 at 2:00 p.m. the Riverwalk unit shower room was inspected.

The shower room was filled with resident equipment (wheelchairs, walkers and bedside commodes) with no access to the shower stall. II. Resident representative interviewResident #5's representative was interviewed on 8/19/25 at 3:42 p.m. The representative said one day she observed there was feces all over

the floor in the shower room and in the shower and it smelled very bad. The representative said she had gone into the shower rooms before and had seen used towels on the floor and empty shampoo bottles. III.

Staff interviewsLicensed practical nurse (LPN) #2 was interviewed on 8/20/25 at 1:45 p.m. LPN #2 said the certified nurse aides (CNA) were to clean the shower rooms after each time the room was used. LPN #1 was interviewed on 8/20/25 at 1:51 p.m. LPN #1 said the CNAs were to clean the shower rooms at the end of their shift and the housekeepers deep cleaned the shower rooms weekly. CNA #3 was interviewed on 8/20/25 at 1:57 p.m. CNA #3 said the CNAs cleaned the shower rooms after using them and the housekeepers were supposed to clean the shower rooms weekly. The director of nursing (DON) was interviewed on 8/20/25 at approximately 2:30 p.m. The DON said that the facility was not currently using the tubs but he did not know why. He said if a resident asked to take a bath, first the CNAs would need to determine if a tub was working and then it would have to be cleaned. The DON said his expectation, regardless of if the tubs were working or not, was that the shower rooms were to be cleaned after every use and kept clean and disinfected for the residents by the CNAs.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Holly Heights Care and Rehabilitation

6000 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)

Federal health inspectors cited HOLLY HEIGHTS CARE AND REHABILITATION in DENVER, CO for a deficiency under regulatory tag F-F0605 during a standard health inspection conducted on 2025-08-21.

Category: Freedom from Abuse, Neglect, and Exploitation Deficiencies

The facility was found deficient in the following area: Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 11 deficiencies cited during this inspection of HOLLY HEIGHTS CARE AND REHABILITATION.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-19.

Federal health inspectors cited HOLLY HEIGHTS CARE AND REHABILITATION in DENVER, CO for a deficiency under regulatory tag F-F0684 during a standard health inspection conducted on 2025-08-21.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 11 deficiencies cited during this inspection of HOLLY HEIGHTS CARE AND REHABILITATION.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-19.

Federal health inspectors cited HOLLY HEIGHTS CARE AND REHABILITATION in DENVER, CO for a deficiency under regulatory tag F-F0689 during a standard health inspection conducted on 2025-08-21.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 11 deficiencies cited during this inspection of HOLLY HEIGHTS CARE AND REHABILITATION.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-19.

Federal health inspectors cited HOLLY HEIGHTS CARE AND REHABILITATION in DENVER, CO for a deficiency under regulatory tag F-F0695 during a standard health inspection conducted on 2025-08-21.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide safe and appropriate respiratory care for a resident when needed.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 11 deficiencies cited during this inspection of HOLLY HEIGHTS CARE AND REHABILITATION.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-19.

Federal health inspectors cited HOLLY HEIGHTS CARE AND REHABILITATION in DENVER, CO for a deficiency under regulatory tag F-F0742 during a standard health inspection conducted on 2025-08-21.

Category: Quality of Life and Care Deficiencies

The facility was found deficient in the following area: Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 11 deficiencies cited during this inspection of HOLLY HEIGHTS CARE AND REHABILITATION.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-19.

Federal health inspectors cited HOLLY HEIGHTS CARE AND REHABILITATION in DENVER, CO for a deficiency under regulatory tag F-F0809 during a standard health inspection conducted on 2025-08-21.

Category: Nutrition and Dietary Deficiencies

The facility was found deficient in the following area: Ensure meals and snacks are served at times in accordance with resident’s needs, preferences, and requests. Suitable and nourishing alternative meals and snacks must be provided for residents who want to eat at non-traditional times or outside of scheduled meal times.

Scope/Severity Level E: pattern, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 11 deficiencies cited during this inspection of HOLLY HEIGHTS CARE AND REHABILITATION.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-19.

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

9:32 a.m., the Summit Creek nourishment refrigerator contained a bowl with a white creamy substance that resembled a salad dressing consistency and saran wrap over it without a label or date. C. Staff interviewsLicensed practical nurse (LPN) #1 was interviewed on 8/20/25 at 1:51 p.m. She said the nurses and the certified nurse aides (CNA) were responsible for making sure items were labeled and not spoiled in

the nourishment refrigerators. LPN #1 said if unlabeled or expired items were found, the nurses and CNAs should throw those items out. CNA #3 was interviewed on 8/20/25 at 1:57 p.m. She said it was part of the nightshift staff's responsibility to throw out unlabeled or spoiled items in the nourishment refrigerators.CNA #1 was interviewed on 8/20/25 at 2:02 p.m. She said it was part of the nightshift staff's responsibility to throw out unlabeled or spoiled items in the nourishment refrigerators. CNA #1 said if the day shift sees expired or unlabeled items, they should throw the items out and not wait for the night shift.The RD consultant was interviewed on 8/20/25 at 2:25 p.m. She said the kitchen staff were to check the nourishment refrigerators every morning and on the weekends for expired or unlabeled items.The director of nursing (DON) was interviewed on 8/20/25 at approximately 2:30 p.m. He said the nursing staff and dietary staff were responsible for checking the nourishment refrigerators. daily. The DON said it was important unlabeled and expired items were removed in case a resident accidentally ate those items and had a reaction or became sick.

Event ID:

Facility ID:

If continuation sheet

Printed: 04/13/2026 Form Approved OMB No. 0938-0391

Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION

(X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER:

(X2) MULTIPLE CONSTRUCTION

B. Wing

A. Building

(X3) DATE SURVEY COMPLETED

08/21/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Holly Heights Care and Rehabilitation

6000 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)

Federal health inspectors cited HOLLY HEIGHTS CARE AND REHABILITATION in DENVER, CO for a deficiency under regulatory tag F-F0880 during a standard health inspection conducted on 2025-08-21.

Category: Infection Control Deficiencies

The facility was found deficient in the following area: Provide and implement an infection prevention and control program.

Scope/Severity Level D: isolated, no actual harm with potential for more than minimal harm.

While no actual harm was documented, there was potential for more than minimal harm to residents.

This was one of 11 deficiencies cited during this inspection of HOLLY HEIGHTS CARE AND REHABILITATION.

Correction Status: Deficient, Provider has date of correction.

The facility reported correction as of 2025-09-19.

F 0921 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some

FORM CMS-2567 (02/99) Previous Versions Obsolete

Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and

the public. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on

observations, record review and interviews, the facility failed to provide a safe, sanitary, functional and comfortable environment for residents, staff and the public. Specifically the facility failed to:-Ensure necessary kitchen equipment was maintained in safe, working condition by repairing leaks to sinks timely; and,-Ensure handrails were in safe, operational, and functional conditions. Findings include:I. Failure to ensure kitchen equipment was maintained in safe and working conditionA. ObservationsOn 8/18/25 at 8:45 a.m. during the initial walk through of the kitchen, a P-trap (part of the pipe that is shaped like the letter P) pipe under the kitchen's handwashing sink was leaking water into a three gallon bucket, which was almost completely full.B. Staff interviewsDietary aide (DA) #1 was interviewed on 8/18/25 at 9:00 a.m. He said the handwashing sink had started leaking that same week. The maintenance director (MTD) was interviewed

on 8/21/25 at 1:39 p.m. He said the handwashing sink in the kitchen started leaking several months ago and he noticed it was leaking into the subfloor. He said he replaced the P-trap pipe but it began leaking again a month ago. II. Failure to ensure handrails were in safe, operational, and functional conditions. A.

ObservationsOn 8/18/25 at approximately 9:30 a.m. during an initial walk through, the following was observed:There was gray electrical tape covered the center portions and the curved, connecting sections attaching the hand railings to the wall by room [ROOM NUMBER], #8, #11 and #58.There was gray electrical tape and yellow caution tape on the curved, connecting section attaching the handrailing to the wall outside of room [ROOM NUMBER] was observed;The hand railings were cracked with exposed sharp edges in the center sections and the curved, connecting sections attaching the handrailing to the wall on

the handrails outside of the business office and outside of room [ROOM NUMBER]; and, The handrail was missing the curved, connecting section attaching the handrailing to the wall outside of room [ROOM NUMBER].B. Staff interviewsThe MTD was interviewed on 8/21/25 at 1:39 p.m. He said he was unsure how long the handrails had been damaged. He said it had been an ongoing problem trying to repair the handrails because the residents bumped into handrails and broke the railings. He said the damaged handrails created a hazard for the residents.

Event ID:

Facility ID:

If continuation sheet