Creekside Village Rehabilitation And Nursing Llc

F 0600 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few

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

6/20/25 MDS assessment revealed the resident had severe cognitive impairment with a BIMS score of zero out of 15. The assessment indicated the resident did not have any physical behaviors towards others.2.

Record reviewThe nursing progress note, dated 8/19/25, revealed staff reported that upon entering the dining area of the memory care unit, Resident #3 was observed sitting in her wheelchair with her hands down the front of Resident #4's pants while Resident #4 was standing up. Staff immediately separated the residents. Neither resident could recall the incident due to cognitive impairment. Resident #3 and Resident #4 were assessed for any injuries and no injuries were noted. IV. Staff interviewsCertified nurse aide (CNA) #3 was interviewed on 9/4/25. CNA #3 said Resident #2 did not have aggressive behaviors, but was sensitive to his personal space. She said they were trying to keep residents who wandered on the unit, such as Resident #1, away from Resident #2. She said staff did their best to ensure other residents did not enter into the personal space of Resident #2. She said she was aware of the incident between Resident #2 and Resident #1 (on 6/16/25) and the interventions were to keep the residents away from each other and re-direct them. CNA #3 said Resident #3 had a history of sexually inappropriate behaviors because she confused male residents in the facility with her husband. She said the intervention was to ensure Resident #3 was not too close to male residents when she was in the public areas, and that she did not wander in other resident's rooms. CNA #3 said Resident #4 was not physically aggressive and he did not have a history of inappropriate behaviors. Registered nurse (RN) #1 was interviewed on 9/4/25 at 11:50 a.m. RN #1 said she did not know where Resident #3 was after she left the dining room (on 9/4/25 - see observation above). She said she was able to locate Resident #3 in room [ROOM NUMBER]. She said room [ROOM NUMBER] was not Resident #3's room and she assisted the resident back to her room for a nap. She said Resident #3 was very fast and the staff tried to keep an eye on her. She said Resident #3 occasionally had sexually inappropriate behaviors, such as touching male residents, because she thought male residents were her husband. She said staff ensured that she did not enter the personal space of other residents.-However, Resident #3 was observed entering the room of two male residents and lying on one of

the male residents' beds (see observation above).The director of nursing (DON) was interviewed on 9/4/25 at 2:30 p.m. The DON said she was aware of the incident between Resident #2 and Resident #1 on 6/16/25 and the incident between Resident #3 and Resident #4 on 8/19/25. She said after the incident, staff were re-educated on the prevention and de-escalation of physical altercations and on ensuring that residents did not enter the personal space of other residents. The DON said she would provide additional education regarding Resident #3 to ensure she did not enter other residents' rooms by mistake. She said currently in

the memory care unit, every room had a colored door to help residents remember their own room. She said staff would consider other options to help Resident #3 be able to locate her room more easily. The NHA was interviewed on 9/4/25 at 3:00 p.m. The NHA said the goal of the facility was to keep all residents free from abuse and to ensure appropriate interventions were in place for residents with behaviors. He said the incident between Resident #2 and Resident #1 on 6/16/25 and the incident between Resident #3 and Resident #4 on 8/19/25 were both investigated and reported in a timely manner. He said in both incidents, abuse was substantiated. The NHA said the interdisciplinary team (IDT) met after each abuse incident, talked to the residents' families and always looked for the best and most appropriate solutions to prevent any further abuse incidents.

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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

09/04/2025

NAME OF PROVIDER OR SUPPLIER

STREET ADDRESS, CITY, STATE, ZIP CODE

Creekside Village Rehabilitation and Nursing LLC

1000 E Stuart St Fort Collins, CO 80525

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 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Many

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

monitoring food temperatures and functioning of the refrigeration equipment daily and at routine intervals

during all hours of operation; placing hot food in containers (shallow pans) that permit the food to cool rapidly; separating raw foods (beef, fish, lamb, pork, and poultry) from each other and storing raw meats on shelves below fruits, vegetables or other ready-to-eat foods so that meat juices do not drip onto these foods; labeling, dating, and monitoring refrigerated food, including, but not limited to leftovers, so it is used by its use-by date, or frozen (where applicable)/discarded; and, keeping foods covered or in tight containers.C. ObservationsDuring the initial kitchen walk through on 9/3/25 at 2:20 p.m. the following was observed:The walk-in refrigerator's digital thermometer was not in working condition. The refrigerator's door was ajar and maintenance personnel was standing on the ladder fixing the refrigerator. Multiple food items were observed on the shelves in the refrigerator including two flats of eggs and two large plastic bags of shredded cheese. D. Record reviewA request was made for the facility's monitoring system that was in place while the walk-in refrigerator was not working on 9/3/25. The DM said the facility did not have a monitoring system in place while the refrigerator was not functioning properly. E. Staff interviewsThe DM was interviewed on 9/3/25 at 2:25 p.m. The DM said the walk-in refrigerator broke today (9/3/25). He said according to the regulations, the facility had six hours to fix the refrigerator without compromising the food.

He said the refrigerator had not been broken for six hours. He said he did not record the time when the refrigerator broke and he did not have documentation to demonstrate when was the last time the refrigerator was at the appropriate temperature. -However, according to the food regulations, food can be without temperature control for up to four hours (see professional reference above).The DM was interviewed a second time in the presence of a nursing home administrator on 9/4/25 at 3:15 p.m. The DM said the walk-in refrigerator was fixed and was working appropriately. He said the refrigerator was fixed within four hours and it did not compromise the quality of food. He said he did not check the temperature of food and did not have any evidence to prove that food was kept at the appropriate temperature while the refrigerator was broken.

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