Eagle Ridge Post Acute

F-F580 notification of a change in condition). She said Resident #173 told her she fell when

she was outside at night smoking. She said the resident told her she slipped off her scooter and hit her face

on the concrete.

IV. Resident interview

Resident #173 was interviewed on 6/11/24 at 6:51 p.m. Resident #173 said she had two falls during her stay at the facility. She said the first fall happened in the morning when she slid off her bed trying to reach for her scooter. Resident #173 said she fell a second time when she went outside alone at night to smoke. She said

a cigarette fell on the ground. She said she went to reach for it and her scooter cushion slipped off and she hit the ground hard. She said a CNA came outside to smoke and found her on the ground after 10 to 15 minutes. She said the CNA notified the nurse. The resident said she asked the nurse not to make a report because she was going to be able to be discharged home soon and did not want any setbacks or concerns of her returning home. She said the nurse agreed not to report the incident and told her she hated doing accident reports. Resident #173 said she had a bruise under her eye and her face was swollen the next day.

She said another CNA asked her what happened after seeing the facial injuries. The resident said she told

the CNA she hit her face on her scooter's handlebars when her cushion slid from her. She said she lied because she wanted to go home and did not want to get anyone in trouble.

V. Record review

Resident #173'ssmoking care plan, initiated on 2/5/24, read Resident #173 had potential for

injury related to smoking. The resident'ssafety and hygiene was to be maintained every shift. The care plan did not identify interventions to direct staff of the safe smoking safety needs of Resident #173.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 7 of 25 065286 Department of Health & Human Services Printed: 09/23/2025 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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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 0689 -The review of Resident #173'scomprehensive care plan, initiated on 2/5/24, 2/6/24 and 2/9/24 and revised

on 2/26/24, did not identify the resident was at risk for falls or fell at the facility. Level of Harm - Minimal harm or potential for actual harm -The care plan did not identify interventions to decrease the risk of her falls.

Residents Affected - Few The 2/10/24 fall risk observation/assessment read the resident was at a moderate risk for falls and ambulated with problems and devices.

The 2/10/24 nurses note read Resident #173 had an unwitnessed fall on 2/10/24. The resident fell when she was transferring herself from her bed to her scooter and lost her balance then lowered herself to the floor.

The resident was found sitting on the floor between the bed and her scooter. According to the note, there were no injuries or bruising and the resident did not hit her head.

-The review of the progress notes did not identify there was a second fall between 2/10/24 and the resident's discharge on 2/14/24.

-The review of the progress notes did not identify the resident had bruising and swelling to her face or other related injuries.

The 2/10/24 change of condition evaluation documented in part, that a change of condition had been noted.

The symptoms included a fall on 2/10/24.

-The resident was not identified to have injuries to her face.

-The review of the resident'sassessments did not identify the resident had a second fall or injuries to her face from a fall or hitting her scooter.

The 2/10/24 post fall review documented the resident had not had any falls at the facility prior to the 2/10/24 fall.

The 2/10/24 fall risk observation/assessment read the resident was at a moderate risk for falls and ambulated with problems and devices.

The 2/10/24 unwitnessed incident report read Resident #173 was transfering from her bed to the scooter, lost her balance and lowered herself to the floor so she would not fall. According to the incident report, the resident was assessed after the fall and there were no injuries observed at the time of the fall.

The interdisciplinary team (IDT) fall note read Resident #173 had an unwitnessed fall on 2/10/24 at 6:32 a.m.

The note did not identify the details of the fall or if the resident had injuries. According to the note, the intervention after the 2/10/24 fall was to ensure non-slip footwear or non-skid socks were on during resident transfers.

The 2/12/24 daily skilled charting form for the night shift, completed on 2/13/24 at 5:15 a.m. read the resident needed extensive assistance with transfers with two staff but was able to reposition herself in bed. According to the skilled charting, the resident had bilateral leg edema and a healing post surgical incision. No other concerns were identified for the resident's skin.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 8 of 25 065286 Department of Health & Human Services Printed: 09/23/2025 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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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 0689 -The skilled charting did not identify the resident had a fall or injuries that were being monitored.

Level of Harm - Minimal harm or The 2/13/24 daily skilled charting form for the day shift, completed on 2/13/24 at 2:22 p.m. read the resident potential for actual harm was a current smoker and there were no signs or symptoms of distress observed and she used a motorized wheelchair. The form did not identify concerns with the resident'sskin. Residents Affected - Few -The skilled charting form did not identify the resident had a fall or injuries that were being monitored

The 2/13/24 daily skilled charting form for the night shift, completed on 2/13/24 at 5:46 a.m. did not identify

the resident had a fall or injuries that were being monitored. According to the skilled charting, the resident had a healing post surgical incision. No other concerns were identified for the resident'sskin.

The 2/13/24 nurse'snote at 9:56 a.m. read day three of three post fall neurological checks. According to the note, there were no delayed injuries voiced or observed.

The review of Resident #173's neurological checks with the director of nursing (DON) identified the checks ended the morning of 2/13/24. The checks did not continue until the resident was discharged on [DATE REDACTED].

The 2/14/24 at 11:55 a.m. nurse note read discharge instructions were discussed with Resident #173. The resident'scaregiver gathered all the belongings of the resident. The note at discharge did not document the resident'sbruise on her face.

VI. Staff interviews

The DON was interviewed on 6/12/24 at 11:58 a.m. The DON said all residents should be assessed after a fall. She said the nurses should complete a risk management assessment and check the resident for injuries.

She said if the resident hit their head, staff would complete neurological checks for three days.

The DON said Resident #173 was at the facility for a short rehabilitation stay. She said the resident was discharged from the facility on 2/14/24. She said the resident fell on [DATE REDACTED] and was seen by the physician

on 2/12/24 and there was no bruising noted to the resident'sface. She said the resident did not have injuries from her fall on 2/10/24 and there were no other falls documented or injuries to the resident'sface identified.

Certified nurse aide (CNA) #2 was interviewed on 6/12/24 at 1:07 p.m. CNA #2 said she noticed the resident had a bruise under her eye under her eye glasses. She said the bruise was blue in color when she first noticed it. She said the resident told her that she hit her face when she was attempting to transfer from her bed to her scooter and did not want anyone to know she had a bruise. She said the resident did not tell anyone she hit her face. CNA #2 said she reported the bruise to the nurse. The CNA said the bruise started under her eye but then moved down one side of her face by her cheekbone. She said the bruised area was not protruding and then started to fade yellow.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 9 of 25 065286 Department of Health & Human Services Printed: 09/23/2025 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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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 0689 The DON was interviewed again on 6/12/24 at 4:11 p.m. The DON said she interviewed all the nurses and CNAs who worked the night of 2/12/24 and those who called her back did not recall Resident #173 falling Level of Harm - Minimal harm or outside or any other location. The DON said she contacted Resident #173 on 6/12/24 and the resident told potential for actual harm her she had a second fall. She said the resident said she fell when she was outside smoking. The DON said

the resident said she yelled out and a CNA came outside to find her on the ground. She said the resident Residents Affected - Few said she begged the nurse not to report the fall.

The DON said the bruise on her face was from the fall outside. The DON said she interviewed CNA #2 who confirmed the bruise was found under the resident's eye prior to discharge. She said CNA #2 reported the injury to the nurse but the nurse did not notify the DON of the reported bruise. The DON said there was no documentation to show the resident was assessed after the resident fell outside or after a bruise on the resident'sface was identified.

The DON said the nurse should have reported the incident and injury to the DON, assessed the resident and documented the fall and injury. The DON said she needed staff to report any incident so the facility could determine the next follow-up action and interventions and notify the physician and family. She said she would follow-up and complete an education with the nurses and the CNAs to report all incidents to the DON and would educate them on the importance of reporting incidents.

The DON said she would inform her staff that it was important to timely assess residents after an incident to ensure resident safety and ensure there was no head trauma and the completion of neurological checks.

She said staff needed to completely assess the resident to know all the circumstances associated with the fall/and or injuries, monitor for injuries and create interventions to help prevent future falls. The DON said if

she had been made aware the resident'scushion slipped/moved from her scooter seat, a non-slip material could have been placed under the seat.

The DON said all of the residents were supervised smokers. She said there was a breakdown in the smoking policy. She said the resident should not have been smoking outside alone. She said all of the residents should have their cigarettes in a locked box with the nurse. She said she was not sure if the resident had cigarettes in her room not locked up or if she got the cigarettes from the nurse who knew she went outside to smoke. The DON said the resident told her she did not know if staff knew she went outside to smoke when

she fell . The DON said, starting 6/13/24, all staff and resident smokers would be re-educated on the smoking policy and the risk of not following the smoking policy. She said the risk of staff and residents not following the smoking policy could result in burns, falling if the resident attempted to pick up a fallen cigarette and the risk of a fire. The DON said the education would also include agency staff and would be continued with all new hire staff during orientation.

VII. Facility follow-up

The facility initiated fall investigation was provided by the DON on 6/12/24 at approximately 4:30 p.m. The investigation included a 6/12/24 interview with CNA #2, an interview with Resident #173 and a list of staff she contacted or attempted to contact who worked the night shift around the approximate time the resident had a second fall or report of injury.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 10 of 25 065286 Department of Health & Human Services Printed: 09/23/2025 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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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 0689 The DON's interview with Resident #173 read the resident fell four days or so prior to her discharge. The resident said she went out to the courtyard at 1:00 a.m. or 2:00 a.m. Her cushion on her scooter slipped. Level of Harm - Minimal harm or According to the documented interview, the resident started to yell and a CNA came outside and found her. potential for actual harm The CNA then got a nurse. The resident did not know the name of the nurse but was able to describe her.

Residents Affected - Few A 6/12/24 witness statement from CNA #2 read CNA #2 entered Resident #173's room. The resident had glasses on and when she turned her head CNA #2 noticed a bruise on the side of her face. According to the statement, CNA #2 asked the resident what happened and the resident told her she hit her head while transferring. CNA #2 asked the resident if the nurse was aware and the resident said no. CNA #2 left the room and reported the incident to the nurse on duty. CNA #2 did not recall who she reported the incident to.

The list of staff the DON contacted documented the staff who returned the DON's call did not recall the incident, injury or CNA #2 reporting a bruise.

The staff education on safe resident smoking and smoking policy, conducted on 6/14/24 and 6/17/24, was provided by the NHA on 6/17/24 at 2:36 p.m. via email. According to the provided education, 36 staff members received education on the smoking policy, resident smoking times, and safe smoking standards at

the facility to include:

-Residents must be supervised by a staff member;

-Residents were not allowed to smoke outside of smoking times unless accompanied by family or a friend; and,

-The cigarettes and lighters were to remain in a locked box at the nurses station and a staff member would light the cigarette for the residents.

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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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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 0692 Provide enough food/fluids to maintain a resident's health.

Level of Harm - Actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50314

Residents Affected - Few Based on observations, record review and interviews, the facility failed to ensure one (#54) of five residents out of 45 sample residents received the care and services necessary to meet their nutrition needs and to maintain their highest level of physical well-being.

Resident #54 was admitted to the facility for long term care on 11/10/23 with diagnoses of chronic obstructive pulmonary disease (COPD), diabetes and generalized muscle weakness. The resident was initially weighed

on 11/19/23 and weighed 149 pounds (lbs).

The resident was admitted to the hospital from 1/2/24 to 1/8/24 for electrolyte imbalances. Upon readmission to the facility the resident weighed 135.2 lbs. On 1/22/24 and 1/29/24 the resident weighed 123.6 lbs. On 2/5/24 the resident weighed 123 lbs. The resident sustained a 26 lbs (17.4%) weight loss in three months and 12.2 lbs (9%) in one month, which was considered severe weight loss.

The facility failed to assess the resident and implement nutrition interventions after the resident sustained severe weight loss on 2/5/24. The facility did not weigh the resident after she sustained severe weight loss, despite the registered dietitian (RD) requesting the resident to be weighed.

Findings include:

I. Facility policy and procedure

The nutritional assessment policy, revised October 2017, was provided by the nursing home administrator (NHA) on 6/11/24 at 3:14 p.m. It documented in pertinent part:

The dietitian, in conjunction with the nursing staff and healthcare practitioners, will conduct a nutritional assessment for each resident upon admission (within current baseline assessment timeframes) and as indicated by a change in condition that places the resident at risk for impaired nutrition.

Once current conditions and risk factors for impaired nutrition are assessed and analyzed, individual care plans will be developed that address or minimize to the extent possible the resident' s risks for nutritional complications. Such interventions will be developed within the context of the resident' s prognosis and personal preferences

II. Resident #54

A. Resident status

Resident #54, over the age of 65, was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED]. According to the June 2024 computerized physician orders (CPO), diagnoses included COPD, diabetes type II and generalized muscle weakness.

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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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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 0692 The 4/9/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of 11 out of 15. The resident required set-up or clean-up Level of Harm - Actual harm assistance with eating. The resident required substantial or maximum assistance with transfers, showers, toileting and personal hygiene. Residents Affected - Few

The assessment documented the resident was 64 inches (5 foot, 4 inches) tall.

The assessment did not indicate the residents weight. It documented the resident had not had any significant weight loss or weight gain.

-However, the resident had sustained a 26 lbs (17.4%) weight loss in three months and 12.2 lbs (9%) in one month, which was considered severe weight loss.

B. Resident interview

Resident #54 was interviewed on 6/6/24 at 9:41 a.m. Resident #54 said she preferred to eat in her room with her roommate. Resident #54 said she was served scrambled eggs for breakfast several times per week and

she did not like them because of how bland they were. Resident #54 said she sent her breakfast back several times each week because of how bland the scrambled eggs were. Resident #54 said she had lost weight because of this. Resident #54 said she skipped several meals throughout the week because she did not like to eat the bland eggs. Resident #54 said she often felt very hungry by lunch time.

C. Observations

On 6/10/24 at 8:12 a.m., Resident #54 was observed to have a breakfast tray on her bedside table. The breakfast had been consumed except for scrambled eggs that were untouched on the breakfast tray.

D. Record review

The nutrition care plan, initiated on 11/21/23 and revised on 11/28/23, documented the resident was at a minimal nutritional risk with consistent food intake greater than 50%. The care plan documented the resident would be offered nutrition for comfort and pleasure while the resident was receiving hospice services. The interventions included monitoring the resident' s intake, obtaining weights as ordered, completing an assessment by the RD and monitoring the resident' s skin for signs of breakdown.

-However, a review of the resident' s electronic medical record (EMR) did not reveal the resident was receiving hospice services.

-A review of the comprehensive care plan did not reveal documentation indicating new interventions were implemented after the resident sustained severed weight loss on 2/5/24.

The 11/14/23 dietary pre-screen assessment documented the resident liked fried and poached eggs and spicy foods.

The resident was hospitalized on [DATE REDACTED], and readmitted to the facility on [DATE REDACTED] for electrolyte imbalances.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 13 of 25 065286 Department of Health & Human Services Printed: 09/23/2025 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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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 0692 The December 2023 CPO revealed Resident #54 was to be weighed weekly for four weeks on Friday mornings, initiated on 11/17/23 and discontinued on 12/8/23. Level of Harm - Actual harm

The June 2024 CPO revealed the resident had a physician' s order to be weighed weekly for four weeks, Residents Affected - Few every Monday, ordered 1/15/24 and discontinued on 2/6/24.

Resident #54' s weights were documented in the EMR as follows:

-On 11/19/23, the resident weighed 149 lbs;

-On 1/8/24, the resident weighed 135.2 lbs;

-On 1/22/24, the resident weighed 123.6 lbs;

-On 1/29/24, the resident weighed 123.6 lbs; and,

-On 2/5/24, the resident weighed 123 lbs.

-The resident lost 12.2 lbs (9%) from 1/8/24 to 2/5/24, in one month, which was considered severe.

-The resident lost 26 lbs (17.4%) from 11/19/23 to 2/5/24, in three months, which was considered severe.

-No additional physician orders to obtain weight were documented in the resident' s EMR. The facility had not obtained the resident' s weight in more than four months between 2/6/24 and 6/11/24 after this significant weight loss was documented.

A review of the certified nurse aide (CNA) task response history (from 5/15/24 to 6/11/24) revealed staff had documented the amount the resident had eaten for 51 out of 81 meal opportunities during the review period.

-There were no documented resident refusals for meals. It was documented the resident ate less than 50% of her meals for two of 51 documented meals.

The 6/11/24 nutrition progress note documented the resident was last weighed on 2/5/24 when the resident weighed 123 pounds.

IV. Staff interviews

Licensed practical nurse (LPN) #1 was interviewed on 6/10/24 at 8:42 a.m. LPN #1 said he had seen the kitchen serve Resident #54' s scrambled eggs. He said when this occurred he would ask the kitchen for different eggs.

LPN #6 was interviewed on 6/12/24 at 10:29 a.m. LPN #6 said there was not a current physician' s order to weigh Resident #54 weekly or monthly. LPN #6 said nursing staff followed the physician' s order for obtaining the resident's weights. She said a nurse could request to weigh a resident if there was a weight concern identified by nursing staff.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 25 065286 Department of Health & Human Services Printed: 09/23/2025 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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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 0692 The RD was interviewed on 6/12/24 at 11:47 a.m. The RD said the facility did not have a current weight for Resident #54. The RD said she was concerned about the facility using different scales from January 2024 to Level of Harm - Actual harm February 2024 to weigh the resident.

Residents Affected - Few The RD said she had verbally requested the nursing staff to obtain additional weights. The RD said she did not document when she requested to have the resident reweighed after 2/5/24. The RD said she did not know why the significant weight loss was not identified or followed up on. The RD said new interventions should have been identified when Resident #54 sustained significant weight loss to prevent further weight loss.

The director of nursing (DON) was interviewed on 6/12/24 at 1:05 p.m. The DON said Resident #54 experienced significant weight loss and the facility did not identify it. The DON said no new nutrition interventions were implemented to prevent further weight loss after 2/5/24. The DON said no new weights were obtained for Resident #54 after she sustained severe weight loss on 2/5/24.

The DON said Resident #54 should have had her significant weight loss identified in her plan of care and more weights should have been obtained after 2/5/24 to monitor the resident' s status. The DON said the facility could have offered a nutritional supplement, such as a Mighty shake (frozen nutritional supplement), to help maintain Resident #54' s weight. The DON said she was not aware of any inaccurate scales in the facility.

The DON was interviewed again on 6/12/24 at 4:32 p.m. The DON said the quality assurance and performance improvement (QAPI) committee had identified that the facility had an issue obtaining and documenting weights in the facility within the last few months, but had not implemented a correction plan.

The DON said she needed to work with the RD to ensure residents were getting weighed on a regular basis.

The DON said she needed to review weight loss interventions in the facility to ensure they were being updated and documented.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 25 065286 Department of Health & Human Services Printed: 09/23/2025 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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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 0804 Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

Level of Harm - Minimal harm or 48412 potential for actual harm Based on observations, record review and interviews, the facility failed to ensure residents consistently Residents Affected - Some received food prepared by methods that conserve nutritive value, palatable in taste, texture, appearance and temperature.

Specifically, the facility failed to ensure food was served palatable, attractive and served at the appropriate temperature.

Findings include:

I. Resident interviews

Resident #4 was interviewed on 6/5/24 at 10:25 a.m. Resident #4 said the food was not always good. Resident #4 said the food was under seasoned at times and sometimes he received his meal cold.

Resident #22 was interviewed on 6/5/24 at 11:00 a.m. Resident #22 said the food was awful and tasted bad.

He said he ate his meals in his room and the food was delivered to him cold. Resident #22 said the food looked how it tasted. He said the food was undercooked and over-seasoned.

Resident #57 was interviewed on 6/5/24 at 3:35 p.m. Resident #57 said the food was awful and his lunch on 6/5/24 had no seasoning to it. The resident said his food was normally bland and he did not like to eat it.

Resident #17 was interviewed on 6/6/24 at 9:20 a.m. Resident #17 said the quality of the food was not good.

He said the food was processed and bland.

Resident #54 was interviewed on 6/6/24 at 11:36 a.m. Resident #54 said she skipped several meals a week because the food did not taste good.

II. Observations

A test tray for a regular diet was evaluated by three surveyors immediately after the last resident had been served their room tray for lunch on 6/10/24 at 12:51 p.m.

The test tray consisted of spaghetti and meatballs, lima beans, garlic toast and chocolate pudding.

-The spaghetti and meatballs were 130 degrees Fahrenheit (F);

-The lima beans were 103 degrees F and mushy and bland. The lima beans appeared gray and were not a vibrant green;

-The garlic toast was overcooked and hard, chewy and salty. The garlic toast appeared partially burnt; and,

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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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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 0804 -The chocolate pudding was 54.5 degrees F and did not feel cold.

Level of Harm - Minimal harm or III. Staff interviews potential for actual harm

The dietary director (DD) and the nursing home administrator (NHA) were interviewed together on 6/12/24 at Residents Affected - Some 1:17 p.m. The DD said the pudding cups were prepared, portioned out and placed in the walk-in refrigerator until it was time to serve. The DD said the pudding should have been stored on ice during the meal service to help maintain the correct temperature since the pudding was made with dairy products.

The DD said cold foods needed to be served below 41 degrees F. The DD said the containers of pudding on

the counter were going to be thrown away at the end of the meal service, since they had not been held at the correct temperature. The DD said he wanted the residents to receive the hot foods at 135 degrees F and the hot boxes were set to 135 degrees F.

The NHA said more education would be provided and the facility had started a food committee for the residents on 6/12/24 (during the survey). The NHA said the residents' feedback from the food committee was going to help improve the food.

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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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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** 50314 potential for actual harm Based on observations, record review and interviews, the facility failed to maintain an infection control Residents Affected - Many 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 housekeeping staff changed gloves and performed hand hygiene consistently when appropriate

during resident room cleaning;

-Ensure housekeeping staff properly used a disinfectant chemical per manufacturer's instructions when cleaning resident rooms;

-Ensure staff donned (put on) the appropriate personal protective equipment (PPE) when providing direct care to residents on enhanced barrier precautions (EBP);

-Ensure a process was in place to ensure staff were aware of which residents required EBP;

-Provide clean linens after performing wound care and a wound dressing change;

-Offer hand hygiene to residents before meals; and,

-Implement an effective water management plan.

Findings include:

I. Housekeeping failures

A. Facility policy and procedure

The Infection Prevention and Control Program policy, revised October 2018, was received from the nursing home administrator (NHA) on 6/10/24 at 10:24 a.m. It documented in pertinent part,

Policies and procedures reflect the current infection prevention and control standards of practice.

Important facets of infection prevention include educating staff and ensuring that they adhere to proper techniques and procedures, implementing appropriate isolation precautions when necessary, and following established general and disease-specific guidelines such as those of the Centers for Disease Control (CDC).

The Hand Hygiene policy, revised October 2023, was provided by the nursing home administrator (NHA) on 4/12/24 at 2:59 p.m. It read in pertinent part:

All personnel are trained and regularly in-serviced on the importance of hand hygiene in preventing the transmission of healthcare-associated infections.

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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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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 All personnel are expected to adhere to hand hygiene policies and practices to help prevent the spread of infections to other personnel, residents and visitors. Level of Harm - Minimal harm or potential for actual harm Hand hygiene is indicated immediately before touching a resident, before performing an aseptic task, after contact with blood, bodily fluids, or contaminated surfaces, after touching a resident, after touching a Residents Affected - Many resident's environment, before moving from work on a soiled body site to a clean body site on the same resident; and immediately after glove removal.

The Centers for Disease Control and Prevention (CDC) Environment Cleaning Procedures, (revised 3/19/24) was retrieved on 6/20/24 from https://www.cdc. gov/healthcare-associated-infections/hcp/cleaning-global/appendix-c.html. It read in pertinent part,

High-Touch Surfaces: The identification of high-touch surfaces and items in each patient care area is a necessary prerequisite to the development of cleaning procedures, as these will often differ by room, ward and facility.

Common high-touch surfaces include: bed rails, IV (intravenous) poles, sink handles, bedside tables, counters, edges of privacy curtains, patient monitoring equipment (keyboards, control panels), call bells and door knobs.

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

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

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

B. Manufacturer's guidelines for Diffense disinfecting cleaner

The Diffense disinfecting cleaner instructions were retrieved from https://www.spartanchemical. com/products/product/102403#top on 6/18/24. It read in pertinent part:

Diffense offers 60-second disinfection for most common bacteria and viruses.

Diffense kills clostridium difficile (C-diff) in 8 (eight) minutes.

C. Observations

On 6/10/24 at 10:18 a.m. housekeeper (HSKP) #2 was observed cleaning room [ROOM NUMBER]. HSKP #2 sprayed high-touch surfaces with Diffense disinfecting cleaner. While spraying high-touch surfaces, HSKP #2 touched the toilet seat with gloved hands. HSKP #2 then cleaned the sink and mirror.

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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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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 After cleaning the sink and mirror, HSKP #2 changed her gloves and performed hand hygiene. HSKP #2 then donned new gloves and began cleaning the door and cabinet handles. HSKP #2 sprayed the door and Level of Harm - Minimal harm or cabinet handles with Diffense disinfecting spray, then immediately wiped the wet spray off with a dry cloth. potential for actual harm -The call light cord in the bathroom was not touched or cleaned by HSKP #2 during the room cleaning Residents Affected - Many process.

-HSKP #2 failed to change gloves and perform hand hygiene after touching the toilet seat before cleaning

the sink and mirror.

-HSKP #2 failed to allow the disinfectant to remain on surfaces for the manufacturer's recommended dwell time to ensure effective disinfection.

-HSKP #2 failed to clean the room call light cord.

On 6/11/24 at 10:12 a.m. HSKP #3 was observed cleaning room [ROOM NUMBER]. HSKP #3 was observed to spray Diffense disinfecting cleaner on the room's door handles before immediately wiping off the wet spray with a dry cloth.

-The call light cord in the bathroom was not touched or cleaned by HSKP #3 during the room cleaning process.

-HSKP #3 failed to allow the disinfectant to remain on surfaces for the manufacturer's recommended dwell time to ensure effective disinfection.

D. Staff interviews

HSKP #2 was interviewed on 6/10/24 at 10:38 a.m. HSKP #2 said she was not fluent in the English language, and this created a communication barrier between both spanish-speaking housekeepers and administrative staff. HSKP #2 said Diffense disinfecting cleaner required one minute to kill most bacteria and viruses, and required three minutes to kill clostridium difficile.

-However, according to the manufacturer's guideline, the disinfectant required eight minutes to kill clostridium difficile (see manufacturer's guidelines above).

HSKP #2 said she had not left the Diffense disinfecting spray on the door and cabinet handles for long enough before wiping it off with a dry cloth. HSKP #2 said gloves must be changed in between contaminated surfaces. HSKP #2 said she had not received training in the facility for how to clean rooms in her preferred language because her supervisors did not speak Spanish.

HSKP #3 was interviewed on 6/11/24 at 10:11 a.m. HSKP #3 said she was not fluent in the English language, and this created a communication barrier between the housekeeping staff and all other staff who only spoke English. HSKP #3 said the Diffense disinfecting cleaner had a 60-second dwell time to kill bacteria. HSKP #3 said she did not allow the disinfectant to dwell for 60 seconds before wiping it off with a cloth. HSKP #3 said she had not received training on how to clean a room from her supervisor in her preferred language.

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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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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 NHA was interviewed on 6/11/24 at 2:04 p.m. The NHA said she was currently acting in the role of the housekeeping supervisor. The NHA said housekeepers should change their gloves and perform hand Level of Harm - Minimal harm or hygiene after touching a resident's toilet. The NHA said housekeepers should allow enough time for the potential for actual harm Diffense disinfectant solution to properly disinfect the high touch surface areas before wiping off the disinfectant. The NHA said door handles, call lights, and cabinet handles were considered high-touch areas Residents Affected - Many that should be disinfected every day to prevent the spread of infection.

II. Enhanced barrier precautions (EBP)

A. Facility policy and procedure

The Enhanced Barrier Precautions policy, undated, was received from the NHA on 6/10/24 at 10:24 a.m. It documented in pertinent part,

All staff receive training on enhanced barrier precautions upon hire and at least annually and are expected to comply with all designated precautions.

Clear signage will be posted on the door or wall outside of the resident room indicating the type of precautions, required personal protective equipment (PPE), and the high-contact resident care activities that require the use of gown and gloves.

Nursing staff may place residents with certain conditions or devices on enhanced barrier precautions empirically while awaiting physician orders.

Make gowns and gloves available immediately outside of the resident's room.

The infection preventionist will incorporate periodic monitoring and assessment of adherence to determine

the need for additional training and education.

The Personal Protective Equipment policy, dated October 2018, was received from the NHA on 6/10/24 at 10:24 a.m. It documented in pertinent part, PPE required for transmission-based precautions is maintained outside and inside the resident's room, as needed.

B. Record review

According to the EMR of Resident #19 (admitted [DATE REDACTED]), the resident had an ostomy, which necessitated EBP to be identified and PPE to be worn during direct care of the resident.

According to the EMR of Resident #16 (admitted [DATE REDACTED]), the resident had a wound and a catheter, which necessitated EBP to be identified and PPE to be worn during direct care of the resident.

According to the EMR of Resident #34 (admitted [DATE REDACTED]), the resident had a catheter, which necessitated EBP to be identified and PPE to be worn during direct care of the resident.

C. Observations

On 6/10/24 at 10:31 a.m. licensed practical nurse (LPN) #1 was observed assisting Resident #19 to the bathroom without wearing PPE.

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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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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 On 6/10/24 at 4:19 p.m., an unidentified staff member was observed assisting Resident #16 without wearing PPE. The director of nursing observed this with the survey team. (see interview below) Level of Harm - Minimal harm or potential for actual harm On 6/10/24 at 9:27 p.m. LPN #8 was observed assisting Resident #16 with eating and drinking without wearing PPE. Residents Affected - Many

On 6/10/24 at 9:39 p.m. LPN #8 was observed assisting Resident #34 to the bathroom in his room without wearing PPE.

D. Staff interviews

CNA # 2 was interviewed on 6/10/24 at 10:38 a.m. CNA #2 said that she did not know what enhanced barrier precautions were or which residents required PPE for EBP. CNA #2 said if she was unsure if a resident required PPE during care, she would ask a nurse what to do.

Licensed practical nurse (LPN) #1 was interviewed on 6/10/24 at 11:29 a.m. LPN #1 said that he was unsure if one of the residents identified as needing EBP required contact isolation precautions instead. LPN #1 said that he followed the directions of what was on the isolation door sign when he did wound care. LPN #1 said if

a room did not have an isolation type sign on the door, there was no requirement to wear PPE during resident care.

-However, Resident #19 required PPE for EBP when staff provided direct care for the resident (see

observations above).

The DON was interviewed on 6/10/24 at 4:23 p.m. The DON said the staff member assisting Resident #16 should have been wearing PPE while assisting the resident. She said staff should wear PPE with residents who were on EBP when providing direct care to residents.

-However, staff members continued to assist residents on EBP without wearing PPE after the DON's interview. (see observations above)

III. Failure to offer hand hygiene to residents before meals

A. Observations

On 6/5/24 at 11:53 a.m. an unidentified resident in a plaid shirt was observed using his hands to wheel himself in his wheelchair to a table in the main dining hall.

-The resident was not offered hand hygiene before his meal was served.

On 6/5/24 at 11:55 a.m., Resident #2 was observed using his hand to wheel himself in his wheelchair to the main dining hall.

-The resident was not offered hand hygiene before his meal was served. The resident ate a hamburger which required the use of his hands.

On 6/5/24 at 12:03 p.m. Resident #19 was observed using his hands to wheel himself in his wheelchair to

the main dining hall.

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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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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 resident was not offered hand hygiene before his meal was served.

Level of Harm - Minimal harm or -On 6/10/24 at 11:58 a.m. residents eating at the table in the common area of the rehabilitation unit were not potential for actual harm offered hand hygiene prior to receiving their meal.

Residents Affected - Many B. Resident Interview

Resident #5 was interviewed on 6/5/24 at 11:47 a.m. Resident #5 said nursing staff did not normally offer hand hygiene to all residents before meals. Resident #5 said she tried to assist nursing care staff with remembering to offer hand hygiene to residents, but she was unable to watch everyone because she also needs to eat a meal during meal times.

C. Staff interviews

Certified nurse aide (CNA) #7 was interviewed on 6/6/24 at 3:14 p.m. CNA #7 said residents should be offered hand hygiene before meals.

The NHA and the regional operations manager (ROM) were interviewed on 6/12/24 at 4:32 p.m. The NHA said that the facility had not identified hand hygiene as a concern in the facility. The NHA said all staff assisted during meal times with resident trays. The NHA said the facility needed to do more to ensure residents received hand hygiene before meals.

The ROM said hand hygiene concerns had been discussed among administration several times in the recent past.

IV. Failure to change soiled bedding after wound dressing change

A. Observations

On 6/10/24 at 11:29 a.m. Resident #166's wound dressing change was observed with LPN #1. A draw sheet containing a mixture of blood and yellow drainage was observed under the resident's legs during the wound dressing change.

After the leg wound dressing changes had been completed by LPN #1, the resident's leg, with the new dressing on it, was placed on top of the old draw sheet containing the old wound drainage. LPN #1 proceeded to doff (remove) his PPE, performed hand hygiene and left the room.

-Resident #166's bed linens were not appropriately changed after his wound dressing change. (see Resident #166 interview below)

B. Resident Interview

Resident #166 was interviewed on 6/11/24 at 1:05 p.m. Resident #166 said no one had changed his soiled draw sheet from 6/10/24 dressing change. Resident #166 volunteered to lift his top bed sheet which exposed

a blood and yellow fluid-soaked bed sheet under the resident's legs.

-The facility failed to change soiled linens for more than 24 hours following a wound dressing change.

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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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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

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

F 0880 C. Staff interview

Level of Harm - Minimal harm or The DON was interviewed on 6/11/24 at 1:14 p.m. The DON said a newly-changed wound dressing should potential for actual harm not be placed on dirty linens. The DON said placing a new wound dressing on soiled linens could invite contamination of the wound. The DON said more education was needed in the facility to ensure cleaned Residents Affected - Many wounds were not placed on soiled bed linens.

V. Failure to have an effective water plan

A. Facility policy

The Legionella Water Management Program policy was obtained from the director of maintenance (DM) on 6/11/24 at 2:51 p.m. It documented in pertinent part,

As part of the infection control program, our facility has a water management program, which is overseen by

the water management team.

The purpose of the water management program is to identify areas in the water system where legionella bacteria can grow and spread, and to reduce the risk of legionnaire's disease.

The water management program used by our facility is based on the Centers for Disease Control and Prevention and ASHRAE recommendations for developing a legionella water management program.

B. Record review

The facility's water management plan was requested from the DM. On 6/11/24 at 2:51 p.m. the DM provided

the following information:

A facility water map which contained hand-drawn lines in pen indicating where water pipes were in the building.

-The facility failed to assess all locations where legionella and other waterborne pathogens could spread in

the facility (see interview below).

A document which identified the facility had tested for Legionella on 8/23/23 and the test was negative.

-However, the test was completed as an independent action of the facility and was not a part of a documented full water management plan (see interview below).

-The documentation provided by the DM failed to include an assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread. and

-Additionally, the documentation failed to identify measures implemented by the facility, such as visible inspections, disinfectant use and water temperature monitoring, to prevent the growth of opportunistic waterborne pathogens and how to monitor the measures.

C. Staff interviews

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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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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 DM and the ROM were interviewed together on 6/11/24 at 3:01 p.m. The DM said he did not know what

a water management program was or what elements were required to be in compliance with federal Level of Harm - Minimal harm or regulations. The DM said the water management program responsibility was given to him a week prior to the potential for actual harm survey and he was not given any guidance or training regarding water management programs. The DM said

the facility's water systems had been upgraded many times over the years and he did not know where all the Residents Affected - Many water pipes in the facility were. The DM said there could be old pipes with stagnant water in the facility that

he did not know about.

The DM said he knew empty rooms needed to have the water run weekly, but that had not been a problem in

the facility as there has not been a vacant room in the facility for seven continuous days.

The DM said the facility map with hand-drawn lines was provided to demonstrate that he knew where all water pipe access points were in the facility.

The ROM said the facility did not have a water management program in place currently. The ROM said he understood the facility was not in compliance with water management program requirements. The ROM said that he did not know how to develop a federally-compliant management plan and would research it.

The ROM was interviewed again on 6/12/24 at 4:32 p.m. The ROM said the Quality Assurance and Performance Improvement (QAPI) committee had not previously identified concerns with the water management program in the facility.

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F-F689 accident hazards). The resident representative said

she was the resident's power of attorney (POA) and emergency contact and should have been made aware of and notified when the resident fell .

B. Unwitnessed fall documentation

The 2/10/24 nurses note read Resident #173 had an unwitnessed fall on 2/10/24. The resident fell when she was transferring herself from her bed to her scooter and lost her balance then lowered herself to the floor.

The resident was found sitting on the floor between the bed and her scooter. According to the note, there were no injuries and the resident did not hit her head.

The 2/10/24 change of condition evaluation documented in part that a change of condition had been noted.

The symptoms included a fall on 2/10/24. Under the resident representative notification section, the evaluation listed Resident #173 as the family/resident representative notified on 2/10/24 at 6:10 a.m.

-The evaluation did not identify the resident's family/representative was notified after the fall.

The 2/10/24 unwitnessed incident report identified Resident #173 was notified of her fall on 2/10/24 at 6:47 a. m.

-The incident report did not identify the resident's representative was notified after the fall.

IV. Staff interviews

The director of nursing (DON) was interviewed on 6/12/24 at 11:58 a.m. The DON said staff needed to notify

the physician, the DON and the power of attorney (POA) after a resident fell . The DON said the family of the resident should always be contacted when listed as the emergency contact.

The DON was interviewed again on 6/12/24 at 4:11 p.m. The DON reviewed the documented notifications

after Resident #173's fall on 2/10/24. The DON said the notification of the fall should not have been the resident but the resident's family. She said the resident's emergency contact should have been notified after

the fall.

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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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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 0688 Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 50314

Residents Affected - Few Based on record review and interviews, the facility failed to ensure one (#54) of three residents with limited range of motion received appropriate treatment and services out of 45 sample residents.

Specifically, the facility failed to provide restorative therapy services to Resident #54.

Findings include:

I. Professional Reference

According to the American Association of Post-Acute Nursing (AAPACN) Guidelines for Restorative Nursing Programs, retrieved on 6/17/24 from aapacn.org/restorative-programs-guide/, The risk for functional decline

in long term care residents is a serious issue that often leads to falls, pressure ulcers/injuries, weight loss, depression, and other negative outcomes. To ensure quality outcomes and to comply with federal regulation, nursing facilities must have a comprehensive and effective restorative therapy program that encourages each resident's highest level of function.

II. Resident #54

A. Resident status

Resident #54, age greater than 65, was admitted to the facility on [DATE REDACTED] and readmitted on [DATE REDACTED]. According to the June 2024 computerized physician orders (CPO), diagnoses included chronic obstructive pulmonary disease (COPD), diabetes and generalized muscle weakness.

The 4/9/24 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairments with a brief interview for mental status (BIMS) score of 11 out of 15. The resident required set-up or clean-up assistance with eating. The resident required substantial or maximum assistance with transfers, showers, toileting and personal hygiene.

B. Resident interview

Resident #54 was interviewed on 6/5/24 at 10:14 a.m. Resident #54 said she was not receiving restorative therapy services to prevent physical decline. Resident #54 said she felt like she had become weaker since her readmission to the facility on [DATE REDACTED]. Resident #54 said she wanted to work towards walking more so

she could be more independent in her room.

Resident #54 said she felt both worried and sad that she was becoming more dependent on staff for assistance when she would rather work with the therapy department to keep as much of her independence as possible.

C. Record review

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 3 of 25 065286 Department of Health & Human Services Printed: 09/23/2025 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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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 0688 An interdisciplinary team (IDT) conference review summary was documented on 1/19/24 at 1:24 p.m by the social services director (SSD). The assessment documented the resident was not receiving restorative Level of Harm - Minimal harm or therapy services. potential for actual harm

A physical therapy discharge summary dated, 1/26/24, documented that physical therapy services ended Residents Affected - Few because of a lack of payment source for the resident's physical rehabilitation services. The discharge summary recommended a home exercise program and a restorative therapy program for the resident.

The discharge summary documented Resident #54 and facility staff were educated on positioning maneuvers, pressure relieving techniques, safe transfer techniques, assistive device use and compensatory strategies in order to facilitate functional independence for Resident #54.

-A review of the June 2024 CPO revealed the resident did not have an order for restorative nursing services.

III. Staff interviews

Certified nurse aide (CNA) #2 was interviewed on 6/10/24 at 10:38 a.m. CNA #2 said she did not know what restorative therapy services were. CNA #2 said she knew physical therapy was provided in the building, but was unsure who provided restorative therapy services to residents.

Licensed practical nurse (LPN) #6 was interviewed on 6/12/24 at 10:29 a.m. LPN #6 said she knew what restorative therapy services were, but she was not aware of any restorative therapy services being provided

in the building. LPN #6 said Resident #54 was not receiving restorative therapy services. LPN #6 said Resident #54 did not have a physician's order for restorative therapy services.

The physical therapist (PT) was interviewed on 6/11/24 at 1:19 p.m. The PT said restorative therapy services were recommended for residents whenever physical therapy ended for a resident without any expectation of improvement. The PT said she had started working at the facility in March 2024 and did not know anything about residents in the facility before that time. The PT said no one in the physical therapy department had worked with Resident #54 in the last several months. The PT said she did not know the resident wished to continue working with restorative therapy services to maintain her current level of function.

The director of rehabilitation (DOR) was interviewed on 6/12/24 at 12:24 p.m. The DOR said restorative therapy services were an important maintenance program to maintain a resident's current level of function and to prevent further physical decline. The DOR said the therapy department at the facility did not complete restorative therapy services, but the therapy department would provide recommendations to the nursing staff for residents to receive restorative therapy services, which was documented in the residents' medical record.

The DOR said restorative therapy services would have helped prevent physical decline for Resident #54.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 4 of 25 065286 Department of Health & Human Services Printed: 09/23/2025 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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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 0688 The director of nursing (DON) was interviewed on 6/12/24 at 1:05 p.m. The DON said restorative therapy services were important to maintain a resident's baseline physical function. The DON said Resident #54 did Level of Harm - Minimal harm or not receive restorative therapy services. The DON said there was no documentation in Resident #54's potential for actual harm medical record to indicate she received restorative therapy services. The DON said the facility had experienced significant turnover in the physical therapy department and recommendations for restorative Residents Affected - Few therapy services were not communicated effectively due to the turnover.

-However, PT discharge summary documentation revealed the PT department had communicated and educated nursing staff on the restorative therapy services Resident #54 required on 1/26/24.

The nursing home administrator (NHA), the regional operations manager (ROM), and the DON were interviewed together on 06/12/24 at 4:32 p.m. The NHA said the facility had identified restorative therapy services as an area of needed improvement within the facility quality assurance and performance improvement (QAPI) committee.

The DON said the facility had been talking about the need to properly offer and complete restorative therapy services for residents in the facility. The DON said she had been working to provide restorative therapy services education to nursing staff.

The ROM said the DOR identified a need to hire a restorative therapy services aide to ensure restorative therapy services were appropriately completed.

The DON said a restorative therapy services aide would be starting in the facility in July 2024 to provide restorative services to residents.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 5 of 25 065286 Department of Health & Human Services Printed: 09/23/2025 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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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 0689 Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 40467

Residents Affected - Few Based on record review and interviews, the facility failed to provide adequate supervision and assistance to prevent falls, and failed to assess, implement and monitor interventions consistent with resident needs for one (#173) of four residents reviewed for falls out of 45 sample residents.

Specifically, the facility failed to:

-Assess Resident #173 after a potential fall and after injuries were identified and report the potential fall;

-Monitor Resident #173 after facial injuries were identified;

-Ensure safe smoking practices were conducted for Resident #173 and care planned; and,

-Ensure interventions were care planned for Resident #173 who was identified at moderate risk for falls.

Findings include:

I. Facility policy

The Fall and Fall Risk Managing policy, revised March 2018, was provided by the facility on 6/12/24. The policy documented in pertinent part, Based on previous evaluations and current data, the staff will identify interventions related to the resident specific risk and cost to prevent the resident from falling and try to minimize complications from falling.

The staff, with input from the attending physician, will implement a resident centered fall prevention plan to reduce the specific risk factors of falls for each resident at risk or with a history of falls. If a systematic evaluation of a resident's fall risk identifies several possible interventions, the staff may choose to prioritize interventions.

If underlying causes cannot be readily identified or corrected, staff will try various interventions, based on assessment of the nature of the category of falling, until falling is reduced or stopped, or until the reason for

the continuation of the falling is identified as unavoidable. In conjunction with the attending physician, staff will identify and Implement relevant interventions to try to minimize serious consequences of falling.

The Smoking Residents policy, revised October 2023, was provided by the nursing home administrator (NHA) on 6/12/24 at 4:26 p.m. According to the policy, the facility established and maintained safe resident smoking practices. The policy read in pertinent part, Any resident with smoking privileges requiring monitoring shall have direct supervision of a staff member, family member, visitor or volunteer at all times while smoking.

II. Resident #173

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 6 of 25 065286 Department of Health & Human Services Printed: 09/23/2025 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 065286 B. Wing 06/12/2024

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

Eagle Ridge Post Acute 2425 Teller Ave Grand Junction, CO 81501

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 0689 A. Resident status

Level of Harm - Minimal harm or Resident #173, age 68, was admitted on [DATE REDACTED] and discharged on [DATE REDACTED]. According to the February 2024 potential for actual harm computerized physicians orders (CPO), diagnoses included fusion of the spine in the cervical region, encounter for surgical aftercare following surgery of the nervous system, acquired absence of left leg below Residents Affected - Few knee, difficulty walking, lack of coordination, dependence on a wheelchair, muscle weakness and adjustment disorder with mixed anxiety and depressed mood.

The 2/14/24 minimum data set (MDS) assessment identified the resident was cognitively intact with a brief

interview for mental status (BIMS) score of 15 out 15. She required set-up and supervision or touch assistance for transferring.

The MDS assessment documented the resident did not have any falls or injuries since her admission to the facility.

III. Resident representative interview

Resident #173's representative #1 was interviewed on 6/11/24 at 5:19 p.m. The representative said Resident #173 had a fall at the facility which resulted in a bruise and swelling under her eye and cheekbone. The resident'srepresentative said she was not notified of the fall but believed the fall occurred on 2/12/24 (cross-reference