Eagle Ridge Post Acute

F-F565: The facility failed to ensure effective interventions to resident council grievances of call light response time.

Cross-reference

F-F567: The facility failed to ensure proper consent and notification of spending of personal funds.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 54 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 0867 Cross-reference

F-F580: The facility failed to ensure a resident's representative was notified after a change in condition. Level of Harm - Minimal harm or potential for actual harm Cross-reference

F-F582: The facility failed to give the proper two day notification before Medicare A benefits expired. Residents Affected - Many Cross-reference

F-F610: The facility failed to investigate a potential allegation of abuse.

Cross-reference

F-F644: The facility failed to submit a PASRR Level I based on diagnosis.

Cross-reference

F-F645: The facility failed to complete a PASRR Level II after a PASRR Level I determination.

Cross-reference

F-F661: The facility failed to ensure a discharge summary was completed after a resident was discharged .

Cross-reference

F-F685: The facility failed to ensure a resident received eye glasses after an eye exam.

Cross-reference

F-F688: The facility failed to provide restorative nursing services.

Cross-reference

F-F689: The facility failed to assess a resident after injuries were identified after a potential fall.

Cross-reference

F-F692:The facility failed to implement interventions to prevent further weight loss after a resident had significant weight loss.

Cross-reference

F-F730: The facility failed to complete annual evaluations for certified nurse aides (CNA).

Cross-reference

F-F732: The facility failed to have an accurate nursing staff posting.

Cross-reference

F-F744: The facility failed to provide adequate dementia care training for the secure unit; failed to implement a dementia care plan for refusals of food, medications, fluids and vital signs.

Cross-reference

F-F758: The facility failed to limit PRN (as needed) psychotropic medications to 14 days or have physician documentation of the rationale.

Cross-reference

F-F761: The facility failed to ensure all medications were stored appropriately and maintain medication refrigerator temperature logs.

Cross-reference

F-F804: The facility failed to serve palatable food in taste and temperature.

Cross-reference

F-F805: The facility failed to serve food according to a physician's order.

Cross-reference

F-F812: The facility failed to prepare, store and serve food in a sanitary manner.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 54 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 0867 Cross-reference

F-F842: The facility failed to accurately document fluid intake.

Level of Harm - Minimal harm or Cross-reference

F-F849: The facility failed to ensure the facility received hospice notes and physician orders. potential for actual harm Cross-reference

F-F880 for failure to implement an effective infection prevention and control program.

III. Interviews

The director of nursing (DON) was interviewed on 6/10/24 at 3:51 p.m. The DON said she was also the infection preventionist and was operating in both roles at the facility. The DON said she did not have enough time to effectively conduct the infection preventionist's responsibilities.

The regional operations manager (ROM) was interviewed on 6/12/24 at 4:35 p.m. The ROM said he recognized the DON could not complete all of the infection preventionist assignments she was currently responsible for. The ROM said the facility had been working to hire another staff member to take over the role of the infection preventionist for the DON.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 54 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 0908 Keep all essential equipment working safely.

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 all mechanical, electrical Residents Affected - Some and patient care equipment in safe operating condition.

Specifically, the facility failed to ensure facility staff used a blood pressure cuffs which were rated for medical use.

Findings include:

I. Professional reference

According to the [NAME] Advantage for Basic Nursing handbook, third edition, retrieved on 6/17/24 from Treas, [NAME] S., et al. [NAME] Advantage for Basic Nursing: Thinking, Doing, and Caring. F. A. [NAME] Company, 2022., Blood Pressure - Practical Knowledge,

Electronic blood pressure monitors may be less accurate than those with an aneroid monitor (a manual blood pressure measuring device). To ensure accuracy, you should auscultate (listen to) a baseline blood pressure

before initiating automatic monitoring.

Ensure devices are rated for medical use.

The width of the blood pressure cuff bladder of a properly fitting cuff will cover approximately two-thirds of the length of the upper arm for an adult, and the entire upper arm for a child.

Alternative sites you can use are the forearm, thigh, or calf. However, systolic pressure may be 20 to 30 mmHg (millimeters of mercury) higher in the lower extremities than in the arms, but diastolic pressures are similar.

Abnormally high or low blood pressure readings should be rechecked by the provider.

According to Medaval Certified Accuracy (a company that provides accreditation, validation and equivalence services for medical devices) Equate 4000 series (UA-4000WM, retrieved on 6/20/24 from https://www. medaval.ie/resources/EN/devices/Equate-4000-Series-UA-4000WM.html,

The Equate 4000 Series (UA-4000WM) is an automatic blood pressure monitor. Medaval has not found evidence proving the accuracy of its blood pressure measurement technology. Blood pressure measurements are taken from the upper arm. It is intended for self-measurement and home use.

II. Observations

On 6/6/24 at 9:48 a.m., licensed practical nurse (LPN) #5 was observed using an Equate model VA-4000WM blood pressure cuff to take Resident #166's blood pressure.

-LPN #5 did not use a blood pressure cuff rated for medical use to obtain Resident #166's blood pressure (see professional references above and interview below).

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 49 of 54 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 0908 On 6/10/24 at 9:08 p.m., registered nurse (RN) #1 was observed taking Resident #51's blood pressure using

an Ever Ready First Aid wrist blood pressure cuff. Level of Harm - Minimal harm or potential for actual harm -RN #1 did not use a blood pressure cuff rated for medical use to obtain Resident #51's blood pressure (see professional references above and interview below). Residents Affected - Some III. Staff interviews

LPN #5 was interviewed on 6/6/24 at 9:49 a.m. LPN #5 said she used the Equate model VA-4000WM blood pressure cuff to obtain blood pressures on residents.

RN #1 was interviewed on 6/10/24 at 9:19 p.m. RN #1 said that she used the Ever Ready First Aid blood pressure cuff to take blood pressures on residents. RN #1 said if the reading was inaccurate she would use

the Equate model VA-4000WM blood pressure cuff to obtain physician-ordered blood pressures on residents.

LPN #6 was interviewed on 6/11/24 at 10:18 a.m. LPN #6 said she used the Equate model VA-4000WM blood pressure cuff to obtain physician-ordered blood pressures on residents.

The nursing home administrator (NHA) was interviewed on 6/11/24 at 3:41 p.m. The NHA said the Equate model VA-4000WM blood pressure cuff and the Ever Ready First Aid blood pressure cuff were not rated for medical use.

The NHA said there was no documentation to indicate that the Equate model VA-4000WM blood pressure cuff and the Ever Ready First Aid blood pressure cuff were safe or accurate to use at the facility to obtain accurate resident blood pressures.

The NHA said the facility was ordering new blood pressure cuffs on 6/11/24 that were rated for medical use.

The NHA said new blood pressures would be obtained on all residents in the facility using blood pressure equipment rated for medical use by the end of the day on 6/11/24.

The NHA said it was important to use blood pressure cuffs rated for medical use to ensure blood pressure readings could be accurately obtained.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 50 of 54 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 0943 Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. Level of Harm - Minimal harm or potential for actual harm 48412

Residents Affected - Some Based on record review and interview, the facility failed to provide training to their staff that at a minimum educates staff on activities that constitute abuse, neglect, exploitation and misappropriation of resident property as set forth, procedures for reporting incidents of abuse, neglect, exploitation, or misappropriation of resident property and dementia management and resident abuse prevention.

Specifically, the facility failed to:

-Ensure the activities assistant (AA), the cook (CK) and housekeeper (HSKP) #1 received annual training that covered abuse, reporting incidents of abuse and resident abuse prevention over the last 12 months; and,

-Ensure the CK, dietary aide (DA) #2 and the maintenance assistant (MA) received annual training that covered dementia management.

Findings include:

I. Facility policies

The Abuse, Neglect, Exploitation and Misappropriation Prevention Program, revised April 2021, was provided by the nursing home administrator (NHA) on 6/6/24 at 2:40 p.m. It read in pertinent part,

Residents have the right to be free from abuse, neglect, misappropriation of resident property and exploitation. The resident abuse, neglect, exploitation prevention program consists of a facility-wide commitment and resource allocation to support the following objectives provide staff orientation and training or orientation programs that include topics such as abuse prevention, identification and reporting of abuse, stress management and handling verbally or physically aggressive resident behavior.

The Dementia Clinical Protocol policy, revised 2001, was provided by the NHA on 6/10/24 at 1:00 p.m. It read in pertinent part,

Nursing assistants will receive initial training in the care of residents with dementia and related behaviors. In-services will be conducted at least annually thereafter. Additionally, performance reviews will be conducted annually and in-service education will be based on the results of the review.

II. Training records

A request was made for training records for the past 12 months (June 2023 to June 2024) for documentation to indicate the AA, the CK, HSKP #1 and the MA had participated in annual abuse and dementia training.

The NHA provided the training records on 6/10/24 at approximately 1:00 p.m.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 51 of 54 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 0943 -The training records indicated the CK, the AA and HSKP #1 had not received training that covered abuse, reporting incidents of abuse and resident abuse prevention over the past 12 months. Level of Harm - Minimal harm or potential for actual harm -The training records further indicated DA #2, the CK and the MA had not received training that covered dementia management over the past 12 months. Residents Affected - Some III. Staff interviews

The director of nursing (DON) was interviewed on 6/6/24 at 4:25 p.m. The DON said she was the staff development coordinator because the facility hired someone who was still in training.

The NHA and the DON were interviewed together on 6/11/24 at 4:10 p.m. The DON said the facility offered a four-hour dementia class to the staff and abuse training was provided through the facility' s electronic training system.

The NHA said she was unaware that non-clinical staff needed abuse and dementia training. The NHA said

she was unable to find the completed abuse training for the CK, the AA and HSKP #1.

The NHA said she was unable to find the completed dementia training for DA #2, the CK and the MA. The NHA said she was working on a new process to track the trainings.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 52 of 54 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 0947 Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. Level of Harm - Minimal harm or potential for actual harm 48412

Residents Affected - Some Based on interviews and record review, the facility failed to ensure certified nurse aides (CNA) received at least 12 hours of annual in-service training that also included dementia management training and resident abuse prevention training to ensure continued competence for four out of five staff reviewed.

Specifically, the facility failed to ensure CNA #2, #5, #4 and #1 received 12 hours of continuing education annually in all required training topic areas, including dementia management training and resident abuse prevention training.

Findings include

I. Training record review

Five randomly selected CNA training records were reviewed on 6/10/24. Of the five employees reviewed, four of the CNAs (#2, #5 #4 and #1) did not receive a full 12 hours of annual training.

A. CNA #2

-CNA #2, hired on 5/16/23, had participated in six hours and 45 minutes of training during the annual training year.

B. CNA #5

-CNA #5, hired on 8/18/21, had participated in a four-hour dementia class. The nursing home administrator (NHA) was unable to provide her complete training record, including completed training for abuse, neglect or exploitation.

C. CNA #4

-CNA #4, hired on 4/6/17, had participated in four hours and 30 minutes of training during the annual training year and had no record of completing abuse, neglect or exploitation training.

D. CNA #1

-CNA #1, hired on 4/6/23, had participated in six hours and 30 mins of training during the annual training year.

II. Staff interviews

The director of nursing (DON) was interviewed on 6/6/24 at 4:25 p.m. The DON said she was the staff development coordinator because the facility just hired someone who was still in training.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 53 of 54 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 0947 The NHA and the DON were interviewed together on 6/11/24 at 4:10 p.m. The DON said she was unaware when she provided CNAs with in-service training she needed to document the length of the training. Level of Harm - Minimal harm or potential for actual harm The NHA said staff training was an area the facility needed to improve and it was a work in progress.

Residents Affected - Some CNA #5 was interviewed on 6/12/24 at 10:36 a.m. CNA #5 said the staff were assigned training on the computer and she tried to complete it when she was able to. She said she completed a four-hour dementia training that she signed up for to attend.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 54 of 54 065286

F-F882: The facility failed to have an infection preventionist at least part time to run an effective infection control program.

Cross-reference

F-F908: The facility failed to ensure the use of appropriate medical grade blood pressure cuffs.

Cross-reference

F-F943: The facility failed to ensure all staff completed abuse training annually.

Cross-reference

F-F947: The facility failed to ensure CNAs received 12 hours of required training annually.

Cross-reference EP004: The facility failed to ensure the emergency preparedness plan was reviewed annually.

Cross-reference EP039: The facility failed to conduct emergency exercises annually.

II. Interviews

The NHA, the regional operations manager (ROM) and the director of nursing (DON) were interviewed together on [DATE REDACTED] at 4:32 p.m. The NHA said the QAPI committee meeting was held monthly. The NHA said the meeting included the interdisciplinary (IDT) team as well as the medical director and pharmacist.

The NHA said the QAPI committee identified areas of concerns, created performance improvement plans, set goals and reviewed the progress of the plans and determined if additional meetings and education were needed on the concerns and/or one-on-on interventions. The NHA said to ensure systematic change, the facility continued the conversations of the identified concern and determined if revisions to the plan were necessary.

The NHA said several of the identified concerns were reviewed in the QAPI meetings but the facility had had changes to personnel and the support provided was not enough. The NHA said the facility had to make significant changes over the last few months. The NHA said the changes were underway but not as quickly as the facility would want.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 54 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 0867 The ROM said the QAPI committee was not really conducting a full quality assurance review with the ongoing concerns. He said the IDT discussed several of the identified concerns in the morning stand up Level of Harm - Minimal harm or meetings, but not all the discussed concerns were brought to QAPI, so the breakdown of the problems did potential for actual harm not fully occur. The ROM said the facility's QAPI plan failed.

Residents Affected - Many The DON said some areas of concern had been overlooked. The DON said the QAPI committee needed to look at all concerns and potential concerns with fresh eyes. The DON said the committee needed to hold each other accountable and determine what the facility could do to help each other with the identification and correction of the concerns.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 54 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 0882 Designate a qualified infection preventionist to be responsible for the infection prevent and control program in

the nursing home. Level of Harm - Minimal harm or potential for actual harm 50314

Residents Affected - Many Based on observations and interviews, the facility failed to ensure a qualified infection preventionist (IP) was

in place for providing guidance to the facility on the infection control policy and programs which had the potential to affect all 74 residents residing in the facility at the time of the survey.

Specifically, the facility failed to have a designated IP who had the time necessary to properly assess, develop, implement, monitor, and manage the infection prevention and control program (IPCP) for the facility.

Findings include:

I. 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.

II. Observations

Observations throughout the survey (from 6/5/24 to 6/12/24) revealed multiple infection control failures within

the facility.

Cross-reference