Center At Centerplace, Llc, The

F-F684: The facility failed to provide quality care by not sending a resident to the hospital when indicated, resulting in the death of the resident.

The facility's failure to provide quality of care put residents in a situation where a serious outcome occurred and created an immediate jeopardy situation.

III. Staff interviews

The medical director (MD) was interviewed on 2/12/25 at 3:53 p.m. The MD said he was not informed of the immediate jeopardy. However he said the NHA was out of the facility last night and today (2/11/25 and 2/12/25). The MD said he was in the facility at least two times per month. The MD said he attended QAPI committee meetings regularly. The MD said he had been the medical director since the facility was initially built.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 14 of 15 065431 Department of Health & Human Services Printed: 09/08/2025 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 065431 B. Wing 02/13/2025

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

Center at Centerplace, Llc, The 4356 24th St Rd Greeley, CO 80634

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 MD said he was not aware there was a quality of care issue by not sending residents to the hospital when indicated, resulting in a death due to a GI (gastro-intestinal) bleed. Nor was he aware of any quality of Level of Harm - Minimal harm or care problems related to anticoagulant monitoring, care plans or obtaining consents for anticoagulant use. potential for actual harm The MD said the prior administrators may have discussed the issues before, however he said it had not been discussed in QAPI recently. Residents Affected - Many

The MD said he was frustrated with the high turnover rate with staff and leadership at the facility and felt more stability would improve the quality of care for residents.

The NHA was interviewed on 2/13/25 at 1:49 p.m. The NHA said the QAPI committee met monthly and included every department. The NHA said he was new to the facility as of October 2024. The NHA said he established a pre-QAPI preparation to talk about follow up from previous QAPI meetings. He said all departments discussed what was going on, such as falls, wounds, grievances, resident council and staffing concerns.

The NHA said the QAPI committee included more than all the required members and they all knew if a corrective action had been implemented. The NHA said quality of care with change of condition documentation and when decisions were made to send to the hospital would be discussed moving forward and added to QAPI.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 15 of 15 065431