Riverdale Post Acute

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

Administration Deficiencies

Provide a neutral and fair arbitration process and agree to arbitrator and venue.

Egress Deficiencies

Install emergency lighting that can last at least 1 1/2 hours.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Smoke Deficiencies

Install smoke barrier doors that can resist smoke for at least 20 minutes.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Miscellaneous Deficiencies

Have simulated fire drills held at unexpected times.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Resident Assessment and Care Planning Deficiencies

Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

Pharmacy Service Deficiencies

Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Administration Deficiencies

Inform resident or representatives choice to enter into binding arbitration agreement and right to refuse.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Environmental Deficiencies

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

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Smoke Deficiencies

Install a fire alarm system that can be heard throughout the facility.

Pharmacy Service Deficiencies

Ensure medication error rates are not 5 percent or greater.

Resident Rights Deficiencies

Keep residents' personal and medical records private and confidential.

Quality of Life and Care Deficiencies

Provide basic life support, including CPR, prior to the arrival of emergency medical personnel , subject to physician orders and the resident’s advance directives.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

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

Quality of Life and Care Deficiencies

Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube.

Administration Deficiencies

Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services.

Egress Deficiencies

Provide rooms that can be unlocked from inside without a key.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper fire barriers, ventilation and signs for the transfilling of oxygen.

Resident Rights Deficiencies

Post a list of names, addresses, and telephone numbers of all pertinent State agencies and advocacy groups and a statement that the resident may file a complaint with the State Survey Agency.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Nutrition and Dietary Deficiencies

Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.

Nutrition and Dietary Deficiencies

Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Freedom from Abuse, Neglect, and Exploitation Deficiencies

Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.

A complaint survey, prompted by #CO2570131; #CO2573675, Incident #1929901, Incident #2570020, Incident #2573424, Incident #2573457, Incident #2592583, Incident #2592748, Incident #2621282, Incident #2621298, Incident #2627594 and Incident #2631133 was completed on 9/30/25 to 12/1/25. Two deficiencies were cited.The actual exit date was 10/1/25. Per AHFSA guidance from CMS on 11/17/25, the survey end date has been adjusted to the date the CMS-2567 was issued to the provider, on 12/1/25. Based on record review and interviews, the facility failed to report alleged violations of physical abuse to the State Survey and Certification Agency in accordance with state law for two (#6 and #17) of 17 residents reviewed for abuse out of 18 sample residents.Specifically, the facility failed to ensure incidents of alleged physical abuse involving Resident #6 and Resident #17 were reported to the State Survey Agency (SSA). III. Resident #17A. Resident statusResident #17, age 72, was admitted on 6/3/24. According to the September 2025 computerized physician orders (CPO), diagnoses included dementia with behavioral disturbance, adult failure to thrive and senile degeneration of the brain.The 8/29/25 minimum data set (MDS) assessment revealed the resident had moderate cognitive impairment with a brief interview for mental status (BIMS) score of nine out of 15. The resident required substantial assistance from staff for most activities of daily living (ADL).The MDS assessment documented the resident did not have physical or verbal behaviors directedat others or other behavioral symptoms not directed toward others during the assessment period.B. Record reviewA progress note, dated 8/31/25 at 7:20 p.m., revealed a nurse was standing at her cart when she looked down the hall and observed Resident #17 attempting to kick another resident (Resident #19). Resident #1.. This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records Team for the full citation text at cdphe_hfemsd_records@state.co.us. Within your email, please include Facility Name, Inspection ID and Citation Code.

Based on document review, observation and interview, it was determined that the Fire Alarm system was not maintained. The deficient practice could affect 4 out of 4 smoke compartments, 105 out of 105 residents, and.. Based on document review, observation and interview, it was determined that the Fire Sprinkler system was not maintained. The deficient practice could affect 4 out of 4 smoke compartments, 105 out of 105 residents, and.. Based on document review, observation, and interview, it was determined that fire-rated door assemblies were not maintained. The deficient practice could affect 4 out of 4 smoke compartments, 105 out of 105 residents, and an ind.. Based on document review, observation, and interview, it was determined that fire-resistant construction was not maintained. The deficient practice could affect 4 out of 4 smoke compartments, 105 out of 105 residents, and an ind.. Based on document review, observation, and interview, it was determined that the electrical wiring was not maintained. The deficient practice could affect 4 out of 4 smoke compartments, 105 out of 105 residents, and an ind.. Based on document review, observation, and interview, it was determined that the facility failed to conduct fire drills. The deficient practice could affect four out of four smoke compartments, 105 out of 105 residents, and an ind.. Based on document review, observation, and interview, it was determined that the facility failed to maintain proper electrical practices.. The deficient practice could affect four out of four smoke compartments, 105 out of 105 reside.. Based on document review, observation, and interview, it was determined that the facility failed to maintain the emergency power generator properly. The deficient practice could affect four out of four smoke compartments, 105 .. Based on document review, observation, and interview, it was determined that the facility failed to provide proper personal protective equipment in the oxygen transfilling room. The deficient practice could affect 1 out of four smok.. Based on observation and interview, it was determined that the Fire Alarm system was installed improperly. The deficient practice could affect 2 out of 4 smoke compartments, 53 out of 105 residents, and an indeterminable numb.. Based on observation and interview, the facility failed to have UL-listed exit signs on both courtyard egress doors. The deficient practice affected 2 out of 4 smoke compartments. The deficient practice could affect 4 out of 4 smoke com.. Based on observation and interview, the facility failed to maintain the fire rating of hazardous areas. The deficient practice affected 4 out of 4 smoke compartments. During walk-through with the director of maintenance (DoM) and t.. Based on observation and staff interviews, it was determined that the facility failed to arrange and maintain the means of egress. This affects 1 out of 4 smoke compartments, affecting 27 of 105 residents and an indeterminable nu.. Based on observation and staff interviews, it was determined that the facility failed to maintain locking arrangements and delayed egress doors. This affected 2 out of 4 smoke compartments, 27 of 105 residents, and an indeterminable .. Based on the records review and the interview, the facility failed to inspect and test all emergency lighting. The deficient practice affected four out of four smoke compartments, and all residents, staff and visitors within the facili.. INITIAL COMMENTS (ID Prefix Tag #K000) are informational only and represent the facility' s general characteristics.This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).This survey was conducte..

A recertification survey with complaint #CO39419, #CO39564, Incident #39361, Incident #39466, Incident #39604 and .. An Emergency Preparedness survey was conducted from 3/23/25 to 3/26/25. No deficiencies were cited. Based on observations and interviews, the facility failed to post, in a form and manner accessible and understandabl.. Based on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable envir.. Based on observations, interviews and record review, the facility failed to maintain an infection control program desi.. Based on observations, record review and interviews, the facility failed to ensure one (#50) of three residents out of .. Based on observations, record review and interviews, the facility failed to ensure residents received food and fluids .. Based on observations, record review and interviews, the facility failed to ensure residents were treated with respec.. Based on observations, record review and interviews, the facility failed to ensure residents with a feeding tube recei.. Based on observations, record review and interviews, the facility failed to ensure the medication administration erro.. Based on observations, record review and interviews, the facility failed to ensure three (#97, #37 and #47) of eight r.. Based on observations, record review and interviews, the facility failed to keep resident medical records in a secure .. Based on observations, record review and interviews, the facility failed to store, prepare, distribute, and serve food .. Based on record review and interviews, the facility failed to develop a comprehensive care plan for three (#1, #75 an.. Based on record review and interviews, the facility failed to document resuscitation choices accurately in the medica.. Based on record review and interviews, the facility failed to ensure one (#1) of one resident received treatment and .. Based on record review and interviews, the facility failed to ensure the facility' s binding arbitration agreement conta.. Based on record review and interviews, the facility failed to ensure the facility' s binding arbitration agreement was t.. Based on record review and interviews, the facility failed to ensure three (#95, #75 and #249) of five residents out of.. Based on record review and interviews, the facility failed to meet all the requirements for the provision of hospice c.. Based on record review and interviews, the facility failed to report alleged violations of potential abuse to the State .. This Citation text meets this visualizations limit for 32,000 characters, please reach out to CDPHE HFEMSD Records T..