Katherine and Charles Hover Green Houses

In the surveyor’s words

From the most serious findings on record at Katherine and Charles Hover Green Houses, in the surveyor’s own words.

• Actual harm, isolatedF688Jan 29, 2026

  Based on record review, observations, and interviews, the facility failed to ensure two (#4 and #28) out of three residents received services and assistance to prevent a reduction in range of motion out of 31 sample residents. Resident #4 was admitted to the facility on [DATE]. According to diagnoses on admission, Resident #4 did not admit to the facility with a contracture to her hands, but based on observations and interviews on 1/26/26 to 1/29/26, the resident was unable to extend her fingers independently and/or without pain. The facility failed to provide the resident interventions to prevent a reduction in the resident's range of motion of her hands. […]

• Actual harm, isolatedF689Jan 29, 2026

  Based on observations, record review and interviews, the facility failed to ensure residents had adequate supervision and assistive devices to prevent accidents for one of one (#2) residents reviewed out of 31 sample residents. Resident #2, who was at risk for falls and had a history of falls, experienced eleven falls since her date of admission of 12/2/25. The interdisciplinary team (IDT) determined Resident #2 had poor safety awareness and was impulsive. On 12/12/25 Resident #2 self-propelled herself outside, where her wheelchair tipped off of the sidewalk. Resident #3 was sent to the hospital and was diagnosed with three rib fractures. On 12/17/25 Resident #2 sustained an unwitnessed fall and was bleeding from her head and was running down her neck. […]

• No harm, potential for more than minimal, widespreadF880Jan 29, 2026

  Based on observations, record review and interviews, the facility failed to ensure an infection prevention and control program was maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on two of four units. Specifically, the facility failed to: -Implement an effective water management plan to monitor for Legionella-Ensure staff wore the appropriate personal protective equipment (PPE) when providing incontinence care and transfers for Resident #14 and Resident #24, who was on enhanced barrier precautions (EBP) for wounds; and,-Ensure hand hygiene was performed appropriately in the dining areas. Findings include: I. Water management failures A. […]

• No harm, potential for more than minimal, patternF802Jan 29, 2026

  Based on observations, record review and interviews the facility failed to provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service. Specifically, the facility failed to ensure all staff that were responsible for preparing and cooking meals for the residents were fully educated on proper food handling and food preparation. Findings include:I. Professional referenceThe Colorado Department of Public Health and Environment Colorado Retail Food Establishment Rules and Regulations, revised 3/16/24, was retrieved on 2/4/26. It read in pertinent part, Employees are properly trained in food safety, including food allergy awareness, as it relates to their assigned duties. […]

• No harm, potential for more than minimal, patternF607Nov 8, 2023

  Based on record review and interviews, the facility failed to implement policies and procedures to prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property for six of 60 employee files reviewed. Specifically, the facility failed to complete criminal background checks for six employees prior to the employees working with residents. Findings include: I. Facility policy and procedures The Abuse Prevention Program policy, revised December 2016, was provided by the nursing home administrator (NHA) on 11/8/23 at 2:21 p.m. It read in pertinent part, Our elders have the right to be free from abuse, neglect, misappropriation of elder property and exploitation. […]