JUNIPER VILLAGE AT LOUISVILLE

A licensure revisit was completed on 9/7/23 for all previous deficiencies cited on 1/9/23. The residence is in compliance with all regulations surveyed. Deficiencies were cited.

Based on record review and interview, the residence failed to evaluate a resident transferred to another health care entity prior to readmission, affecting one former resident (#19). (Cross-reference Q1180) Findings include: 1. Residence Policy The residence's undated Resident Evaluation and Level of Care Determination policy read in part; "An evaluation and level of care determination will be completed on residents at move in, quarterly and change of condition ... The resident evaluation and level of care determination form is completed prior to move in, quarterly and when there is a significant change of condition and/or readmission from the hospital ..." 2. Former Resident #19 was admitted to the residence on 2/21/23 with diagnoses that included unspecified dementia with other behavioral disturbance and anxiety disorder. Progress notes for Former Resident #19, date 7/15- 8/13/23, read the following: On 7/15/23, Former Resident #20 sustained a fall and was transported to the hospital. On 7/17/23, Former Resident #19 was readmitted to the residence. The former resident was noted as having returned in power of attorney's (POAs) car and the director of wellness went outside to assist the POA. Former Resident #19 was noted as being agitated, confused and verbally aggressive with staff. The former resident refused to get out of the car. Staff were able to get the former resident into a wheelchair and to her room. Former Resident #19 "argued and resisted the entire time." On 7/17/23, a second note: hospital paperwork was received by the residence and read Former Resident #19 sustained left superior pubic rami fractures and acute subdural bilateral hematoma's. The hospital paperwork included an order for as needed (PRN) Tylenol. Staff noted they were unable to accept the PRN order due to Former Resident #19 residing in a secure environment. Additionally orders were received for a walker, physical and occupational therapy and a follow up computed tomography scan on 8/11/23. On 7/18/23, an order for Enoxaparin (lovenox) intramuscular injections for blood clots for 28 days to be completed every evening by a nurse was scheduled to start. However, the medication was not administered due to the former resident refusing. On 7/18/23 a second note read, Former Resident #19 was noted as vomiting before breakfast. Former Resident #19 was showing signs of pain, grimacing, holding her groin, yelling out in pain when standing or walking. The former resident was reported talking to herself, having hallucinations. Former Resident #19 was repeatedly noted trying to stand without assistance or walker. Staff documented crushing medications to put in ice cream after the former resident refused her medications. The former resident did not take medication and was refused to eat meals. On 7/19/23, the residence received a telephone call received from Former Resident #19's practitioner directing staff to send the former resident to the hospital. However, "POA and (residence) nurses do not feel (former) resident needs to be sent to ER (emergency room)." Former Resident #19 was not sent to the hospital. The POA for Former Resident #19 instead requested practitioner orders for gastroesophageal reflux medication and pain medication. On 7/20/23, Former Resident #19 stayed in bed most of the day and complained of pain in her pelvic area and nausea. The nurse injected lovenox injections. On 7/24/23, when staff arrived at the residence there were informed the former resident had been sent out during the overnight shift. Former Resident #19 was screaming out in pain holding her head crying help. EMS was telephoned and the former resident was sent to hospital. Former Resident #19's family member discussed an external hospice evaluation with a residence nurse. On 7/26-7/28/23, Former Resident #19 refused her lovenox injections. On 7/30/23, Former Resident #19 refused her lovenox and was noted as withdrawn, and isolated. On 8/1/23, external hospice services were initiated. On 8/4/23, Former Resident #19 was noted to be up in her wheelchair and sleepy most of the time. The a fall risk evaluation for Former Resident #19, dated 7/18/23, (completed one day after Former Resident #19 was readmitted to the residence) read Former Resident #19 sustained three or more falls in the prior three months, required regular assistance with elimination, had balance problems while standing/walking and required the use of assistive devices. The residence had no additional documented evaluation completed between 7/15-7/17/23 when Former Resident #19 was in the hospital. Additionally, the evaluation completed on 7/18/23 did not include Former Resident #19's fractures or subdural hematoma. The evaluation did not include any changes in the former resident's level of care needs including staff assistance needed with tasks. The evaluation did not include an evaluation of Former Resident #19's pain levels or medication management with new injection medication orders. 3. InterviewsOn 9/7/23 at 12:40 p.m., Staff #8 stated Former Resident #19 had fallen in July 2023, and was readmitted to the residence after a hospitalization. Staff #8 stated when residents returned from the hospital staff were usually given instructions on care changes. He stated "I remember thinking it was odd she returned so quickly and everything was the same as before, no changes in her care needs." Staff #8 stated Former Resident #19 was in pain when she was readmitted and required her incontinence product to be checked and changed in bed. He stated normally residents with the injuries Former Resident #19 sustained went to rehab to heal before coming back to the residence. Staff #8 stated he was not aware Former Resident #19 had a brain bleed when she readmitted to the residence. Staff #8 stated he believed Former Resident #19 required a higher level of care and should not have been readmitted to the residence. He stated assessments should have been completed by the nurses when a resident required a change in their care. On 9/7/23 at 2:49 p.m., the administrator stated she believed Former Resident #19 was readmitted to the residence with external hospice services in place. She stated, contrary to her previous statement, the POA was evaluating and talking with external hospice agencies and Former Resident #19 began services shortly after she returned. The administrator stated she believed the residence had completed an assessment for Former Resident #19. The administrator stated if a resident was admitted to the hospital for 24 hours she would have expected a reassessment to have be completed. She stated if the POA brought the former resident back to the residence one of the nurses would have completed an assessment. However, despite the administrator's previous statement, an assessment completed after Former Resident #19 went to the hospital on 7/15/23 and prior to her return on 7/17/23 was not provided.

Based on record review and interview, the residence failed to implement a fall management program which included detailing in each resident's care plan the individual approach necessary to address fall risk related to deficits in strength and balance, affecting one former resident (#19). Specifically, Former Resident #19 was admitted to the residence on 2/21/23. Former Resident #19 was found on the floor in her room between her recliner and the bathroom. Former Resident #19 complained of pain in her hip and emergency medical services (EMS) was telephoned. Former Resident #19 was admitted to the hospital due with left superior pubic rami fractures and acute subdural bilateral hematoma's. Former Resident #19 returned from the hospital on 7/18/23 and the care plan was not updated to include Former Resident #19's changed care needs related to assistance with ambulation or individualized approaches necessary to address Former Resident #19's fall risk related to deficits in strength and balance. Subsequently, Former Resident #19 was found on the floor, face down, on 8/5/23. Former Resident #19 was observed by staff with blood on her face, hands and the floor in her room. Former Resident #19 was noted to have an abrasion and blood coming out of her mouth as a result of the fall. Former Resident #19 was pronounced deceased on 8/12/23. Findings include: 1. References and Residence Policy a. According to Medical News Today, "A pubic ramus fracture describes a type of crack or break in a person's pelvis. Pubic ramus fractures are not typically life threatening and typically heal well. However, this kind of fracture can be serious for older people ... low energy trauma accidents may also cause people to sustain a pubic ramus fracture. These accidents can involve slips, or small falls from standing height ..." Medical News Today (2023), What is a Pubis Ramus Fracture, Retrieved from: https://www.medicalnewstoday.com/articles/pubic-ramus-fracture. b. According to UCLA Health, "An acute subdural hematoma (SDH) is a clot of blood that develops between the surface of the brain and the durra mater, the brain 's tough outer covering, usually due to stretching and tearing of veins on the brain's surface. These veins rupture when a head injury suddenly jolts or shakes the brain ... The mortality rate for patients with an acute SDH ranges from 50 percent to 90 percent. A significant percentage of these deaths result from the underlying brain injury and pressure on the brain that develops in the days after injury ..." UCLA Health (2023), Acute Subdural Hematoma, retrieved from: https://www.uclahealth.org/medical-services/neurosurgery/conditions-treated/acute-subdural-hematomas#:~:text=An%20acute%20subdural%20hematoma%20(SDH,jolts%20or%20shakes%20the%20brain. c. The residence's Fall Management and Lift Assistance Program policy, revised 2/2/23, read in part; "... Fall evaluation is completed on all residents and detailed interventions are incorporated within each resident's service plan. Fall risk related to deficits in strength, balance and eyesight and effects of medication are noted if applicable ... Residents who have experienced a fall will be reevaluated by wellness and (external agency) to determine additional interventions if indicated ..." 2. Former Resident #19 was admitted to the residence on 2/21/23 with diagnoses that included unspecified dementia with other behavioral disturbance and anxiety disorder. Progress notes for Former Resident #19, date 7/15- 8/13/23, read the following: On 7/15/23, late entry note created on 7/18/23: staff reported the former resident was on the floor between her recliner and bathroom. Former Resident #19 was reported as yelling in pain and resident reported hip pain. Emergency medical services (EMS) were telephoned and the family member was telephone. Former Resident #19 was admitted to the hospital with a pelvic fracture. On 7/17/23, Former Resident #19 was readmitted to the residence. The former resident was noted as having returned in power of attorney's (POAs) car and the director of wellness went outside to assist the POA. Former Resident #19 was noted as being agitated, confused and verbally aggressive with staff. The former resident refused to get out of the car. Staff were able to get the former resident into a wheelchair and to her room. Former Resident #19 "argued and resisted the entire time." On 7/17/23, a second note read, hospital paperwork was received by the residence and read Former Resident #19 sustained left superior pubic rami fractures and acute subdural bilateral hematoma's. The hospital paperwork included an order for as needed (PRN) Tylenol. Staff noted they were unable to accept the PRN order due to Former Resident #19 residing in a secure environment. Additionally orders were received for a walker, physical and occupational therapy and a follow up computed tomography scan on 8/11/23. On 7/18/23 a second note read, Former Resident #19 was noted as vomiting before breakfast. Former Resident #19 was showing signs of pain, grimacing, holding her groin, yelling out in pain when standing or walking. The former resident was reported talking to herself, having hallucinations. Former Resident #19 was repeatedly noted trying to stand without assistance or walker. Staff documented crushing medications to put in ice cream after the former resident refused her medications. The former resident did not take medication and was refused to eat meals. On 7/24/23, when staff arrived at the residence they were informed the former resident had been sent out during the overnight shift. Former Resident #19 was screaming out in pain holding her head crying help. EMS was telephoned and the former resident was sent to hospital. Former Resident #19's family member discussed an external hospice evaluation with a residence nurse. On 8/4/23, a new order for Former Resident #19 was added for Ativan twice daily. The former resident was noted to be up in her wheelchair and "sleepy most of the time." On 8/5/23, staff found Former Resident #19 on the floor next to her bed. Former Resident #19 was face down, bleeding from her mouth and seemed in pain. Staff notified Former Resident #19's external hospice nurse. The external hospice agency telephoned EMS for lift assistance for Former Resident #19. Former Resident #19 was noted as having a few small abrasions on right side of her face and her right eye was bruised. On 8/5/23, late entry completed on 8/7/23, a new intervention was noted to keep Former Resident #19's bed in the lowest position to prevent fall injuries. On 8/5/23, a second late entry completed on 8/17/23, Staff clarified blood was observed on Former Resident #19's face, her floor, and her hands. Staff were not able to verify the origin of the blood and noted it could have been from her nose or the abrasion. On 8/7/23, late entry completed on 8/17/23, a new intervention was implemented to include; "One side of bed to wall at all times, fall mat to open side of bed." However, the intervention was created after Former Resident #19 was documented as deceased (8/13/23). Hospital discharge paperwork for Former Resident #19, dated 7/17/23, read Former Resident #19's diagnoses were subdural hematoma, unwitnessed fall, dementia, closed fracture of multiple pubic rami and fracture of sacrum. The care plan for Former Resident #19, dated 2/23/23, was reviewed and read Former Resident #19 was at risk for falls. On 7/15/23 a fall intervention was added that read "admission, quarterly and as needed fall assessments." No additional fall interventions were added for Former Resident #19 after she fell on 7/15/23 and sustained pubic rami fractures and subdural hematoma's. The care plan read an update intervention was added on 8/5/23, after her second fall, that read "keep (Former Resident #19's) bed in lowest position to prevent fall injuries"3. InterviewsOn 9/7/23 at 8:16 a.m., Staff #9 stated Former Resident#19 had sustained falls and had been found on the floor by the morning shift staff. She stated she believed the former resident had fallen two to three times. Staff #9 stated the only interventions she was aware of for falls for Former Resident #19 was increased checks every 15-30 minutes. On 9/7/23 at 12:40 p.m., Staff #8 stated Former Resident #19 had fallen on 8/5/23 and was found with blood on her face. He stated residents fell regardless of what staff tried to do and added a resident could have fallen right after a check. Staff #8 stated Former Resident #19 had fallen overnight more than once. He stated after her fall in July 2023, Former Resident #19 was readmitted to the residence and had no interventions in place to prevent additional falls. On 9/7/23 at 2:32 p.m., the administrator stated Former Resident #19 went to the hospital twice and was a high fall risk. At 2:49 p.m., the administrator stated she was not at the residence when Former Resident #19 returned from the hospital. She stated she would have expected the care plan to have been updated after Former Resident #19 was readmitted with fall interventions. The administrator stated she believed the residence had added a light intervention; however, she could not recall the date.

A licensure complaint, prompted by #CO33218, was completed on 9/7/23. Deficiencies were cited.

Based on record review and interview, the residence failed to evaluate a resident transferred to another health care entity prior to readmission, affecting one former resident (#19). (Cross-reference Q1180) Findings include: 1. Residence Policy The residence's undated Resident Evaluation and Level of Care Determination policy read in part; "An evaluation and level of care determination will be completed on residents at move in, quarterly and change of condition ... The resident evaluation and level of care determination form is completed prior to move in, quarterly and when there is a significant change of condition and/or readmission from the hospital ..." 2. Former Resident #19 was admitted to the residence on 2/21/23 with diagnoses that included unspecified dementia with other behavioral disturbance and anxiety disorder. Progress notes for Former Resident #19, dated 7/15- 8/13/23, read the following: On 7/15/23, Former Resident #20 sustained a fall and was transported to the hospital. On 7/17/23, Former Resident #19 was readmitted to the residence. The former resident was noted as having returned in power of attorney's (POAs) car and the director of wellness went outside to assist the POA. Former Resident #19 was noted as being agitated, confused and verbally aggressive with staff. The former resident refused to get out of the car. Staff were able to get the former resident into a wheelchair and to her room. Former Resident #19 "argued and resisted the entire time." On 7/17/23, a second note: hospital paperwork was received by the residence and read Former Resident #19 sustained left superior pubic rami fractures and acute subdural bilateral hematoma's. The hospital paperwork included an order for as needed (PRN) Tylenol. Staff noted they were unable to accept the PRN order due to Former Resident #19 residing in a secure environment. Additionally orders were received for a walker, physical and occupational therapy and a follow up computed tomography scan on 8/11/23. On 7/18/23, an order for Enoxaparin (lovenox) intramuscular injections for blood clots for 28 days to be completed every evening by a nurse was scheduled to start. However, the medication was not administered due to the former resident refusing. On 7/18/23 a second note read, Former Resident #19 was noted as vomiting before breakfast. Former Resident #19 was showing signs of pain, grimacing, holding her groin, yelling out in pain when standing or walking. The former resident was reported talking to herself, having hallucinations. Former Resident #19 was repeatedly noted trying to stand without assistance or walker. Staff documented crushing medications to put in ice cream after the former resident refused her medications. The former resident did not take medication and was refused to eat meals. On 7/19/23, the residence received a telephone call received from Former Resident #19's practitioner directing staff to send the former resident to the hospital. However, "POA and (residence) nurses do not feel (former) resident needs to be sent to ER (emergency room)." Former Resident #19 was not sent to the hospital. The POA for Former Resident #19 instead requested practitioner orders for gastroesophageal reflux medication and pain medication. On 7/20/23, Former Resident #19 stayed in bed most of the day and complained of pain in her pelvic area and nausea. The nurse injected lovenox injections. 7/24/23- when staff arrived at the residence was informed resident had been sent out over night. resident was screaming out in pain holding her head crying help. EMS was telephoned and the former resident was sent to hospital. Former Resident #19's family member discussed an external hospice evaluation with a residence nurse. On 7/26-7/28/23, Former Resident #19 refused her lovenox injections. On 7/30/23, Former Resident #19 refused her lovenox and was noted as withdrawn, and isolated. On 8/1/23, external hospice services were initiated. On 8/4/23, Former Resident#19 was noted to be up in her wheelchair and sleepy most of the time. The a fall risk evaluation for Former Resident #19, dated 7/18/23, (completed one day after Former Resident #19 was readmitted to the residence) read Former Resident #19 sustained three or more falls in the prior three months, required regular assistance with elimination, had balance problems while standing/walking and required the use of assistive devices. The residence had no additional documented evaluation completed between 7/15-7/17/23 when Former Resident #19 was in the hospital. Additionally, the evaluation completed on 7/18/23 did not include Former Resident #19's fractures or subdural hematoma. The evaluation did not include any changes in the former resident's level of care needs including staff assistance needed with tasks. The evaluation did not include an evaluation of Former Resident #19's pain levels or medication management with new injection medication orders. 3. InterviewsOn 9/7/23 at 12:40 p.m., Staff #8 stated Former Resident #19 had fallen in July 2023, and was readmitted to the residence after a hospitalization. Staff #8 stated when residents returned from the hospital staff were usually given instructions on care changes. He stated "I remember thinking it was odd she returned so quickly and everything was the same as before, no changes in her care needs." Staff #8 stated Former Resident #19 was in pain when she was readmitted and required her incontinence product to be checked and changed in bed. He stated normally residents with the injuries Former Resident #19 sustained went to rehab to heal before coming back to the residence. Staff #8 stated he was not aware Former Resident #19 had a brain bleed when she readmitted to the residence. Staff #8 stated he believed Former Resident #19 required a higher level of care and should not have been readmitted to the residence. He stated assessments should have been completed by the nurses when a resident required a change in their care. On 9/7/23 at 2:49 p.m., the administrator stated she believed Former Resident #19 was readmitted to the residence with external hospice services in place. She stated, contrary to her previous statement, the POA was evaluating and talking with external hospice agencies and Former Resident #19 began services shortly after she returned. The administrator stated she believed the residence had completed an assessment for Former Resident #19. The administrator stated if a resident was admitted to the hospital for 24 hours she would have expected a reassessment to have be completed. She stated if the POA brought the former resident back to the residence one of the nurses would have completed an assessment. However, despite the administrator's previous statement, an assessment completed after Former Resident #19 went to the hospital on 7/15/23 and prior to her return on 7/17/23 was not provided.

Based on record review and interview, the residence failed to implement a fall management program which included detailing in each resident's care plan the individual approach necessary to address fall risk related to deficits in strength and balance, affecting one former resident (#19). Specifically, Former Resident #19 was admitted to the residence on 2/21/23. Former Resident #19 was found on the floor in her room between her recliner and the bathroom. Former Resident #19 complained of pain in her hip and emergency medical services (EMS) was telephoned. Former Resident #19 was admitted to the hospital due with left superior pubic rami fractures and acute subdural bilateral hematoma's. Former Resident #19 returned from the hospital on 7/18/23 and the care plan was not updated to include Former Resident #19's changed care needs related to assistance with ambulation or individualized approaches necessary to address Former Resident #19's fall risk related to deficits in strength and balance. Subsequently, Former Resident #19 was found on the floor, face down, on 8/5/23. Former Resident #19 was observed by staff with blood on her face, hands and the floor in her room. Former Resident #19 was noted to have an abrasion and blood coming out of her mouth as a result of the fall. Former Resident #19 was pronounced deceased on 8/12/23. Findings include: 1. References and Residence Policy a. According to Medical News Today, "A pubic ramus fracture describes a type of crack or break in a person's pelvis. Pubic ramus fractures are not typically life threatening and typically heal well. However, this kind of fracture can be serious for older people ... low energy trauma accidents may also cause people to sustain a pubic ramus fracture. These accidents can involve slips, or small falls from standing height ..." Medical News Today (2023), What is a Pubis Ramus Fracture, Retrieved from: https://www.medicalnewstoday.com/articles/pubic-ramus-fracture. b. According to UCLA Health, "An acute subdural hematoma (SDH) is a clot of blood that develops between the surface of the brain and the durra mater, the brain's tough outer covering, usually due to stretching and tearing of veins on the brain's surface. These veins rupture when a head injury suddenly jolts or shakes the brain ... The mortality rate for patients with an acute SDH ranges from 50 percent to 90 percent. A significant percentage of these deaths result from the underlying brain injury and pressure on the brain that develops in the days after injury ..." UCLA Health (2023), Acute Subdural Hematoma, retrieved from: https://www.uclahealth.org/medical-services/neurosurgery/conditions-treated/acute-subdural-hematomas#:~:text=An%20acute%20subdural%20hematoma%20(SDH,jolts%20or%20shakes%20the%20brain. c. The residence's Fall Management and Lift Assistance Program policy, revised 2/2/23, read in part; "... Fall evaluation is completed on all residents and detailed interventions are incorporated within each resident's service plan. Fall risk related to deficits in strength, balance and eyesight and effects of medication are noted if applicable ... Residents who have experienced a fall will be reevaluated by wellness and (external agency) to determine additional interventions if indicated ..." 2. Former Resident #19 was admitted to the residence on 2/21/23 with diagnoses that included unspecified dementia with other behavioral disturbance and anxiety disorder. Progress notes for Former Resident #19, dated 7/15- 8/13/23, read the following: On 7/15/23, late entry note created on 7/18/23: Staff reported the former resident was on the floor between her recliner and bathroom. Former Resident #19 was reported as yelling in pain and resident reported hip pain. Emergency medical services (EMS) were telephoned and the family member was telephone. Former Resident #19 was admitted to the hospital with a pelvic fracture. On 7/17/23, Former Resident #19 was readmitted to the residence. The former resident was noted as having returned in power of attorney's (POAs) car and the director of wellness went outside to assist the POA. Former Resident #19 was noted as being agitated, confused and verbally aggressive with staff. The former resident refused to get out of the car. Staff were able to get the former resident into a wheelchair and to her room. Former Resident #19 "argued and resisted the entire time." On 7/17/23, a second note read, hospital paperwork was received by the residence and read Former Resident #19 sustained left superior pubic rami fractures and acute subdural bilateral hematoma's. The hospital paperwork included an order for as needed (PRN) Tylenol. Staff noted they were unable to accept the PRN order due to Former Resident #19 residing in a secure environment. Additionally orders were received for a walker, physical and occupational therapy and a follow up computed tomography scan on 8/11/23. On 7/18/23 a second note read, Former Resident #19 was noted as vomiting before breakfast. Former Resident #19 was showing signs of pain, grimacing, holding her groin, yelling out in pain when standing or walking. The former resident was reported talking to herself, having hallucinations. Former Resident #19 was repeatedly noted trying to stand without assistance or walker. Staff documented crushing medications to put in ice cream after the former resident refused her medications. The former resident did not take medication and was refused to eat meals. On 7/24/23 when staff arrived at the residence they were informed the former resident had been sent out during the overnight shift. Former Resident #19 was screaming out in pain holding her head crying help. EMS was telephoned and the former resident was sent to hospital. Former Resident #19's family member discussed an external hospice evaluation with a residence nurse. On 8/4/23, a new order for Former Resident #19 was added for Ativan twice daily. The former resident was noted to be up in her wheelchair and "sleepy most of the time." On 8/5/23, staff found Former Resident #19 on the floor next to her bed. Former Resident #19 was face down, bleeding from her mouth and seemed in pain. Staff notified Former Resident #19's external hospice nurse. The external hospice agency telephoned EMS for lift assistance for Former Resident #19. Former Resident #19 was noted as having a few small abrasions on right side of her face and her right eye was bruised. On 8/5/23, late entry completed on 8/7/23, a new intervention was noted to keep Former Resident #19's bed in the lowest position to prevent fall injuries. On 8/5/23, a second late entry completed on 8/17/23, Staff clarified blood was observed on Former Resident #19's face, her floor, and her hands. Staff were not able to verify the origin of the blood and noted it could have been from her nose or the abrasion. On 8/7/23, late entry completed on 8/17/23, a new intervention was implemented to include; "One side of bed to wall at all times, fall mat to open side of bed." However, the intervention was created after Former Resident #19 was documented as deceased (8/13/23). An external investigation, dated 8/9/23, read in part: As of 8/12/23, Former Resident #19 passed away. Hospital discharge paperwork for Former Resident #19, dated 7/17/23, read Former Resident #19's diagnoses were subdural hematoma, unwitnessed fall, dementia, closed fracture of multiple pubic rami and fracture of sacrum. The care plan for Former Resident #19, dated 2/23/23, was reviewed and read Former Resident #19 was at risk for falls. On 7/15/23 a fall intervention was added that read "admission, quarterly and as needed fall assessments." No additional fall interventions were added for Former Resident #19 after she fell on 7/15/23 and sustained pubic rami fractures and subdural hematoma's. The care plan read an update intervention was added on 8/5/23, after her second fall, that read "keep (Former Resident #19's) bed in lowest position to prevent fall injuries"3. InterviewsOn 9/7/23 at 8:16 a.m., Staff #9 stated Former Resident #19 had sustained falls and had been found on the floor by the morning shift staff. She stated she believed the former resident had fallen two to three times. Staff #9 stated the only interventions she was aware of for falls for Former Resident #19 was increased checks every 15-30 minutes. On 9/7/23 at 12:40 p.m., Staff #8 stated Former Resident #19 had fallen on 8/5/23 and was found with blood on her face. He stated residents fell regardless of what staff tried to do and added a resident could have fallen right after a check. Staff #8 stated Former Resident #19 had fallen overnight more than once. He stated after her fall in July 2023, Former Resident #19 was readmitted to the residence and had no interventions in place to prevent additional falls. On 9/7/23 at 2:32 p.m., the administrator stated Former Resident #19 went to the hospital twice and was a high fall risk. At 2:49 p.m., the administrator stated she was not at the residence when Former Resident #19 returned from the hospital. She stated she would have expected the care plan to have been updated after Former Resident #19 was readmitted with fall interventions. The administrator stated she believed the residence had added a light intervention; however, she could not recall the date.

A relicensure survey with complaint #CO30463 was completed on 1/9/23. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure the administrator complied with all applicable state laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 47 current residents. Findings include: 1. ReferenceThe Residential Care Facility (RCF) Comprehensive Mitigation Guidance dated 11/3/22, required residences to:-Ensure at least one designated person completes the Colorado RCF Infection Prevention Training using CO.TRAIN within two weeks of the assignment of duties and each following calendar year thereafter. The information must be reported in EMResource and remain updated.-Ensure the residence establish and maintain a COVID-19 mitigation, vaccine, and treatment plan that promotes vaccine confidence and acceptance. The COVID-19 ongoing vaccination plan must be kept current by the facility. 2. Record ReviewOn 1/5/22 at approximately 8:50 a.m., the residence's COVID-19 ongoing vaccination plan was requested from the acting administrator (AA); however she was unable to provide the documentation. On 1/5/22 at approximately 4:00 p.m., the residence's COVID-19 ongoing vaccination plan was requested again from the acting administrator (AA); however she was unable to provide the documentation. On 1/9/22 at approximately 1:00 p.m., the residence's ongoing vaccination plan was provided; however, it had not been updated as required. The vaccination plan contained names of previous staff and did not contain a designated infection control person with proof any training had been completed. 3. InterviewsOn 1/5/23 at 4:00 p.m., the AA and the director of wellness (DOW) stated they were unaware what the ongoing COVID-19 vaccination plan was. The AA stated that could have been something that had been completed by the previous administrator but was unsure where the documentation was located. On 1/9/23 at 12:00 p.m., the AA stated she thought the DOW was the designated infection control person but was unsure if he had been trained. On 1/9/23 at 1:22 p.m., the DOW stated the residence did not have a designated infection control person; however, he was currently in the process of being trained.

Based on observation and interview, the administrator failed to ensure contact information for the administrator or the administrator designee was readily available to the residents and the public, affecting 47 current residents. Findings include: On 1/5/22 from 7:00 a.m. to 5:00 p.m., there was no contact information for the administrator or administrator designee readily available to residents or the public. On 1/9/22 at 12:00 p.m., the acting administrator stated she was unaware if the information was available. She stated the contact information probably still had the previous administrator's information on it which was why it was not available.

Based on record review and interview the residence failed to ensure the residence's policies and procedures were reviewed at least annually, affecting 47 current residents. Findings include:On 1/5/23 at approximately 10:00 a.m., the administrator was asked to provide the following policies and procedures:a. The residence's Evacuation plan policy, read the policy had not been reviewed since 8/1/2014.b. The residence's Maintenance supplies, equipment and material safety policy, read the policy had not been reviewed since 7/1/2014.c. The residence's Hazard communication, Housekeeping policy, read the policy had not been reviewed since 7/1/2014.d. The residence's Residents rights policy, read the policy had not been reviewed since 1/1/2017.e. The residence's Abuse policy, read the policy had not been reviewed since 2/3/2017.f. The residence's Grievance policy, read the policy had not been reviewed since 8/24/2018.g. The residence's Controlled substance policy, read the policy had not been reviewed since 2/1/2018.h. The residence's Disposal of medication policy, read the policy had not been reviewed since 2/1/2018. I. The residence's Medication assistance policy, read the policy had not been reviewed since 2/1/2018. J. The residence's Medication audit policy, read the policy had not been reviewed since 2/1/2018. K. The residence's Fall management and lift assistance policy, read the policy had not been reviewed since 1/1/2019. L. The residence's Influenza policy, read the policy had not been reviewed since 4/20/2020. On 1/9/23 at 12:30 p.m., the acting administrator (AA) stated the home office was responsible for ensuring the policies and procedures were reviewed and annually updated. The AA acknowledged that the review date on the given policies were wrong as it was updated recently. She added the regional director of operations (RDO) was telephoning the home office to get the updated policies. However, none were provided before the exit on 1/9/23 at 2:00 p.m.

Based on record review and interview, the residence failed to arrange to evaluate the resident prior to re-admission to the residence affecting one of one sample residents (#2). Findings include:1. Residence Policiesa. The residence's Resident Agreement, dated 12/20/23 (sic), read, in part, "Level of care assessment charges. If it is determined by community that resident requires a higher level of care within community then previously assigned due to a amended (sic) and resident will be reassigned to a higher level of care within community ... The purpose of the screening process, initial assessment and medical evaluation is to provide basic information about the care needed by resident. Additional assessments are required ... if the condition of resident significantly changes prior to the annual assessment ... Personalized program for care and service. Community shall develop and implement a written personalized program for care and service for resident ... The personalized program for care and service shall describe the care, service or treatment needs of resident ... Resident's personalized program for care and service shall be revised within 30 days upon ... changes in resident's needs as indicated on the current assessment ..." b. The residence's Fall Management and Lift Assistance policy, dated 1/1/19, read, in part, "Residents who have experienced a fall will be reevaluated by wellness ... to determine additional interventions if indicated."2. Resident #2 was admitted to the residence on 4/26/21 with diagnoses including fracture of lumbosacral of spine/pelvis. Progress notes in November 2022 and January 2023 for Resident #2 revealed the following:On 11/26/22 Resident #2 expressed pain on her left groin and hip area and hesitated to walk and used a wheelchair. Resident #2 was transferred to the hospital for evaluation. On 11/28/22 Resident #2 was in the hospital. On 11/29/22 Resident #2 returned from the hospital, had a closed non-displaced fracture of the anterior wall of left acetabulum (socket of the hip bone). Resident #2 was toe touch weight bearing status, used a wheelchair and required pain medication. On 1/1/23 Resident #2 was found lying on the floor and complained of right hip pain. On 1/3/23 Resident #2 was in the hospital. On 1/4/23 Resident #2 returned from the hospital had right pelvic fracture and an older left pelvic fracture, had lots of pain when transferred and was non-weight bearing. Was admitted to the hospital for three days. There was no evidence in Resident #2's record that evaluations were completed at the hospital, prior to readmission to the residence for both hospital admissions on 11/26/22 and 1/1/23.3. InterviewsOn 1/5/23 at 4:09 p.m., the wellness nurse (WN) stated when a resident was sent to the hospital, an assessment (evaluation) was completed at the hospital to ensure the residence was able to provide care and services to the resident. The WN stated he did not evaluate Resident #2 in the hospital after she fell on 11/26/22 and 1/1/23. He added, the director of wellness (DOW) was notified by the hospital that Resident #2 was going to be discharged from the hospital after the 1/1/23 fall and stated he approved her readmission back to the residence. On 1/5/22 at 4:24 p.m., the DOW stated the residence had two full time nurses. He added he expected either of the nurses to evaluate Resident #2 at the hospital prior to her readmission back to the residence. The DOW acknowledged that neither wellness nurses evaluated Resident #2, as required. On 1/9/23 at approximately 12:15 p.m., the acting administrator (AA) stated the DOW or the two wellness nurses were responsible for evaluating residents prior to their readmission from a hospitalization. The AA stated she was not aware either wellness nurse evaluated Resident #2 at the hospital after she fell on 11/26/22 and 1/1/23. She added the wellness nurses should have evaluated Resident #2, as required.

Based on record review and interview, the residence failed to ensure a comprehensive assessment was updated for residents whenever residents' conditions changed from baseline status, affecting one of one resident who experienced a change from baseline status (#2). Findings include:1. Reference and Residence Policiesa. Chapter VII regulations governing assisted living residences, part 12.7, requires that the comprehensive assessment shall include all the following items:(J) History and circumstances of recent falls and any known approaches to prevent future falls.b. The residence's Change in Condition policy, dated 11/1/22, read, in part, "When a licensed wellness staff is alerted to a resident's change in condition ... the change in condition evaluation is used as a reference to manage any change of condition ... Symptom or sign ... fall ... immediate ... with any suspected severe injury (e.g. fracture) any hip pain, or more than minor pain elsewhere ... "c. The residence's Fall Management and Lift Assistance policy, revised 1/1/19, read, in part, "Residents who have experienced a fall will be reevaluated by wellness and Theralink to determine additional interventions if indicated."2. Resident #2 was admitted to the residence on 4/26/21. An assessment for Resident #2, dated 11/3/22, read that Resident #2 was a fall risk, required safety checks, adequate lighting, pain evaluation, did not require any fall management devices, required minimal assistance with her walker, ambulates independently, and required implementation of fall protocols. There were no other assessments in Resident #2's record. Progress notes in November 2022 and January 2023 for Resident #3 revealed the following:Progress notes in November 2022 and January 2023 for Resident #3 revealed the following:On 11/26/22 Resident #2 expressed pain on her left groin and hip area and hesitated to walk and used a wheelchair. Resident #2 was transferred to the hospital for evaluation. On 11/28/22 Resident #2 was in the hospital. On 11/29/22 Resident #2 returned from the hospital, had a closed non-displaced fracture of anterior wall of left acetabulum (hip). Resident #2 was toe touch weight bearing status, used a wheelchair and required pain medication. On 1/1/23 Resident #2 was found lying on the floor and complained of right hip pain. On 1/3/23 Resident #2 was in the hospital. On 1/4/23 Resident #2 returned from the hospital had right pelvic fracture and an older left pelvic fracture, had lots of pain when transferred and was non-weight bearing. 1/5/23 Resident #2 was found lying on her left side on the floor next to her bed. Resident #2 screamed when the staff touched her legs. Hospital discharge records in Resident #2's record, dated 11/29/22, read that Resident #2 fractured her left pelvis. Hospital discharge records in Resident #2's record, dated 1/4/23, read that Resident #2 had a fracture of the right acetabulum (socket of the hip bone). Resident #2 was non weight bearing and required to be transferred in and out of bed using a mechanical lift. 3. InterviewsOn 1/5/23 at 4:09 p.m., the wellness nurse (WN) stated an assessment was completed after a resident returned from the hospital from a fall. He added he expected the assessment to contain interventions to help mitigate future falls. The WN stated he had not completed an assessment on Resident #2, as required. On 1/5/23 at 4:24 p.m., the director of wellness (DOW) stated he expected the residence to complete a change of condition assessment once a resident returned from the hospital. He added he expected whomever was present to reassess Resident #2 at the hospital to complete an assessment once she returned. On 1/9/23 at approximately 12:00 p.m., the acting administrator (AA) stated either one of the WNs or the DOW were responsible for completing an assessment if a resident had a change in baseline status. She added, she considered a change in baseline status to include falls when careneeds changed and increased falls. The AA stated she expected the residence to complete an assessment, as required and was not sure why one was not completed for Resident #2 after Resident #2 went to the hospital on 12/26/22 and 1/1/23 and experienced a change in baseline status.

Based on observation, record review and interview, the residence failed to develop policies and procedures to establish a fall management program, affecting one of two sample residents (#2) with a history of falls. (Cross-reference Q1068 and Q1146)Specifically, a care plan for Resident #2, revised on 11/3/22, identified Resident #2 as a fall risk and needed a quarterly and as needed fall assessment. The care plan did not detail the individualized approaches necessary to address Resident #2's risk for falling. Progress notes for Resident #2, dated 11/26 and 11/29/22 read Resident #2 complained of left hip/groin pain, was sent to the hospital and was diagnosed with a fractured left hip. The residence had not completed an assessment after Resident #2 returned from the hospital. On 1/1 and 1/3/23, Resident #2 was found on the floor next to her bed, complained of right hip pain and was diagnosed with a fractured right hip. On 1/4/23 Resident #2 was enrolled with an external hospice provider. No assessment was completed after Resident #2 returned from the hospital on 1/4/23. Findings include:1. Residence PolicyThe residence's Fall Management and Lift Assistance policy, revised 1/1/19, read, in part, "Fall management education and training is provided to residents, families and associates. Fall evaluation is completed on all residents and detailed interventions are incorporated within each resident's service plan. Fall risk related to deficits in strength, balance and eyesight and effect of medication are noted, if applicable. Resident engagement programs are provided daily that include exercises developed by the Theralink therapy provider designated to improve strength, balance and endurance ... Residents who have experienced a fall will be reevaluated by wellness and Theralink to determine additional interventions if indicated."2. Resident #2 was admitted to the residence on 4/26/21 with diagnoses including Alzheimer's disease, fracture of spine/pelvis and history of falling. a. ObservationOn 1/5/23 at approximately 8:00 a.m., Resident #2 was observed on the floor next to the left side of her bed. Resident #2 complained of pain. The wellness nurse (WN) attempted to move Resident #2 and Resident #2 screamed out in pain. The WN telephoned an external hospice representative and was directed to leave Resident #2 on the floor in a comfortable position until paramedics arrived to safely place Resident #2 back in bed. b. Record ReviewProgress notes in November 2022 and January 2023 for Resident #3 revealed the following:On 11/26/22 Resident #2 expressed pain on her left groin and hip area and hesitated to walk and used a wheelchair. Resident #2 was transferred to the hospital for evaluation. On 11/28/22 Resident #2 was in the hospital. On 11/29/22 Resident #2 returned from the hospital, had a closed non-displaced fracture of the anterior wall of left acetabulum (socket of the hip bone). Resident #2 was toe touch weight bearing status, used a wheelchair and required pain medication. On 1/1/23 Resident #2 was found lying on the floor and she complained of right hip pain. On 1/3/23 Resident #2 was in the hospital. On 1/4/23 Resident #2 returned from the hospital had a right pelvic fracture and an older left pelvic fracture, had lots of pain when transferred and was non-weight bearing. Was admitted to the hospital for three days. Resident #2 enrolled with an external hospice provider. c. InterviewsOn 1/5/23 at 7:46 a.m., Staff #1 stated Resident #2 was on the floor next to her bed complaining of pain. On 1/5/23 at approximately 8:00 a.m., the WN stated Resident #2 fell a week prior to the onsite visit and fractured her right hip. On 1/5/23 at approximately 12:00 p.m. Staff #1 and #5 stated they did not receive any fall management training and there were no interventions in place for Resident #2 after she fell on 11/26/22 and 1/1/23. On 1/5/23 at 3:03 p.m., Staff #6 stated she did not receive any resident specific fall management trainingfrom the residence after Resident #2 fell on 11/26/22 and 1/1/23. On 1/5/23 at 3:07 p.m., Staff #7 stated after Resident #2 fell on 11/26/22 and 1/1/23 she did not receive any resident specific fall management training. On 1/5/23 at 4:24 p.m., the director of wellness (DOW) stated the residence should have included more fall interventions in the care plan for Resident #2. On 1/9/23 at approximately 12:00 p.m., the acting administrator (AA) stated the WNs were responsible for completing reassessments, fall management education and coordinating external service provider services after a resident experienced falls with changes in baseline status. The AA stated she was unsure if educational materials were provided to Resident #2's family. She added the nurses should have followed up with the practitioner's external service provider's recommendation after Resident #2's first fall on 11/26/22. She added she expected the residence to add resident engagement activities, if applicable to Resident #2's care plan.

Based on observation and interview, the residence failed to ensure the written house rules were placed in a publicly visible location so that they were always available to residents and visitors, affecting 47 residents. Findings include:1. Observations The environmental tour of the residence on 1/5/23 and 1/9/23 revealed no evidence of the house rules posted in a visible location of the residence. 2. Interviews On 1/5/23 at 1:45pm., the wellness nurse (WN) stated the house rules were not posted because he believed it was removed from the walls. WN added the residents with their cognitive impairment removed the house rules from the bulletin board where they had previously been posted. On 1/9/23 at 8:30 a.m., Staff #1 stated she worked in the residence for three months and never saw the house rules posted. On 1/9/23 at approximately 12:15 p.m., the acting administrator (AA) stated that the house rules were not posted in the residence. She added she was aware of the requirement but they removed the posting two months ago to paint the walls. She added the painting was completed two weeks ago but she acknowledged that they failed to put the house rules on the walls. She added the home office is coming in the first week of February to put the postings again.

Based on record review and interview,the residence failed to ensure medication audits were completed by the administrator and qualified medication administration person (QMAP) supervisor on a quarterly basis, affecting 47 current residents. Findings include: The residence's Medication Audit policy, dated 2/1/18, read, 'The director of wellness completes an audit of medications quarterly or more frequently as needed. The house pharmacy may be requested to complete audits of medications quarterly or as needed. The medication audit tool is used."On 1/5/23 at 8:50 a.m., the last three medication audits were requested from the acting administrator (AA); however, she was unable to provide the documentation. On 1/9/22 at approximately 12:00 p.m., the AA stated she was unaware the medication audits were required to be completed by the administrator/interim administrator and the QMAP supervisor.

Based on observation and interview, the residence failed to ensure residents had independent access to drinks at all times and drinks between meals affecting 12 residents in the Garden wing of the secure environment. Findings include:On 1/5/23-1/9/23, during the onsite survey, no drinks were available for residents to independently access at all times. On 1/5/23 at 7:20 a.m., Resident #1, #6, #13 and #14 waited for the staff to bring them water. On 1/5/23 at 7;35 a.m., Staff #3 stated residents were not permitted access to the kitchen; however, some residents entered the kitchen and were redirected to step out of the kitchen. On 1/5/23 at 8:30 a.m., Resident #6 stated she had to wait for staff to bring her a drink and could not access a drink independently. On 1/5/23 at 8:45 a.m., Staff #4 stated residents were given water with each meal that is breakfast, lunch, and dinner and during snacks. She added "I think giving water five times is enough."On 1/5/23 at 9:05 a.m., Resident #13 stated he had to ask staff to get him a drink because the kitchen was not accessible to residents. On 1/5/23 at 9:30 a.m., Resident #14 stated she had to ask staff for a beverage including coffee or cranberry/orange juice because the kitchen was not accessible to the residents. On 1/5/23 at 3:30 p.m., the acting administrator stated the expectation was that residents had access to get water from the dispenser on the refrigerator. She stated she was unaware that the refrigerator located in the Garden wing of the residence did not have a water dispenser on the refrigerator. She added all the refrigerators in the four wings were replaced and added "somebody might have ordered the wrong refrigerator for the Garden wing of the residence."

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 2 and Chapter 7.2.3.6. Applicants must show compliance with the Colorado Adult Protective Services Data System (CAPS Check) requirements as set forth in section 26-3.1-111, C.R.S.12.11 The assisted living residence shall be responsible for the coordination of resident care services with known external service providers. 13.10 Each assisted living residence shall develop and implement an internal process to ensure the routine and prompt handling of grievances or complaints brought by residents, family members, or advocates. The process for raising and addressing grievances and complaints shall be placed in a visible on-site location along with full contact information for the following agencies:(A) The state and local long-term care ombudsman;(B) The Adult Protection Services of the appropriate county Department of Social Services;(C) The advocacy services of the area's agency on aging;(D) The Colorado Department of Public Health and Environment; and(E) The Colorado Department of Health Care Policy and Financing, in those cases where the assisted living residence is licensed to provide services specifically for persons with intellectual and developmental disabilities. 14.10 Unless otherwise allowed by statute, the assisted living residence shall not permit a qualified medication administration person to perform any of the following tasks:(I) Masking or deceiving administration of medication including, but not limited to, concealing in food or liquid. 14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers. 14.27 No stock medications shall be stored or administered by qualified medication administration persons. A) All over-the-counter medication prescribed for administration shall be labeled or markedwith the individual resident ' s full name. 17.14 Staff who assist feeding a resident shall be trained in the proper techniques for supportingnutrition and hydration by a licensed or registered professional qualified by education and training to assess choking risks, such as a registered nurse, speech language pathologist, or registered dietitian. 25.10 In addition to the information required for a resident care plan at Part 12.10, the care plan for each resident in a secure environment shall include the following:(A) A description of the resident ' s wandering patterns and known behavioral expressions,along with individualized approaches to be implemented by staff to protect the residentand other residents with whom they have contact;(B) A description of how the resident will have continuous independent access to his or herindividual room, along with the ALR ' s plan to protect the resident from unwanted visitation by other residents;(C) Identification of the type and level of staff oversight, monitoring, and/or accompanimentthat the ALR deems necessary to meet the needs of the resident within the secure environment and secure outdoor area; and(D) Documentation describing the personal grooming and hygiene items that are determinedsafe for the resident to have in their own possession for self-care, and how those itemsare stored to prevent unauthorized access by other residents. 25.26 A secure environment shall meet the following criteria:(C) There shall be a storage area which is inaccessible to residents for storage of items that could pose a risk or danger such as chemicals, toxic materials, and sharp objects;