BROOKDALE BRIGHTON

A relicensure survey with complaint #CO35588 was completed on 4/18/24. Deficiencies were cited.

Based on record review and interview, the residence failed to provide, upon request, residence documents as requested by the department, affecting five of five sample residents (#1-#5). Findings include:1. ReferenceChapter VII regulations governing assisted living residences, part 18.8 requires that Resident records shall contain, but not be limited to, the following items: (B) Practitioner order; (D) Progress notes which shall include information on resident status and wellbeing, as well as documentation regarding any out of the ordinary event or issue that affects a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's changing needs; (1) The assisted living residence shall require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident that they personally observed, or was reported to them. 2. Record ReviewOn 4/16/24 at 10:00 a.m., medication orders to correspond with the March and April 2024 electronic medication administration records (eMARs) were requested for Resident #2, and progress notes were requested for Residents #1-#5. On 4/16/24 at 11:20 a.m., orders for Resident #2 were provided; however, there were no orders dated prior to 3/26/24 to correspond with administration events between 3/1-3/26/24. On 4/16/24 at 11:55 a.m., all medication orders for Resident #2 dated prior to 3/11/24 with order changes since and progress notes for Residents #1-#5 were requested a second time. On 4/16/24 at 12:34 p.m., orders signed 3/11/24 were provided. However, there were no orders to correspond with administration events between 3/1-3/11/24. All of Resident #2's orders were re-requested a third time. On 4/16/24 at approximately 1:40 p.m., progress notes for Residents #1-#5 were provided, over three hours after requested. On 4/16/24 at 2:15 p.m., the rest of Resident #2 orders were provided, four hours after requested the first time, and over one and a half hours after requested the second time. 3. InterviewsOn 4/16/24 at approximately 12:40 p.m., the administrator stated there were other staff assisting providing orders who were not familiar with the residents at the residence, and must have misunderstood to provide all medication orders for Resident #2. The administrator stated the resident had a paper file with older quarterly orders. On 4/16/24 at 12:42 p.m., the district director of operations (DDO) stated she had not realized progress notes had not been provided for Residents #1-#5. The DDO stated the administrator had not provided orders for the previous quarter and once those orders were provided, that would be all they had on the resident. On 4/17/24 at approximately 3:30 p.m., the DDO stated she was aware of the requirement to provide documentation upon request; however, there were miscommunications on 4/16/24 due to being unaware what was asked and a paper jam with the copier. The DDO stated she thought all orders were provided for Resident #2 timely.

Based on observation, interview and record review, the residence failed to ensure the administrator was responsible for managing the overall day-to-day operations of the assisted living residence as described in the resident agreement, affecting 36 current residents. (Cross reference S1410)Findings include:Chapter VII regulations governing assisted living residences, part 2.2, defines "Administrator" as a person who is responsible for the overall operation, daily administration, management and maintenance of the assisted living residence. The term "administrator" is synonymous with "operator" as that term is used in Title 25, Article 27, Part 1. The residence's staff list read the administrator of record was not the administrator. The staff list only listed their newly hired executive director (ED) who would be replacing the administrator of record. On 4/16/24 at 7:30 a.m., upon entrance into the residence, the health and wellness director (HWD) stated the interim executive director (IED) was not there yet, but would have been there shortly. The HWD stated he was unaware that the IED was not the administrator of record and did not know who the current administrator was. On 4/16/24 at 10:43 a.m., Staff #2 stated she reported anything that was out of the ordinary to the HWD. On 4/16/24 at 11:26 a.m., the IED stated the residence was in the process of transitioning to a new administrator. On 4/16/24 at 12:42 p.m., the business office coordinator (BOC) stated she thought the administrator was a district director of nursing and had thought the district director of operations (DDO) was the administrator. On 4/17/24 at 3:20 p.m., the DDO stated the HWD oversaw the day to day operations of the residence when the administrator was not present. She stated the administrator averaged approximately four to five visits per week at the residence. The DDO further stated the residence had hired the ED the month of the onsite investigation who would be replacing the administrator.

Based on interview and record review, the residence failed to establish a fall management program which included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting two sample residents who sustained injuries from falls (#1 and #2). (Cross reference S1324 and S1410)Specifically, Resident #1 had sustained a fall with head injury on 2/18/24. The residence failed to implement individualized interventions when Resident #1's care plan was updated on 2/20/24. Ultimately, Resident #1 sustained an additional fall on 4/6/24 that resulted in a clavicle fracture, bruising on the elbow and skin tears on the resident's right hand and left "pinky' toe. Resident #1 sustained two additional falls on 4/8/24. However, the care plan updated 4/8/24 did not include individualized interventions. Further, staff were not aware of fall interventions for Resident #1. The resident experienced pain in her pinky toe the day of the onsite investigation. Findings include:1. Residence policyThe residence's fall management policy dated February 2022, read in part, when a resident has fallen, individualized interventions are considered and placed in a resident's record. 2. Resident #1 was admitted to the residence on 5/3/21 with a diagnosis of dementia. A progress note dated 2/18/24 read Resident #1 sustained a fall in the residence dining area. The resident was bleeding from the head and was transported to the hospital. The resident got staples in her scalp. A care plan for Resident #1 dated 2/20/24, read Resident #1 was independent going to and from the residence dining room, had sustained a fall with injury and was at a heightened risk for falling, and used a walker for mobility. The care plan contained a section that read "universal fall interventions." Under the section labeled "fall interventions not listed above (under universal)" it read resident stable and independent with mobility. However, the care plan did not include individualized fall interventions such as how staff would monitor/supervise the resident to ensure safety. A progress note completed by Staff #6 dated 4/6/24 at 1:46 a.m., read on 4/4/24 at 11:40 a.m. the resident was found on the bathroom floor with the hot water running and yelled in pain when staff attempted to move her. The resident's left shoulder was red and bruised, bruising on the elbow and skin tears on the resident's right hand and left "pinky' toe. However, Resident #1 had not sustained a fall on 4/4/24 at 11:40 a.m. The incident had occurred on 4/6/24 at 12:04 a.m., and Staff #6 who observed the incident, had written the incorrect date and time. A progress note dated 4/8/24 at 7:30 a.m., read Resident #1 sustained a fall near her bed trying to pick something up off of the floor. A progress note dated 4/8/24 at 11:00 a.m., read Resident #1 had an unwitnessed fall near her reclining chair in her bedroom. The residence's care plan for Resident #1 dated 4/8/24 was updated to include the resident required escort assistance to the dining area due to memory impairment and will have escort and mobility needs met. The care plan also read the resident used a walker as a mobility aid. However the care plan did not include individualized interventions. A radiology report, dated 4/8/24, read the resident had an acute avulsion fracture of the distal clavicle. On 4/16/24 at 10:19 a.m., Resident #1 stated her left toe had been hurting her and flinched as she moved her foot in her reclining chair. On 4/16/24 at 10:43 a.m., Staff #2 stated she did not think she was supposed to monitor Resident #1 on 4/5/24, since her care plan read that she was independent. On 4/16/24 at 12:19 p.m., Resident #1's family member stated she helped get Resident #1 off the floor after midnight on 4/6/24 since she was in pain and observed a bruise on her shoulder, which was discovered on 4/8/24 to be a clavicle fracture. The family member stated she had not wanted to send the resident to the hospital to get imaging after the 4/6/24 fall since she would be removed from external hospice provider care, so she got imaging as soon as radiology was available, which was on 4/8/24. The family member stated the resident was independent prior to her fall on 4/6/24 and was unaware of fall interventions in place for her. The family member acknowledged the resident had previously fallen and cut her head open which required staples in her scalp. On 4/17/24 at 7:36 a.m., Staff #6 stated she had not checked on Resident #1 over the course of her double shift, since Staff #7 had stated to her that she checked on Resident #1. Staff #6 acknowledged it was just herself and Staff #7 that were assigned to the hall for Resident #1 after Staff #7 started her shift at 10:00 p.m. Staff #6 stated she entered Resident #1's room on 4/5/24 just before midnight she believed, and found the resident on the floor by the shower with her shower chair knocked over. She further stated Resident #1 expressed pain from the shoulder and noticed a visible bruise on her shoulder and skin tear on the resident's left small toe. The staff member stated herself and Staff #7 were unable to lift the resident due to the resident having expressed pain and required the family member's assistance to lift the resident off of the floor. Staff #6 stated Resident #1 was independent prior to the fall and was unaware of any fall interventions prior or after the fall. On 4/17/24 at 8:09 a.m., Staff #7 stated she was unaware of any fall interventions in place for Resident #1 prior to her fall on 4/5/24 or that were currently in place the day of the onsite investigation. On 4/17/24 at 9:27 a.m., a practitioner at Resident #1's practitioner office stated they were notified of Resident #1's falls on 4/6 and two falls on 4/8/24 and the resident was prescribed acetaminophen on 4/10/24 for pain from the falls. On 4/17/24 at 9:35 a.m., an external hospice provider stated on 4/6/24 Resident #1 sustained bruising on the left side of her head, left shoulder, hip, knees and a skin tear on her left baby toe and verbalized pain. The external hospice provider stated the resident sustained two additional falls on 4/8/24, with the second one observed by an external hospice provider. The external hospice provider stated the resident had a walker since 2/14/24 which external hospice put in place; however, was unaware of any fall interventions the residence had put in place. On 4/17/24 at approximately 11:45 a.m., the health and wellness director (HWD) stated himself and the health and wellness coordinator (HWC) were responsible for updating care plans following falls. The HWD stated the fall interventions currently in place for Resident #1 were frequent checks. The HWD stated prior to Resident #1's fall on 4/6/24, the resident was independent and did not have fall interventions; however stated it was still required that residents be checked on three to four times a shift. The HWD further acknowledged the frequency was not specified in the 2/20 or 4/8/24 care plans. The HWD stated he was informed by the district director of operations (DDO), interim executive director and the administrator with the corporate company, that he could not put a frequency of monitoring in care plans during training he received on 4/16/24. He stated he was told when he was in training around February 2024 by one of the "corporate staff members" it was against assisted living regulations. The HWD stated he updated Resident #1's care plan on 4/16/24 to include escorts to the dining area and verbalized to staff to check her more frequently since he was not allowed to put a frequency of monitoring in the resident's care plan. He stated besides that the resident used a walker for mobility. The HWD stated the fall interventions in resident care plans were universal for all residents who sustained falls unless the care plan read otherwise, which would be put in place when the cause of falls was determined. 3. There was similar deficient practice for Resident #2. 4. InterviewOn 4/17/24 at approximately 3:30 p.m., the DDO stated care plans should be updated after repeated falls or falls with injury by the HWD or HWC. The DDO stated she was aware of the requirement for care plans to include individualized interventions and would have expected this to have occurred for Resident #1 and #2.

Based on observation, interview, and record review, the residence failed to provide all residents with regular opportunities to participate in structured engagement and support the pursuit of each resident's interests, affecting 37 current residents. (Cross-Reference S1230)Findings include: 1. Reference and Residence Policy a. The residence's Resident Agreement, dated April, 2021, read in part: "The residence will provide social and recreational services ..."b. According to the National Institute on Aging, "Being lonely or socially isolated is not good for your overall health. For example, it can increase feelings of depression or anxiety, which can have a negative impact on many other aspects of your health ... Research has shown that older adults with an active lifestyle:Are less likely to develop certain diseases. Participating in hobbies and other social activities may lower risk for developing some health problems, including dementia, heart disease, stroke, and some types of cancer. Have a longer lifespan. Studies looking at people ' s outlooks and how long they live show that happiness, life satisfaction, and a sense of purpose are all linked to living longer. Doing things that you enjoy may help cultivate those positive feelings. Are happier and less depressed. Studies suggest that older adults who participate in activities they find meaningful, such as volunteering in their communities or being physically active, say they feel happier and healthier. Are better prepared to cope. When people feel happier and healthier, they are more likely to be resilient, which is our ability to bounce back and recover from difficult situations. Positive emotions, optimism, physical and mental health, and a sense of purpose are all associated with resilience. May be able to improve their thinking abilities. Research suggests that participating in certain activities, such as those that are mentally stimulating or involve physical activity, may have a positive effect on memory — and the more variety the better. Other studies are providing new information about ways that creative activities, such as music or dance, can help older adults with memory problems or dementia ..." National Institute on Aging (3/28/22) Participating in Activities You Enjoy As You Age, retrieved from: https://www.nia.nih.gov/health/healthy-aging/participating-activities-you-enjoy-you-age#:~:text=Research%20has%20shown%20that%20older,and%20some%20types%20of%20cancer. 2. ObservationsThroughout the onsite visit from 4/16/24 to 4/17/24, an April 2024 activity schedule was posted in an enclosed case in the hallway, which read, in part, the following:3/16/24: Be Fit at 10:30 a.m. 3/16/24: Let's Play Bingo at 1:30 p.m. 3/17/24: Be Fit at 10:30 a.m. 3/17/24: Outing at 11:00 a.m. 3/17/24: Let's Play Bingo at 1:30 p.m. Throughout the onsite visit (two consecutive days), the residence provided no opportunities to participate in any structured engagement, including what was posted on the activities schedule. 3. InterviewsOn 4/16/24 at 7:45 a.m., Resident #6 stated there were no activities being provided to residents since the former activities director (AD) left a few months prior to the onsite investigation. Resident #6 stated there was a posted schedule of activities; however, nothing was going on in accordance with the schedule, only television (TV) in the residence common area. On 4/16/24 at 7:46 a.m., Resident #8 stated there were no activities

Based on observation, interview, and record review, the administrator failed to designate one staff member to be responsible for organizing, conducting, and evaluating resident engagement, affecting 37 current residents. (Cross-Reference S1202)Findings include:Throughout the onsite visit from 4/16/24 to 4/17/24, an April 2024 activity schedule was posted in an enclosed case in the hallway, which read, in part, the following:3/16/24: Be Fit at 10:30 a.m. 3/16/24: Let's Play Bingo at 1:30 p.m. 3/17/24: Be Fit at 10:30 a.m. 3/17/24: Outing at 11:00 a.m. 3/17/24: Let's Play Bingo at 1:30 p.m. Throughout the onsite visit (two consecutive days), the residence provided no opportunities to participate in any structured engagement, including what was posted on the activities schedule. On 4/17/24 at 11:45 a.m., the health and wellness director (HWD) stated the residence had an activities director at one point; however, was unsure exactly when she had left. The HWD confirmed that the residence did not have a designated activities director and that all of the staff members were responsible for pitching in and taking turns coordinating activities for the residents. On 3/17/24 at 3:15 p.m., the district director of operations (DDO) stated she was aware the residence was required to have one designated staff member who was responsible for organizing, conducting, and evaluating resident engagement The DDO confirmed the residence did not currently have an activities director and it was the responsibility of all of the staff members to take turns and coordinate activities.

Based on observation, interview and record review, the residence failed to ensure residents had the right to be free from neglect, affecting one of five sample residents (#1). (Cross reference S1180, S1410 and S1600)Specifically, Resident #1 sustained a fall with injury on 2/18/24. A care plan updated 2/20/24 read the resident used a walker, was independent with transfers to the dining room and was a fall risk due to a fall with injury. However, there were no individualized safety interventions put in place to monitor the resident. Video surveillance evidence and staff interviews revealed on 4/5 at 5:18 a.m., staff had gone into Resident #1's room to throw soiled linens in the laundry due to an episode of incontinence. Resident #1 went into the bathroom to take a shower. From 5:18 a.m. on 4/5 until 12:04 a.m. on 4/6/24, no staff members had gone into Resident #1's room to check on her or put new clean linens back on the resident's bed. Resident #1 had missed three meals and was found by Staff #7 at 12:04 a.m. outside the shower on the bathroom floor, with the shower chair knocked over, the shower still running, and condensation on the walls. Resident #1 was described to appear "wet" and the room was described to feel "as hot as a sauna." The resident's external hospice provider assessed the resident the morning of 4/5/24 and the Resident #1 was found to have sustained bruising to the left side of her head, a skin tear on her left small toe and a clavicle fracture. Findings include:1. References and Residence Policiesa. Chapter VII regulations governing assisted living residences, part 2.12, defines "Caretaker Neglect" as: neglect that occurs when adequate food, clothing, shelter, psychological care, physical care, medical care, habilitation, supervision or any other service necessary for the health or safety of an at-risk person is not secured for that person or is not provided by a caretaker in a timely manner and with the degree of care that a reasonable person in the same situation would exercise, or a caretaker knowingly uses harassment, undue influence or intimidation to create a hostile or fearful environment for an at-risk person.b. The residence's undated resident rights policy, read in part: "every resident shall be entitled to ... civil and religious liberties including ... the right to be free from neglect."c. The residence's abuse and neglect policy, dated May 2021, defined neglect as: "the failure to provide adequate food, clothing, shelter, psychological care, physical care and medical care in a timely manner and with the degree of care that a reasonable person in the same situation would exercise."2. Resident #1 was admitted to the residence on 5/3/21 with a diagnosis of dementia. a. Fall and Absent MonitoringA progress note dated 2/18/24 read Resident #1 sustained a fall in the residence dining area. The resident was bleeding from the head and was transported to the hospital. A care plan for Resident #1 dated 2/20/24, read Resident #1 was independent going to and from the residence dining room, had sustained a fall with injury and was at a heightened risk for falling, and used a walker for mobility. However, the care plan did not include how staff would monitor/supervise the resident to ensure safety. A progress note completed by Staff #6 dated 4/6/24 at 1:46 a.m., read on 4/4/24 at 11:40 a.m. the resident was found on the bathroom floor with the hot water running and yelled in pain when staff attempted to move her. However, Resident #1 had not sustained a fall on 4/4/24 at 11:40 a.m. The incident had occurred on 4/6/24 at 12:04 a.m., and Staff #6 who observed the incident, had written the incorrect date and time. The residence's care plan for Resident #1 dated 4/8/24 was updated to include the resident required escort assistance to the dining area due to memory impairment. However the care plan did not include how frequently staff were to check on the resident. A radiology report, dated 4/8/24, read the resident had an acute avulsion fracture of the distal clavicle. A progress note dated 4/12/24 completed by the health and wellness director (HWD), read Resident #1's family notified him of a fall that occurred on 4/6/24. The family member made allegations the resident was left on the floor for 16-18 hours based on the video surveillance camera the family installed in the resident's room. The HWD reviewed the care plan and noticed it was last updated 2/20/24 when the resident was independent of cares. On 4/16/24 at 12:54 p.m., review of video footage from 4/5/24 at 5:18 a.m. revealed Staff #7 had entered Resident #1's room and found her soiled in her bed, on 4/5/24 at 5:18 a.m. Staff #7 removed the linens from Resident #1's bed to wash them, and at 5:21 a.m., Resident #1 went into her bathroom to take a shower, and closed the bathroom door. The bed remained without linens and there was no evidence of staff having gone into Resident #1's room, or Resident #1 having left the room until 12:04 a.m. on 4/6/24 when Staff #7 entered the room. Staff #7 was observed saying "oh my God," and exited the room to get help, and at 12:06 a.m. Staff #6 went into the resident's room with Staff #7. At 12:07 a.m. one of the staff members was observed saying to the other that day shift must not have come in at all, cause the bed was still not made and the resident went into the shower earlier that morning (4/5/24).b. Inaccurate Vital Sign DocumentationContrary to the video footage from 4/5 at 5:18 a.m. to 4/6/24 at 12:04 a.m., the April 2024 eMAR for Resident #1 read that Resident #1 had monthly vital signs completed by Staff #6 on 4/5/24. However, the vital signs were not completed by Staff #6. c. InterviewsOn 4/16/24 at 9:28 a.m., Staff #5 stated she worked from 2:00 p.m. to 10:00 p.m. on 4/4 and 4/5/24. Contrary to the video, Staff #5 stated she had checked up on Resident #1 before dinner around 5:00 p.m. on 4/5/24 and stated Resident #1's family member had stated the resident did not want to go to dinner. Staff #5 stated she believed Resident #1 required 30 minute safety checks since she was unable to use her call pendant for assistance; however, at least required checks every two hours. Staff #5 would not answer whether she checked Resident #1 any additional times during her shift and instead stated Staff #2 must have failed to check on Resident #1 since she had heard the resident had been on the floor for over "10 hours" based on Staff #2 not having checked on her and "what she heard" from numerous staff. Contrary to the video evidence, Staff #5's own previous statement and Staff #6 and #7's interviews, Staff #5 stated she had found Resident #1 on the floor and that Staff #8 helped lift her and put her back to bed around 8:00 p.m. on 4/4/24. On 4/16/24 at 10:43 a.m., Staff #2 stated she worked from 6:00 a.m. to 2:00 p.m. on 4/5/24. Staff #2 stated she did not think she was supposed to check up on Resident #1 since her care plan read that she was independent. Staff #2 stated she checked on Resident #6 around 8:30 a.m., by talking to her through the door to ask if the resident was doing alright and heard the shower running so she did not enter the resident's room; however stated she did not feel she needed to check on her unless the care plan instructed her to do so. Contrary to Staff #2's previous statement, Staff #2 stated she believed the standard was to complete two hour checks on residents, which she stated did not occur for Resident #1 since she was preoccupied with residents that had a higher acuity. Staff #2 further stated she had not checked in on Resident #6 during breakfast or lunch hours. She further stated she had not noticed the resident in the dining area, since the resident was independent with meals. On 4/17/24 at 7:36 a.m., Staff #6 stated on 4/5/24 she started her shift at 7:00 p.m. and worked a double until 6:00 a.m. on 4/6/24. Staff #6 stated she had not checked on Resident #1 over the course of her double shift, since Staff #7 had stated to her that she checked on Resident #1. Staff #6 stated she noticed an undated note on the medication cart when she had gotten on shift around 7:00 p.m., that contained Resident #1's room number and vitals. Staff #6 stated she felt rushed to complete all her medication administrations before 9:00 p.m., and since Resident #1 was on no medications at the time, she entered the vitals into the eMAR. Staff #6 stated she was unaware who had obtained the vitals and if they were obtained on the shift prior, from a day prior, or longer. Staff #6 stated she had not checked on Resident #1. Staff #6 acknowledged it was just herself and Staff #7 that were assigned to the hall for Resident #1 after Staff #7 started her shift at 10:00 p.m. on 4/5/24. Prior to that, Staff #5 was from 2:00 p.m. to 10:00 p.m., and Staff #2 on the 6:00 a.m. to 2:00 p.m. shift. Staff #6 stated she entered Resident #1's room on 4/5/24 just before midnight, and stated the room was "hot like a sauna," which required her to open both the window and resident's room door to air it out. She stated the resident was naked on the floor outside her shower and was observed to be "wet" with the shower chair knocked over. Staff #6 stated there was condensation on the resident's walls and Resident #1 expressed pain from the shoulder and noticed a visible bruise. On 4/17/24 at 8:09 a.m., Staff #7 stated she believed she had found Resident #1 on the floor on 4/5/24 at around 11:50 p.m. Staff #7 stated she had not started her shift until 10:00 p.m. and the first two hours were spent doing monitoring rounds, which was when she found Resident #1 outside her shower on the floor. Staff #7 stated she had "stripped" Resident #1's bed around 5:00 a.m. on 4/5/24 due to the bed being soaked, asked Resident #1 to take a shower, and informed Staff #2 around 6:00 a.m. on 4/5 that the resident was in the shower and asked her to monitor the resident since she had exhibited "stroke-like symptoms the day before." Staff #7 stated on 4/5/24 at around 11:50 p.m., she had observed the bed had not been made when she found the resident on the floor, which indicated to her that no one had checked on the resident since she last checked on her around 5:00 a.m. on 4/5/24. On 4/17/24 at 9:35 a.m., an external hospice provider stated on 4/6/24 Resident #1 sustained bruising on the left side of her head, left shoulder, hip, knees and a skin tear on her left baby toe and verbalized pain. The resident was observed to have had a broken clavicle, which was confirmed by an x-ray on 4/8/24. The external hospice provider stated on 4/6/24 there was brown liquid in the resident's hair which appeared to be vomit. She further stated the resident was evaluated the morning of 4/6/24 shortly after midnight, when the injuries were noted. On 4/17/24 at approximately 11:45 a.m., the HWD stated prior to Resident #1's fall on 4/6/24, the resident was independent; however, it was still required that residents be checked on three to four times a shift. The HWD stated he was informed by the district director of operations (DDO), interim executive director and the administrator with the corporate company, that he could not put hourly or even bi-hourly checks in resident care plans in a training on 4/16/24. He stated he was told when he was in training around February 2024 by one of the "corporate staff members" it was against assisted living regulations. The HWD would not disclose who stated that to him. The HWD stated he updated Resident #1's care plan on 4/8/24 to include escorts to the dining area and verbalized to staff to check her more frequently since he was not allowed to put a frequency of monitoring in the resident's care plan. On 4/17/24 at approximately 3:00 p.m., the maintenance director stated the residence had two 80 gallon water tanks. He stated, much like a hotel, if the hot water was running for extended periods of time, the water continued to remain hot. Additionally, he stated if the water reached 118 degrees fahrenheit it would automatically shut off. On 4/17/24 at approximately 3:30 p.m., the DDO stated she would consider a resident who had not eaten all day to be hungry, or having drank fluids, to be dehydrated. The DDO further stated she would expect residents to be free from neglect and acknowledged she would consider a resident not being checked on by staff all day to be neglectful. On 4/18/24 at 3:40 p.m., Staff #8 stated he had never lifted Resident #1 from a fall on 4/4, 4/5/24 "or ever" since there had not been any falls during his shift. Staff #8 stated he had not worked at the residence on 4/5/24. Staff #8 stated it was reported to him on 4/6/24 during his 2:00 p.m. to 10:00 p.m. shift, that a fall had occurred earlier that morning; however, that was the only fall he had heard about for Resident #1 that week.

Based on observations, record review and interviews, the residence failed to investigate all allegations of abuse in accordance with regulation and their written policy, affecting 36 current residents. (Cross reference S540, S1180 and S1324)Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residences, requires in part 13.11, that the assisted living residence shall investigate all allegations of abuse, neglect or exploitation of residents in accordance with its written policy. The written policy is required to include the following:A) Reporting requirements to the appropriate agencies, such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator; (B) A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation; (C) The process for investigating such allegations; (D) How the assisted living residence will document the investigation process to evidence the required reporting and that a thorough investigation was conducted; (E) A requirement that the resident shall be protected from potential future abuse or neglect, and/or exploitation while the investigation is being conducted; (F) A requirement that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action; and (G) A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review. b. Chapter VII regulations governing assisted living residences, part 2.12, defines "Caretaker Neglect" as: neglect that occurs when adequate food, clothing, shelter, psychological care, physical care, medical care, habilitation, supervision or any other service necessary for the health or safety of an at-risk person is not secured for that person or is not provided by a caretaker in a timely manner and with the degree of care that a reasonable person in the same situation would exercise, or a caretaker knowingly uses harassment, undue influence or intimidation to create a hostile or fearful environment for an at-risk person.c. Chapter VII regulations governing assisted living residences, part 2.7, defines an "at-risk person" as any person who is 70 years of age or older, or any person who is 18 years of age or older and meets one or more of the following criteria: (E) Is a person with a mental health disorder as defined in Section 27-65-102(11.5), Colorado Revised Statutes (C.R.S.).d. Chapter II regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein."e. The residence's abuse and neglect policy, dated May 2021, defined neglect as: "the failure to provide adequate food, clothing, shelter, psychological care, physical care and medical care in a timely manner and with the degree of care that a reasonable person in the same situation would exercise."2. Record ReviewResident #1 was admitted to the residence on 5/3/21 with a diagnosis of dementia. A progress note completed by Staff #6 dated 4/6/24 at 1:46 a.m., read on 4/4/24 at 11:40 a.m. the resident was found on the bathroom floor with the hot water running and yelled in pain when staff attempted to move her. However, Resident #1 had not sustained a fall on 4/4/24 at 11:40 a.m. The incident had occurred on 4/6/24 at 12:04 a.m., and Staff #6 who observed the incident, had written the incorrect date and time. The residence's care plan for Resident #1 dated 4/8/24 was updated to include the resident required escort assistance to the dining area due to memory impairment. A progress note dated 4/12/24 completed by the health and wellness director (HWD), read Resident #1's family notified him of a fall that occurred on 4/6/24. The family member made allegations the resident was left on the floor for 16-18 hours based on the video surveillance camera the family installed in the resident's room. The HWD reviewed the care plan and noticed it was last updated 2/20/24 when the resident was independent of cares. The HWD started an investigation with the district team on 4/8/24. The interim executive director (IED) attempted to call the family member for Resident #1 three times and spoke with them in person on 4/10/24. There had been multiple conversations with the HWD, clinical staff, external hospice providers and district team. Despite not being able to confirm the family's allegations, the (residence) reported fall to the department and law enforcement on 4/11/24. Resident #1 had not sustained any additional falls since the resident's service plan was updated. On 4/16/24 at 9:59 a.m., investigations of abuse and neglect were requested for the last three months, and re-requested at approximately 5:00 p.m.; however, no investigations were provided. On 4/16/24 at 12:54 p.m., review of video footage from 4/5/24 at 5:18 a.m. revealed Staff #7 had taken Resident #1's soiled linens from her bed. At 5:21 a.m., Resident #1 went into the bathroom to take a shower, and there was no evidence she had left the bathroom. From 5:18 a.m. on 4/5/24 to 12:04 a.m. on 4/6/24, there were no staff observed entering Resident #1's room or Resident #1 having left to go to any meals for over 18 hours. Resident #1 was found on the floor by the shower naked in a steamy room with the hot water running by Staff #7 on 4/6/24 at 12:04 a.m. 3. InterviewsOn 4/16/24 at 10:04 a.m., the family member for Resident #1 stated she had reported to the HWD that Resident #1 had not been checked on from around 5:00 a.m. on 4/5 to after midnight on 4/6/24 and was found to have sustained a clavicle fracture and bruising on the shoulder. The family member stated she contacted adult protective services (APS) around 4/8/24; however, did not have further information or a case number. The family member for Resident #1 stated the resident had not remembered what had occurred on 4/5/24 due to her advanced dementia. On 4/16/24 at 11:24 a.m., the IED stated the residence was not notified of allegations until 4/8/24 and Resident #1's family member had informed them that the resident was on the floor for 18-24 hours and the administrator had reported on 4/8/24 an occurrence of neglect to the department once the family member notified herself and the HWD. The IED stated the residence was still in the process of investigation; however, was unsure as to why there was no investigation prior. The IED further stated Staff #6 and #7 were the staff members who had found Resident #1 on the floor. On 4/16/24 at 11:48 a.m., the district director of operations (DDO) stated there were no investigations conducted by the residence in the previous three months. The DDO stated Resident #1's family member refused to provide a copy of the video surveillance and therefore, was unable to determine how long the resident was not checked on. The DDO stated the residence was aware Resident #1 sustained a fall the night of 4/5/24; however, the HWD was not informed of the length of time the resident was allegedly not checked on, until 4/8, and the residence began an investigation on 4/9/24. On 4/17/24 at 7:36 a.m., Staff #6 stated she had not checked on Resident #1 over the course of her double shift, since Staff #7 had stated to her that she checked on Resident #1. Staff #6 acknowledged it was just herself and Staff #7 that were assigned to the hall for Resident #1 after Staff #7 started her shift at 10:00 p.m. Staff #6 stated she entered Resident #1's room on 4/5/24 just before midnight she believed, and stated the room was "hot like a sauna," which required her to open both the window and resident's room door to air it out. Staff #6 stated there was condensation on the resident's walls and Resident #1 expressed pain from the shoulder and noticed a visible bruise and herself. Staff #6 stated she called Resident #1's family member, external hospice provider and documented in the residence's electronic health system. The staff member stated she was unsure as to how long the resident had been on the floor so she did not contact law enforcement or APS since she did not think at the time it was neglectful. On 4/17/24 at 8:09 a.m., Staff #7 stated she believed she had found Resident #1 on the floor on 4/5/24 at around 11:50 p.m. Staff #7 stated she had "stripped" Resident #1's bed around 5:00 a.m. on 4/5/24 due to the bed being soaked, asked Resident #1 to take a shower, and informed Staff #2 around 6:00 a.m. on 4/5 that the resident was in the shower and asked her to monitor the resident since she had exhibited "stroke-like symptoms the day before." Staff #7 stated on 4/5/24 at around 11:50 p.m., she had observed the bed had not been made when she found the resident on the floor, which indicated to her that no one had checked on the resident since she last checked on her around 5:00 a.m. on 4/5/24. On 4/17/24 at approximately 11:45 a.m., the HWD stated he was made aware from Resident #1's family member stated that the resident had been on the floor for approximately 18 hours on 4/8/24. Contrary to the DDO's interview, the HWD stated the progress note he made on 4/12/24 was the start of his investigation and the IED, DDO and administrator took over the investigation around the same day. The HWD stated he was unsure why there was no further documented investigation and was aware his progress note from 4/12 did not include information and details about who was spoken to and details about what occurred, as well as specifics on how the resident will be protected from further neglect. The HWD further stated he contacted law enforcement within 24 hours of himself being made aware of the allegation and had not contacted APS since they were already notified by someone else. He further stated the resident's care plan was updated on 4/8/24 to include that the resident required escorts to meals; however, did not think he was permitted by the regulations to put a frequency of monitoring in the resident's care plan. On 4/17/24 at approximately 3:00 p.m., the maintenance director stated the residence had two 80 gallon water tanks. He stated, much like a hotel, if the hot water was running for extended periods of time, the water continued to remain hot. On 4/17/24 at 3:20 p.m., Staff #6 stated the HWD had asked her on 4/8/24 what had occurred with Resident #1; however, she was not re-trained on neglect and monitoring residents until 4/16/24; the evening of the first day of the onsite investigation. Staff #6 stated she was retrained by the administrator and DDO.On 4/18/24 at approximately 3:30 p.m., contrary to the DDO's previous statement regarding there being no investigation, the DDO stated the HWD initiated an investigation on 4/8/24 once made aware by Resident #1's family member of her having been on the floor, and the amount of time the family member stated was conflicting between 16 hours and 18 hours. The DDO stated anyone who was made aware of allegations of abuse or neglect could start an investigation. The DDO stated all actions taken, how to protect the resident from future neglect, to notify the appropriate parties, and all relevant information and details of who was spoken to would not be documented outside of a summary such as the HWD progress note. The DDO stated she was aware an investigation was required to be complete within five days and acknowledged it was not. The DDO stated she was unable to complete the investigation without the video footage which Resident #1's family member refused to provide. The DDO stated the IED, administrator and HWD were responsible for retraining and stated it was not provided as part of the investigation since it was still "ongoing" through 4/17/24.

Based on observation, record review and interviews, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting two of four sample residents whose medications were reviewed (#1 and #2). (Cross reference S1600)Specifically, a written practitioner's order, dated 4/10/24, directed the residence to administer acetaminophen 325 mg two tablets three times daily to Resident #1 for pain relief from her injuries following falls on 4/6 and 4/8/24. However, residence staff transcribed the medication on the electronic medication administration record (eMAR) to be administered on an pro re nata (PRN) basis, although the resident was incapable of requesting PRN medication. The resident experienced pain in her left toe due to not being administered the medication as ordered. Findings include:1. Reference and Residence Policya. According to Medline, "Acetaminophen is used to treat mild to moderate pain." The National Library of Medicine (2024) Acetaminophen, retrieved from: https://medlineplus.gov/druginfo/meds/a681004.html#:~:text=Acetaminophen%20is%20used%20to%20relieveb. The residence's medication administration policy dated 3/31/22, read in part: "medication administration/assistance and or treatment shall be provided in a safe and timely manner, and as prescribed by the resident's (practitioner)."2. Resident #1 was admitted to the residence on 5/3/21 with a diagnosis of dementia. AcetaminophenA written practitioner's order, dated 4/10/24, directed the residence to administer acetaminophen 325 mg two tablets three times daily for pain. However, the April 2024 electronic medication administration record (eMAR) read to administer acetaminophen 325 mg two tablets every four hours as needed. Further, the medication was not administered as ordered, on 4/11-4/16/24, for a total of 12 missed doses. An external hospice note, dated 4/10/24, read Resident #1 experienced pain from transferring between a sitting to standing position. The resident was prescribed acetaminophen by her practitioner. On 4/16/24 at 10:19 a.m., Resident #1 stated her left toe had been hurting her and flinched as she moved her foot in her reclining chair. On 4/17/24 at 7:36 a.m., Staff #6 stated when Resident #1 fell on 4/6/24 she noticed a skin tear on her small left toe. On 4/17/24 at 8:29 a.m., a medication cart audit revealed acetaminophen 325 mg two tablets three times daily came in a blister pack with two tablets per dose. The blister pack revealed the medication was dispensed for one dose since the blister pack was delivered from the pharmacy on 4/10/24. However, there were no other doses administered. On 4/17/24 at 8:28 a.m., the health and wellness director (HWD) stated Staff #4 had transcribed the medication on the eMAR incorrectly, and Resident #1 had not received her acetaminophen as ordered, other than the one unknown day the blister pack shows it was administered. On 4/17/24 at 9:27 a.m., a practitioner that worked at Resident #1's practitioner's office stated the practitioner ordered ordered acetaminophen 325 mg two tablets three times daily on 4/10/24 for ongoing pain the resident experienced following her falls on 4/6 and two on 4/8/24. The practitioner stated Resident #1 could experience pain as a result of not being administered the medication as ordered. On 4/17/24 at 9:35 a.m., an external hospice provider stated on 4/6/24 Resident #1 sustained bruising on the left side of her head, left shoulder, hip, knees and a skin tear on her left baby toe and verbalized pain. The external hospice provider stated the resident sustained two additional falls on 4/8/24 and was evaluated by her practitioner and prescribed medication to treat the pain resulting from the falls. On 4/17/24 at approximately 11:45 a.m., the HWD stated the qualified medication administration persons (QMAPs) and resident care coordinator were responsible for transcribing medications onto the eMARs. He further stated QMAPs were responsible for ordering medication from the pharmacy. On 4/17/24 at approximately 3:30 p.m., the district director of operations (DDO) stated QMAPs and the health and wellness coordinator (HWC) were responsible for ordering medications from the pharmacy. The DDO stated she was unaware Resident #1 had experienced pain due to not being administered her acetaminophen as scheduled, and would have expected the residence to comply with practitioner's orders related to administration. 2. Evidence obtained during the onsite visit revealed the residence failed to comply with authorized practitioner's orders associated with medication administration for Resident #2.

Based on observation, interviews and record review, the residence failed to ensure resident's medication administration record contained accurate information, affecting two of four sample residents (#2 and #5). (Cross reference S1568)Findings include:1. Resident #2 was admitted to the residence on 12/18/22. A written practitioner's order, dated 3/11/24, directed the residence to administer lidocaine 5% to the left foot or groin area, wherever needed, once daily. However, the March 2024 electronic medication administration record (eMAR) contained a code "9" for "other see progress notes" on 3/17/24. However, there was no corresponding documentation in progress notes. On 4/17/24 at 3:54 p.m., the district director of operations (DDO) stated there should be corresponding documentation in the progress notes with an exception code "9." The DDO further stated she was aware of the requirement for accurate eMAR documentation and would expect that to have occurred for all residents. 2. There was similar deficient practice for Resident #5.

Based on observation and interview, the residence failed to provide at least three meals in accordance of the resident's needs, affecting one of five sample residents (#1). (Cross reference S1324)Findings include: 1. Residence Policy The signed Resident Agreement for Resident #1, dated 4/30/21, read in part; "Unless otherwise noted in the addendum to the residency agreement, the residence will furnish three meals daily ..."2. Resident #1 was admitted to the residence on 5/31/21 with a diagnosis of dementia. On 4/5/24 at 5:15 a.m., video footage revealed Resident #1 getting out of bed, going into the bathroom, then shutting the door behind her. From 5:15 a.m. on 4/5/24 to 12:30 a.m. on 4/6/24, the resident never emerged from the bathroom. Additionally, video footage revealed none of the staff had not gone into Resident #1's room during this period of time to check on her or ask her why she was not in the dining room for breakfast, lunch or dinner. On 4/5/24, Resident #1 was not provided any meals, drinks, or snacks. 3. Interviews On 4/17/24 at 11:45 a.m. the health and wellness director (HWD) stated meal times were at 8:00 a.m., 12:00 p.m., and 5:00 p.m. He stated if a resident had not come to the dining room for a meal, it was the caregiver's responsibility, who was assigned to that resident, to check on them and ensure everything was okay. The HWD stated Resident #1 had been independent prior to this incident and had not required assistance to the dining room, so he would have expected the caregiver assigned to Resident #1 to check on her and find out why she was not there. The HWD stated she had always made it to the dining room on her own for all three meals. On 4/17/24 at 3:30 p.m., the district director of operations (DDO) stated meal times were at 8:00 a.m., 12:00 p.m., and 5:00 p.m. She stated if a resident had not come to the dining room for a meal, it was the caregiver's responsibility, who was assigned to that resident, to check on the resident. The DDO acknowledged that the caregiver assigned to Resident #1 on 4/5/24 should have gone to check on her after it was realized she was not in the dining room. While it was not confirmed, the DDO stated it was possible Resident #1 was hungry and dehydrated as a result of not receiving any meals, drinks, or snacks on 4/5/24.

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 7.6.5 Each administrator shall have completed 40 hours of administrator training before assuming an administrator position. Individuals appointed as an interim administrator shall have completed 40 hours of administrator training within 30 days of appointment. Written proof regarding the successful completion of such training program shall be maintained in the administrator ' s personnel file. The 40 hours shall be met by one of the following: (B) Completing a 30-hour administrator training program on or before December 31, 2018, and documenting an additional 10 hours of training in topics related to the assisted Living administrator ' s responsibilities, regulatory updates, and/or best practices before June 30, 2024.

A recertification survey with complaint #CO35589 was completed on 4/18/24. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure an informed consent for rights modification, was documented in resident records, affecting one of five sample residents (#1). Findings include:1. Residence PolicyThe residence's electronic monitoring policy, dated October 2023, read in order for residents or their legal representatives to have electronic monitoring in a resident's room, the electronic monitoring form must be completed. 2. Resident #1 was admitted to the residence on 5/3/21 with a diagnosis of dementia. Medical durable power of attorney (MDPOA) paperwork dated 2/5/19, revealed Resident #1's family member was her MDPOA.A "request for electronic monitoring" form dated 8/8/24 filled out by Resident #1's family member and signed by the former administrator, read in part: "the (family member) on behalf of (Resident #1) wish(es) to conduct authorized electronic monitoring in accordance with (the residence's) electronic monitoring policy. (The family member) released (the residence) from any civil liability for a violation of (Resident #1's) privacy rights in connection with the use of the electronic monitoring device." The contract contained a check mark next to whether the device was a video surveillance camera and that the camera would remain unobstructed. The form further read "the legal representative is responsible for the cost of installation of equipment ... any incidents of injury or suspected abuse/neglect must be reported to the (administrator). A copy of the video will be provided."On 4/16/24 at 12:54 p.m., review of video footage from 4/5/24 at 5:18 a.m. revealed Staff #7 had entered Resident #1's room and found her soiled in her bed, on 4/5/24 at 5:18 a.m. Staff #7 removed the linens from Resident #1's bed to wash them, and at 5:21 a.m., Resident #1 was observed naked from the waist down, walking into her bathroom to take a shower, and closing the bathroom door. There was no evidence of anyone having gone into the room or the resident having left the bathroom until staff entered the room on 4/6/24 at 12:04 a.m. On 4/17/24 at 11:29 a.m., Resident #1's family member stated she had installed the video camera herself in the fall of 2022. The family member stated the camera had a view of the residents sleeping area and bathroom door, living room area, and front door. Resident #1's family member stated the camera was put in place originally in 2022 since the resident had concerns someone was stealing from her, and remained in place to keep an eye on her, which the family member stated had helped her to see the resident's falls. The family member stated she refused to provide the residence the video footage. The family member stated the resident was aware the camera was put in place in 2022 and had wanted it in place; however, had not been capable of consenting herself since her dementia worsened over the previous 9 months. On 4/17/24 at approximately 3:30 p.m., the district director of operations (DDO) she was aware of the resident right to privacy in sleeping units. The DDO stated she believed when the family member signed the electronic monitoring form that it released the residence from any liability. The DDO stated the family member was required to provide the residence the video footage to investigate injuries and suspected abuse/neglect in accordance with the form. The DDO stated she was aware of the requirement for an informed consent as well, and had not provided it along with the electronic monitoring form and would look for it. On 4/17/24 at 5:08 p.m., the DDO stated there was no evidence of an informed consent signed, and would have expected that to have occurred.

Based on observation, interview, and record review, the residence failed to provide all residents with regular opportunities to participate in structured engagement and support the pursuit of each resident's interests, affecting 37 current residents. Findings include: 1. Reference and Residence Policy a. The residence's Resident Agreement, dated April, 2021, read in part: "The residence will provide social and recreational services ..."b. According to the National Institue on Aging, "Being lonely or socially isolated is not good for your overall health. For example, it can increase feelings of depression or anxiety, which can have a negative impact on many other aspects of your health ... Research has shown that older adults with an active lifestyle:Are less likely to develop certain diseases. Participating in hobbies and other social activities may lower risk for developing some health problems, including dementia, heart disease, stroke, and some types of cancer. Have a longer lifespan. Studies looking at people ' s outlooks and how long they live show that happiness, life satisfaction, and a sense of purpose are all linked to living longer. Doing things that you enjoy may help cultivate those positive feelings. Are happier and less depressed. Studies suggest that older adults who participate in activities they find meaningful, such as volunteering in their communities or being physically active, say they feel happier and healthier. Are better prepared to cope. When people feel happier and healthier, they are more likely to be resilient, which is our ability to bounce back and recover from difficult situations. Positive emotions, optimism, physical and mental health, and a sense of purpose are all associated with resilience. May be able to improve their thinking abilities. Research suggests that participating in certain activities, such as those that are mentally stimulating or involve physical activity, may have a positive effect on memory — and the more variety the better. Other studies are providing new information about ways that creative activities, such as music or dance, can help older adults with memory problems or dementia ..." National Institute on Aging (3/28/22) Participating in Activities You Enjoy As You Age, retrieved from: https://www.nia.nih.gov/health/healthy-aging/participating-activities-you-enjoy-you-age#:~:text=Research%20has%20shown%20that%20older,and%20some%20types%20of%20cancer. 2. ObservationsThroughout the onsite visit from 4/16/24 to 4/17/24, an April 2024 activity schedule was posted in an enclosed case in the hallway, which read, in part, the following:3/16/24: Be Fit at 10:30 a.m. 3/16/24: Let's Play Bingo at 1:30 p.m. 3/17/24: Be Fit at 10:30 a.m. 3/17/24: Outing at 11:00 a.m. 3/17/24: Let's Play Bingo at 1:30 p.m. Throughout the onsite visit (two consecutive days), the residence provided no opportunities to participate in any structured engagement, including what was posted on the activities schedule. 3. InterviewsOn 4/16/24 at 7:45 a.m., Resident #6 stated there were no activities being provided to residents since the former activities director (AD) left a few months prior to the onsite investigation. Resident #6 stated there was a posted schedule of activities; however, nothing was going on in accordance with the schedule, only television (TV) in the residence common area. On 4/16/24 at 7:46 a.m., Resident #8 stated there were no activities going on during the day d

Based on observation, record review and interview, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII medication administration regulations, affecting three of five sample participants (residents) (#1, #2, #5). Findings include: 1. Chapter VII regulations governing assisted living residences, part 14.21, requires 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. Specifically, a written practitioner's order, dated 4/10/24, directed the residence to administer acetaminophen 325 mg two tablets three times daily for pain relief from her injuries following falls on 4/6 and 4/8/24. However, residence staff transcribed the medication on the electronic medication administration record (eMAR) to be administered on an pro re nata (PRN) basis, although the resident was incapable of requesting PRN medication. The resident experienced pain in her left toe due to not being administered the medication as ordered. Findings include:a. Reference and Residence PolicyAccording to Medline, "Acetaminophen is used to treat mild to moderate pain." The National Library of Medicine (2024) Acetaminophen, retrieved from: https://medlineplus.gov/druginfo/meds/a681004.html#:~:text=Acetaminophen%20is%20used%20to%20relieveThe residence's medication administration policy dated 3/31/22, read in part: "medication administration/assistance and or treatment shall be provided in a safe and timely manner, and as prescribed by the resident's (practitioner)."b. Resident #1 was admitted to the residence on 5/3/21 with a diagnosis of dementia. AcetaminophenA written practitioner's order, dated 4/10/24, directed the residence to administer acetaminophen 325 mg two tablets three times daily for pain. However, the April 2024 electronic medication administration record (eMAR) read to administer acetaminophen 325 mg two tablets every four hours as needed. Further, the medication was not administered as ordered, on 4/11-4/16/24, for a total of 12 missed doses. An external hospice note, dated 4/10/24, read Resident #1 experienced pain from transferring between a sitting to standing position. The resident was prescribed acetaminophen by her practitioner. On 4/16/24 at 10:19 a.m., Resident #1 stated her left toe had been hurting her and flinched as she moved her foot in her reclining chair. On 4/17/24 at 7:36 a.m., Staff #6 stated when Resident #1 fell on 4/6/24 she noticed a skin tear on her small left toe. On 4/17/24 at 8:29 a.m., a medication cart audit revealed acetaminophen 325 mg two tablets three times daily came in a blister pack with two tablets per dose. The blister pack revealed the medication was dispensed for one dose since the blister pack was delivered from the pharmacy on 4/10/24. However, there were no other doses administered. On 4/17/24 at 8:28 a.m., the health and wellness director (HWD) stated Staff #4 had transcribed the medication on the eMAR incorrectly, and Resident #1 had not received her acetaminophen as ordered, other than the one unknown day the blister pack shows it was administered. On 4/17/24 at 9:27 a.m., a practitioner that worked at Resident #1's practitioner's office stated the practitioner ordered ordered acetaminophen 325 mg two tablets three times daily on 4/10/24 for ongoing pain the resident experienced following her falls on 4/6 and two on 4/8/24. The practitioner stated Resident #1 could experience pain as a result of not being administered the medication as ordered. On 4/17/24 at 9:35 a.m., an external hospice provider stated on 4/6/24 Resident #1 sustained bruising on the left side of her head, left shoulder, hip, knees and a skin tear on her left baby toe and verbalized pain. The external hospice provider stated the resident sustained two additional falls on 4/8/24 and was evaluated by her practitioner and prescribed medication to treat the pain resulting from the falls. On 4/17/24 at approximately 11:45 a.m., the HWD stated the qualified medication administration persons (QMAPs) and resident care coordinator were responsible for transcribing medications onto the eMARs. He further stated QMAPs were responsible for ordering medication from the pharmacy. On 4/17/24 at approximately 3:30 p.m., the district director of operations (DDO) stated QMAPs and the health and wellness coordinator (HWC) were responsible for ordering medications from the pharmacy. The DDO stated she was unaware Resident #1 had experienced pain due to not being administered her acetaminophen as scheduled, and would have expected the residence to comply with practitioner's orders related to administration.c. Evidence obtained during the onsite visit revealed the residence failed to comply with authorized practitioner's orders associated with medication administration for Resident #2.2. Chapter VII regulations governing assisted living residences, part 14.29, requires each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident. a. Resident #2 was admitted to the residence on 12/18/22. A written practitioner's order, dated 3/11/24, directed the residence to administer lidocaine 5% to the left foot or groin area, wherever needed, once daily. However, the March 2024 electronic medication administration record (eMAR) contained a code "9" for "other see progress notes" on 3/17/24. However, there was no corresponding documentation in progress notes. On 4/17/24 at 3:54 p.m., the district director of operations (DDO) stated there should be corresponding documentation in the progress notes with an exception code "9." The DDO further stated she was aware of the requirement for accurate eMAR documentation and would expect that to have occurred for all residents. b. There was similar deficient practice for Resident #5.