COURTYARD OF LOVELAND, THE

An involuntary discharge appeal survey, prompted by #CO38433, was completed on 12/12/24. The residence rescinded the discharge notice; therefore, no deficiencies were cited.

An involuntary discharge appeal certification complaint prompted by #CO36162 was completed on 7/18/24. The facility rescinded the discharge notice; therefore, no deficiencies were cited.

An involuntary discharge appeal certification complaint prompted by #CO36161 was completed on 7/18/24. The residence rescinded the discharge notice; therefore, no deficiencies were cited.

A complaint revisit was completed on 7/9/24 for all previous deficiencies cited on 1/18/24. A deficiency was cited.

Based on observation, record review, and interview, the facility (residence) failed to maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, Medication Administration Regulations affecting one of three sample participants (residents) with inaccurate medication administration records (MARs) (#5). This deficiency was cited previously during a survey and complaint investigation concluded on 1/18/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. Chapter VII regulations governing assisted living residences, part 14.29, requires that each qualified medication administration person, nurse, or practitioner accurately document each medication administration or monitoring event at the time the event is completed for each resident. The residence's undated medication record policy read in part: medication administration records (MARs) were maintained for all medications poured and /or passed by QMAPs. The undated medication refusal and/or missed doses policy read in part: missed/refused medications were documented in the resident's medication record, and the prescribing practitioner was notified immediately or according to practitioner parameters, which was retained in writing and kept on file.a. Resident #5 was admitted to the residence on 6/28/22. Lacosamide A written practitioner's order, dated 5/3/23, directed the residence to administer lacosamide 100 mg twice daily. However, the May and June 2024 MARs revealed a blank space on the MAR for the evening doses on 5/8/24 and 6/21/24. AtorvastatinA written practitioner's order, dated 3/1/24, directed the residence to administer atorvastatin 40 mg daily. However, the May and June 2024 MARs revealed a blank space for the evening doses on 5/8/24 and 6/21/24. MetforminA written practitioner's order, dated 3/1/24, directed the residence to administer metformin HCL ER 500, two tablets with evening meals. However, the May and June 2024 MARs revealed a blank space for the evening doses on 5/8/24 and 6/5/24. SertralineA written practitioner's order, dated 3/1/24, directed the residence to administer sertraline hcl 50 mg daily. However, the May and June 2024 MARs revealed a blank space on the MAR for the evening doses on 5/8/24 and 6/21/24. b. Interview On 7/9/24 at 2:30 p.m., the residential care coordinator (RCC) stated the QMAPs were expected to document medication administration on the MAR at the time of administration. The RCC confirmed the QMAP had not documented the above-listed medications on the MAR. Further, the RCC stated he could not explain why there were blank spaces on the MAR for Resident #5; therefore, he could not explain why this deficiency had not been corrected.

A certification complaint, prompted by #CO36418, was completed on 7/9/24. No deficiencies were cited.

A complaint revisit was completed on 7/9/24 for all previous deficiencies cited on 1/18/24. The residence is in compliance with all regulations surveyed. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 11/15/23.

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A complaint revisit was completed on 7/9/24 for all previous deficiencies cited on 1/18/24. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 11/15/23.

Based on interview and record review, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration at the time the event was completed for each resident, affecting one of three sample residents (#5). This deficiency was cited previously during a survey and complaint investigation concluded on 1/18/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. Residence PolicyThe residence's undated medication record policy read in part: medication administration records (MARs) were maintained for all medications poured and /or passed by QMAPs. The undated medication refusal and/or missed doses policy read in part: missed/refused medications were documented in the resident's medication record, and the prescribing practitioner was notified immediately or according to practitioner parameters, which was retained in writing and kept on file. 2. Resident #5 was admitted to the residence on 6/28/22. a. Lacosamide A written practitioner's order, dated 5/3/23, directed the residence to administer lacosamide 100 mg twice daily. However, the May and June 2024 MARs revealed a blank space on the MAR for the evening doses on 5/8/24 and 6/21/24. b. AtorvastatinA written practitioner's order, dated 3/1/24, directed the residence to administer atorvastatin 40 mg daily. However, the May and June 2024 MARs revealed a blank space for the evening doses on 5/8/24 and 6/21/24. c. MetforminA written practitioner's order, dated 3/1/24, directed the residence to administer metformin HCL ER 500, two tablets with evening meals. However, the May and June 2024 MARs revealed a blank space for the evening doses on 5/8/24 and 6/5/24. d. SertralineA written practitioner's order, dated 3/1/24, directed the residence to administer sertraline hcl 50 mg daily. However, the May and June 2024 MARs revealed a blank space on the MAR for the evening doses on 5/8/24 and 6/21/24. 3. Interview On 7/9/24 at 2:30 p.m., the residential care coordinator (RCC) stated the QMAPs were expected to document medication administration on the MAR at the time of administration. The RCC confirmed the QMAP had not documented the above-listed medications on the MAR. Further, the RCC stated he could not explain why there were blank spaces on the MAR for Resident #5; therefore, he could not explain why this deficiency had not been corrected.

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A complaint revisit was completed on 7/9/24 for the previous deficiency cited on 1/18/24. A deficiency was cited.

Based on observation, record review, and interview, the facility (residence) failed to maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, Medication Administration Regulations affecting one of three sample participants (residents) with inaccurate medication administration records (MARs) (#5). This deficiency was cited previously during a survey and complaint investigation concluded on 1/18/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. Chapter VII regulations governing assisted living residences, part 14.29, requires that each qualified medication administration person, nurse, or practitioner accurately document each medication administration or monitoring event at the time the event is completed for each resident. The residence's undated medication record policy read in part: medication administration records (MARs) were maintained for all medications poured and /or passed by QMAPs. The undated medication refusal and/or missed doses policy read in part: missed/refused medications were documented in the resident's medication record, and the prescribing practitioner was notified immediately or according to practitioner parameters, which was retained in writing and kept on file.a. Resident #5 was admitted to the residence on 6/28/22. Lacosamide A written practitioner's order, dated 5/3/23, directed the residence to administer lacosamide 100 mg twice daily. However, the May and June 2024 MARs revealed a blank space on the MAR for the evening doses on 5/8/24 and 6/21/24. AtorvastatinA written practitioner's order, dated 3/1/24, directed the residence to administer atorvastatin 40 mg daily. However, the May and June 2024 MARs revealed a blank space for the evening doses on 5/8/24 and 6/21/24. MetforminA written practitioner's order, dated 3/1/24, directed the residence to administer metformin HCL ER 500, two tablets with evening meals. However, the May and June 2024 MARs revealed a blank space for the evening doses on 5/8/24 and 6/5/24. SertralineA written practitioner's order, dated 3/1/24, directed the residence to administer sertraline hcl 50 mg daily. However, the May and June 2024 MARs revealed a blank space on the MAR for the evening doses on 5/8/24 and 6/21/24. b. Interview On 7/9/24 at 2:30 p.m., the residential care coordinator (RCC) stated the QMAPs were expected to document medication administration on the MAR at the time of administration. The RCC confirmed the QMAP had not documented the above-listed medications on the MAR. Further, the RCC stated he could not explain why there were blank spaces on the MAR for Resident #5; therefore, he could not explain why this deficiency had not been corrected.

A licensure complaint, prompted by #CO36417, was completed on 7/9/24. A deficiency was cited.

Based on record review and interviews, the residence failed to comply with occurrence reporting requirements, affecting one sample resident (#1), who reported misappropriation of property. Findings include:1. References and Residence Policy According to the Occurrence Reporting Manual, dated May 2018, the residence must report an occurrence to the Department when: " Any occurrence involving misappropriation of a client ' s property. Misappropriation of a client ' s property means a pattern of or deliberately misplacing, exploiting, or wrongfully using, either temporarily or permanently, a client ' s belongings or money without the client ' s consent. Section 25-1-124 (2)(f), C.R.S. Two elements needed: Deliberate misplacing, exploiting or wrongful use of a patient ' s or resident ' s property OR A pattern of misplacing, exploiting or wrongful use of a patient ' s or resident ' s property AND Patient/resident consent not given."2. Record ReviewA documented investigation revealed the residence conducted an investigation of the misappropriation of Resident #1's property on 4/9/24, after Resident #1 discovered 31 fraudulent charges on her bank statement dated 2/1/24 to 3/14/24. On 7/1/24 at approximately 8:00 a.m., a review of the Department's database revealed that the residence failed to report the allegation of misappropriation of property to the department as an occurrence. An email from a department representative, dated 7/9/24, confirmed the residence was required to report the alleged misappropriation of funds for Resident #1 to the department as an occurrence. 2. InterviewsOn 7/9/24 at 12:00 p.m., Resident #1 stated in the beginning of April 2024, the business office manager (BOM) had taken her to the bank to withdraw $750 for her rent payment. She stated there was less than $100 in her account and could not understand why because there should have been at least $1000. Resident #1 stated she and the BOM had reviewed her bank statements and discovered that someone had used her bank card number for two different ride-share services, resulting in $1224.00 of fraudulent transactions. She added that she did not use ride-share services. On 7/9/24 at 2:13 p.m., the administrator stated that the residence failed to report the occurrence of misappropriation of property to the department. The administrator stated the residence conducted an internal investigation and notified local law enforcement, adult protective services (APS), and an external agency representative. The administrator stated since they were unable to substantiate staff involvement, she did not report the incident to the department as an occurrence. On 7/9/24 at 2:30 p.m., the BOM stated that they had reported the misappropriation of funds to the ombudsman, APS, and local law enforcement during the residence investigation. However, she stated that since she was unable to substantiate staff involvement, she did not report the incident to the department as an occurrence as required.

An involuntary discharge appeal survey, prompted by #CO36059, was completed on 6/25/24. No deficiencies were cited.

An involuntary discharge appeal survey, prompted by #CO36060, was completed on 6/25/24. No deficiencies were cited.

A certification complaint, prompted by #CO35550, was completed on 4/11/24. No deficiencies were cited.

A licensure complaint, prompted by #CO35549 was completed on 4/11/24. A deficiency was cited.

Based on observation, record review and interviews, the residence failed to request, prior to staff hire, a name-based criminal history record check for each prospective staff member for three of three sample staff (#1-#3), affecting all current residents. Findings include:1. References a. Chapter VII 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.b. Chapter VII regulations governing assisted living residences, part 7.12, requires that each personnel file shall include written documentation regarding the following items:(E) Results of background checks and follow up, as applicable. 2. ObservationsOn 4/10/24 from 7:00 a.m. to 4:00 p.m. Staff #1 was observed administering medications and providing personal care to residents. 3. Record ReviewReview of the personnel files for Staff #1-#3 revealed they were hired on 10/20/23, 12/20/21, and 11/13/23, respectively. The personnel files for Staff #1-#3 contained evidence of CBI results; however, the CBI background checks had not been completed prior to their hire dates. Review of the CBI background checks revealed the checks for Staff #1-#3 were completed on 11/20/23, 1/24/22 , and 11/20/23, respectively. Review of the March and April 2024 staff schedule revealed Staff #1-#3 worked the following dates: Staff #1: 3/1/24, 3/4-3/8/24, 3/11-3/15/24, 3/18-3/22/24, 3/25-3/29/24, 4/2-4/5/24, and 4/8-4/10/24. Staff #2: 3/1/24, 3/4-3/8/24, 3/11-3/15/24, 3/18-3/22/24, 3/25-3/29/24, 4/2-4/5/24, and 4/8-4/10/24. Staff #3: 3/1/24 3/4-3/8/24, 3/11-3/15/24, 3/18-3/22/24, 3/25-3/29/24, 4/2-4/5/24, and 4/8-4/10/24.4. InterviewOn 4/10/24 at 4:30 p.m., the administrator stated she was aware that CBI background checks were required to have been completed for employees prior to their hire date; however, could not explain why the background checks had not been completed as required.

A relicensure survey with complaints #CO32068, #CO34538 was completed on 1/18/24. Deficiencies were cited. A change of ownership occurred on 1/11/23.

Based on observation, interview and record review, the residence failed to make available, either directly or indirectly through a resident agreement, a safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting two of five sample residents (#3, #11). Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.34, defines "Personal services" as those services that an assisted living residence and its staff provide for each resident including, but not limited to:(A) An environment that is sanitary and safe from physical harmb. The residence's Resident Agreement, dated May 2022, read in part, "The resident will be entitled to occupancy and exclusive use (unless shared) of the apartment shall be entitled to use, in common with other residents, the community facilities and common areas. Inside common areas and apartments will be maintained as smoke-free environments."2. Physically Safe Environmenta. ObservationsOn 1/17/24 at 8:15 a.m., Resident #28 and Resident #11's room smelled like cigarette smoke. There was a stronger cigarette smell coming from the bathroom they shared. On 1/18/24 at 8:44 a.m., Resident #3 and #29's bathroom smelled like cigarette smoke.b. Record ReviewDecember 2023 and January 2024 progress notes for Resident #3 revealed Resident #3 was observed by staff smoking in his room on 12/29/23, 1/2, 1/6 , 1/10 and 1/16/24. January 2024 progress notes for Resident #11 revealed she was observed by staff, smoking in her room on 1/10 and 1/17/24.c. InterviewsOn 1/17/24 at 8:05 a.m., Resident #29 stated his roommate (Resident #3) has smoked cigarettes in their room on at least five occasions within the past week. On 1/17/24 at 8:15 a.m., Resident #28 stated her roommate (Resident #11) had just smoked a cigarette in their room. On 1/17/24 at 8:23 a.m., Resident #26 stated Resident #3 smoked a cigarette in the common area of the residence the evening prior to the onsite visit on 1/17/24. On 1/18/24 at approximately 10:45 a.m., the administrator stated residents should not be smoking in their rooms. 3. Sanitary Environmenta. ObservationsOn 1/17/24 at approximately 8:00 a.m., Resident #3 was observed scratching his right lower leg to the point it was bleeding. The white armchair in his room had bronze like colored spots near where Resident #3 scratched his lower leg. On 1/18/24 at approximately 8:45 a.m., the white armchair on Resident #3's side of the room had two stains on the seat cushion and front side of the chair.b. InterviewsOn 1/18/24 at approximately 9:00 a.m.., Staff #8 stated the stains on Resident #3's armchair was urine and blood. She added the urine stain had been there for a while and the blood stain was newer. On 1/18/24 at 9:08 a.m., the resident care coordinator confirmed Resident #3's armchair was stained with blood and urine. He added he was unsure how long the stains had been there but would expect them to be cleaned. On 1/18/24 at approximately 10:45 a.m., the administrator said housekeeping was responsible for cleaning resident rooms. She added if either care staff or housekeeping noticed a stain on a resident chair she expected the stain to be cleaned and did not expect blood or urine stains to be on resident furniture.

Based on record review and interview the residence failed to comply with authorized practitioner orders associated with medication administration, affecting four of four sample residents (#1-#3, #5). Specifically, Resident #5 was admitted the residence on 2/10/21 with diagnosis including type 2 diabetes mellitus with other circulatory complications, hyperlipidemia epilepsy, old myocardial infarction, atherosclerosis of coronary artery bypass graft(s), chronic obstructive pulmonary disease, unspecified cirrhosis of the liver, transient ischemic attack and cerebral infarction without residual deficits. The resident stated he was in constant pain all over his body due to his medications not being available for approximately six weeks. Additionally, he was observed grimacing in pain during the onsite visit on 1/18/24. Findings include:1. Residence Policy and Referencesa. The undated Medication Refill policy read in part, written physicians orders for all medications were maintained in the resident's record in the "physician's orders" section. Medication refills would be obtained in a timely manner (seven days prior to running out) to ensure residents had all physician ordered medication(s) available. Medications were never allowed to run out unless directed to by the physician.b. The resident agreement, dated 5/10/22, read in part, the residence qualified medication administration person (QMAP) would provide assistance to residents the physician deemed necessary.c. The residence bill of rights, dated 5/10/22, read in part, the resident had the right to expect the cooperation of the residence to achieve the maximum degree of benefit from the services made available by the residence. 2. Record ReviewResident #1 was admitted to the residence on 2/10/21 with diagnosis including type 2 diabetes mellitus with other circulatory complications, hyperlipidemia epilepsy, old myocardial infarction, atherosclerosis of coronary artery bypass graft(s), chronic obstructive pulmonary disease, unspecified cirrhosis of the liver, transient ischemic attack and cerebral infarction without residual deficits. A written practitioner's order dated, 5/2/23, directed the residence to administer;Morphine sulfate extended release 30 mg two times daily Levothyroxine 200 mcg one time daily Atorvastatin 20 mg one time daily Glimepiride 4 mg tablet three times daily Sertraline Hd 50 mg one time daily Aspirin 81 mg one time daily Salonpas lidocaine 4% patch one time daily Symbicort 160-4.5 mcg inhaler one time daily Ezetimibe 10 mg tablet one time dailySenna plus doc 8.6/50 mg,trazodone 100 mg two times daily Dicyclomine 10 mg three times dailyDiclofenac sodium 1% gel one time daily However, the December 2023 medication administration record (MAR) read on 12/1-12/31/23, these medications were unavailable for 31 days. The January 2024 MAR read on 1/2-1/17/24, these medications were unavailable for 16 days. It was also revealed that the residence failed to comply with the authorized practitioner orders associated with medication administration for Residents #2, #3 and #5 according to their December 2023 MAR.3. InterviewsOn 1/18/24 at 11:02 a.m., Resident #1 said that many of his medications were not available because he had required hospice services and they were not providing the residence with medication orders or medications. He said that about two weeks ago he discontinued external hospice services, however, his medication was still not administered as ordered. Resident #1 said that he had constant pain "everywhere". On 1/18/24 at approximately 3:30 p.m., the administrator said that Resident #1 had been under the care of three different hospice agencies. She said that each agency discontinued his care, which resulted in Resident #1 without a physician to write orders for his needed medications. She said that after the third hospice agency discontinued care, Resident #1 chose to return to the agency and doctors who worked with the residence. The administrator said that Resident #1 had been without many of his medications and orders for a while,which included when he was with the hospice agencies. She said it was difficult to get a physician's order and medications. She said that she was glad he decided to return to the residence agency and doctors so that he can get the medications and care he needed. Further, the administrator stated the resident was in pain constantly because he did not have his medications. 4. ObservationOn 1/18/24 at 11:02 a.m., Resident #1 was slow to rise from his chair. The resident appeared to grimace and show expressions of pain when transferring and standing.

Based on interview and record review, the residence failed to accurately document each medication administration, affecting two of four sample residents (#2, #5). Findings include:1. Residence PolicyThe undated medication record policy read in part, medication administration records (MAR) were maintained for all medications poured and /or passed by qualified medication administration persons (QMAP). The undated medication refusal and /or missed doses policy read in part, missed/refused medications were documented in the resident ' s medication record and the prescribing physician notified immediately or according to physician parameters, which must be retained in writing and kept on file. 2. Record reviewa. Resident #5 was admitted to the residence on 6/28/22 with diagnosis including illness unspecified. A written practitioner's order, dated 5/19/23, directed the residence to administer atorvastatin 40 mg one time daily. The December 2023 MAR read the medication was unavailable and was not administered on 12/19/23, for a total of one inaccurately documented medication administration.b. Residence #2 was admitted to the residence on 8/16/18 with diagnosis including migraines and muscle weakness. A written practitioner's order, dated 3/29/23, directed the residence to administer lidocaine 5% patch once daily. The December 2023 MAR read the medication was unavailable and not administered on 12/8/23, for a total of one inaccurately documented medication administration. 3. InterviewsOn 1/18/24 at 12:36 p.m., Staff #10 stated the atorvastatin administration for Resident #5 was not accurately documented on 12/19/23. He said that it should have been documented as refused, not as unavailable. Staff #10 also stated the medication administration of the lidocaine patch for Resident #2 was not accurately documented on 12/8/23. He said that it should have been documented as refused, not as unavailable. On 1/18/24 at 3:30 p.m., the administrator said her expectation was that staff documented accurate information on the MAR and she expected refusals of medications would be documented accurately.

Based on record review, observation and interview the residence failed to ensure each room had sufficient heat to meet the needs of the residents, affecting one of five sample residents (#5). (Cross-reference Q2590)Findings include:1. ReferenceThe residence's Resident Agreement, dated May 2022, read, in part, "The community will furnish heat."2. ObservationOn 1/17/24 at approximately 4:00 p.m., the temperature inside Resident #5's room and bathroom was 67.5 degrees F (fahrenheit) and 67.8 F, respectively. 3. InterviewsOn 1/17/24 at 7:36 a.m., Resident #5 stated the thermostat in his room did not work and that he had a space heater because if he did not have one he would be cold. He added he left the space heater on during the night. On 1/17/24 at 4:00 p.m., Resident #5 stated someone removed the portable heater from his room the morning of the onsite visit. He stated he was cold and it would get even colder in his room later in the day. On 1/17/24 at approximately 4:15 p.m., the maintenance director confirmed the thermostat and heater in Resident #5's room was broken. On 1/18/24 at approximately 11:45 a.m., Resident #5 stated he notified staff a week prior to the onsite visit that the heat in his room was not working. He added he was provided a portable heater. On 1/18/24 at approximately 10:34 a.m., the administrator said the residence's boiler went out during the night in December 2023. She added the boiler was repaired the next day. The administrator said the maintenance director was responsible for ensuring that the heaters in resident rooms worked properly. She added that the staff should have notified the maintenance director when Resident #5 stated his heat was not working. She said she expected residents to have adequate heat in their rooms.

Based on observation and interview, the residence failed to prohibit the use of portable heaters in the residents' rooms, affecting four of four sample residents (#1, #11, #27, #29) with portable heaters in their rooms. (Cross-reference Q2520)Findings include:1. Residence Policiesa. The residence's House Rules, dated May 2022, read in part, "All heating elements such as portable heaters, electric heating pads and blankets are not permitted."b. The residence's Resident Agreement, dated May 2022, read in part, "Fire and Safety Policy ... Kerosene heaters, electric heaters, space heaters ... are not permitted in the assisted living residence." 2. ObservationsOn 1/17/24 at 8:10 a.m., a portable heater was observed turned on in Resident #27's room. On 1/17/24 at 8:13 a.m., a portable heater was observed turned on in Resident #1's room. On 1/17/24 at 8:15 a.m., a portable heater was observed turned on in Resident #11's room. On 1/18/24 at 8:42 a.m., a portable heater was observed turned on in Resident #29's room. 3. InterviewsOn 1/17/24 at 7:25 a.m., Resident #11 stated the heat did not work in her bedroom and as a result she used a portable heater. On 1/17/24 at 7:26 a.m., Resident #1 stated the heat in his room did not work well and he had a portable heater. 1/17/24 at 7:36 a.m., Resident #5 stated it was cold in his room and as a result he used a portable heater. On 1/17/24 at 7:43 a.m., Resident #27 stated his room was cold and the heat did not work well in his room and as a result he had a portable heater. On 1/18/24 at approximately 10:45 a.m., the administrator said she was aware portable heaters were not allowed in resident rooms and added she was not aware portable heaters were identified in Resident #1, #11, #27 and #29's rooms.

Based on observation, record review, and interview, the residence failed to ensure that smoking was prohibited in areas where oxygen was used, affecting 39 current residents. Specifically, Resident #3 and Resident #29 were roommates. Resident #3 was identified as smoking cigarettes in his room on 1/10 and 1/16/24. Resident #29 was on continuous oxygen for (chronic obstructive pulmonary disease) COPD and asthma. Resident #29 had six unopened oxygen cylinders in his room. This failure created an immediate jeopardy risk of possible harm to all 39 current residents residing in the residence. On 1/17/24, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. Reference and Residence Policiesa. According to the Cleveland Clinic, "(Oxygen) can cause a fire to burn faster and stronger. The fire can become explosive. For everyone's safety, you should: Never smoke near an oxygen tank." Oxygen Therapy (6/6/22), retrieved from: https://my.clevelandclinic.org/health/treatments/23194-oxygen-therapyb. The residence's May 2022 Resident Agreement read, in part, "Responsibilities and Representations of the Resident ... to live in a peaceful way respecting the rights of others to comfort, safety, privacy, security and peaceful enjoyment and to refrain from all acts which would interfere with such rights ... The resident will be entitled to occupancy and exclusive use (unless shared) of the apartment shall be entitled to use, in common with other residents, the community facilities and common areas. Inside common areas and apartments will be maintained as smoke-free environments." c. The residence's House Rules, dated May 2022 read, in part, "The community is a smoke free environment. Smoking by residents, visitors, staff, volunteers and vendors is not allowed anywhere in the building including resident rooms. Designated places outdoors may be used ... Failure to abide by House Rules may result in the issuance of a discharge notice."2. ObservationsOn 1/17/24 at approximately 8:00 a.m., Resident #29 was lying in bed wearing an oxygen cannula. The oxygen cord was attached to a concentrator and was turned on. On 1/18/24 at approximately 8:45 a.m., Resident #29 was lying in bed wearing an oxygen cannula. The oxygen cord was attached to a concentrator and was turned on. The bathroom Resident #3 and #29 shared smelled like cigarette smoke. 3. Record ReviewResident #3 was admitted to the residence on 2/1/21 with diagnoses including vascular dementia and alcohol induced dementia. Progress notes in Resident #3's record for December 2023 and January 2024 revealed the following:On 1/6/24 staff observed Resident #3 smoking in his room. There were several plastic cups of water around the room that contained cigarette ashes. On 1/10/24 Resident #3 was observed smoking in his bathroom. Specifically the business office manager said, "I had a chat with him letting him know his roommate is on oxygen and he could not smoke in the building and he told me he is 76 years old and he will do whatever he wants."On 1/16/24 Resident #3 was observed smoking in his room on two different occasions. 4. InterviewsOn 1/17/24 at 7:50 a.m., Resident #7 stated Resident #3 smoked in his room and his roommate (Resident #29) was on oxygen. She added Resident #3 smoked the night prior to the onsite visit in his room. On 1/17/24 at approximately 8:00 a.m., Resident #11 stated Resident #3 had been smoking cigarettes in his room. On 1/17/24 at 8:05 a.m., Resident #29 stated he was on continuous oxygen for COPD and asthma. He added since he moved in the residence in the last week, Resident #3 had smoked cigarettes in the room with him present on five occasions. Resident #29 said when Resident #3 smoked in the room he had difficulty breathing. On 1/17/2 at 10:40 a.m., Staff #9 stated a couple days prior to the onsite visit on 1/17/24 Resident #3 was observed smoking cigarettes in his room. On 1/17/24 at 2:24 p.m., the administrator stated she was aware Resident #3 had been smoking in his room with Resident #29 who was on oxygen. The administrator acknowledged Resident #3 was not allowed to smoke cigarettes in his room. On 1/18/24 at 11:56 a.m., the practitioner for Resident #3 said Resident #3 had alcohol induced dementia and stated because of his cognition he should not have cigarettes in his room and he would not know he is not allowed to smoke them in a room with his roommate who is on oxygen. 5. Immediate Jeopardy Risk - Written Evidence, Immediate Correction The investigation established that the findings above placed the 39 current residents at immediate jeopardy risk for serious harm or death in the event Resident #3 smoked his cigarette while Resident #29 wore his oxygen. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 1/17/24 at 3:00 p.m., the administrator submitted written evidence that read in pertinent part: "All supervisors and staff will be provided with training on the smoking policy of the facility, which is only in designated areas (outside) ... We will be having a mandatory staff meeting at 1pm on the 25th of January to make sure all staff are trained and know their duties."However, the written evidence did not indicate the risk had been removed because it did not contain any specific plan of correction for Resident #3. On 1/17/24 at approximately 3:15 p.m., the administrator submitted additional written evidence that read in pertinent part: "(Resident #3) as of January 17, 2024, is no longer allowed to hold his own cigarettes. He must now come to the med room to get them distributed from the qmap (qualified medication administration person) one at a time, qmap is responsible for supervising (Resident #3) in making sure he only smokes in the smoking area."

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 7.7.3 The assisted living residence shall develop and implement policies and procedures regarding the hiring or continued service of any administrator, staff member, or volunteer whose criminal history records do not reveal good, moral, and responsible character or demonstrate other conduct that could pose a risk to the health, safety, or welfare of the residents.(A) At a minimum, the assisted living residence shall consider and address the following items:(1) The history of convictions, pleas of guilty or no contest,(2) The nature and seriousness of the crime(s),(3) The time that has elapsed since the convictions,(4) Whether there are any mitigating circumstances, and(5) The nature of the position to which the individual will be assigned. 18.8 Resident records shall contain, but not be limited to, the following items:(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. 22.32 The assisted living residence shall ensure that oxygen tanks are secured upright at all times in a manner that prevents tanks from falling over, being dropped, or striking each other.

A certification complaint revisit was completed on 1/18/24. A deficiency was cited

Based on observation, record review and interview, the facility (residence) failed to maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, Medication Administration Regulations affecting four of four sample participants (residents) requiring medication administration assistance (#1-#3, #5) and two of four participants with inaccurate medication administration records (MARs) (#2, #5). Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21, requires that 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, Resident #5 was admitted the residence on 2/10/21 with diagnosis including type 2 diabetes mellitus with other circulatory complications, hyperlipidemia epilepsy, old myocardial infarction, atherosclerosis of coronary artery bypass graft(s), chronic obstructive pulmonary disease, unspecified cirrhosis of the liver, transient ischemic attack and cerebral infarction without residual deficits. The resident stated he was in constant pain all over his body due to his medications not being available for approximately six weeks. Additionally, he was observed grimacing in pain during the onsite visit on 1/18/24.a. Residence Policy and ReferencesThe undated Medication Refill policy read in part, written physicians orders for all medications were maintained in the resident's record in the "physician's orders" section. Medication refills would be obtained in a timely manner (seven days prior to running out) to ensure residents had all physician ordered medication(s) available. Medications were never allowed to run out unless directed to by the physician. The resident agreement, dated 5/10/22, read in part, the residence qualified medication administration person (QMAP) would provide assistance to residents the physician deemed necessary. The residence bill of rights, dated 5/10/22, read in part, the resident had the right to expect the cooperation of the residence to achieve the maximum degree of benefit from the services made available by the residence. b. Record ReviewResident #1 was admitted to the residence on 2/10/21 with diagnosis including type 2 diabetes mellitus with other circulatory complications, hyperlipidemia epilepsy, old myocardial infarction, atherosclerosis of coronary artery bypass graft(s), chronic obstructive pulmonary disease, unspecified cirrhosis of the liver, transient ischemic attack and cerebral infarction without residual deficits. A written practitioner's order dated, 5/2/23, directed the residence to administer;Morphine sulfate extended release 30 mg two times daily Levothyroxine 200 mcg one time daily Atorvastatin 20 mg one time daily Glimepiride 4 mg tablet three times daily Sertraline Hd 50 mg one time daily Aspirin 81 mg one time daily Salonpas lidocaine 4% patch one time daily Symbicort 160-4.5 mcg inhaler one time daily Ezetimibe 10 mg tablet one time dailySenna plus doc 8.6/50 mg,trazodone 100 mg two times daily Dicyclomine 10 mg three times dailyDiclofenac sodium 1% gel one time daily However, the December 2023 medication administration record (MAR) read on 12/1-12/31/23, these medications were unavailable for 31 days. The January 2024 MAR read on 1/2-1/17/24, these medications were unavailable for 16 days. It was also revealed that the residence failed to comply with the authorized practitioner orders associated with medication administration for Residents #2, #3 and #5 according to their December 2023 MAR.c. InterviewsOn 1/18/24 at 11:02 a.m., Resident #1 said that many of his medications were not available because he had required hospice services and they were not providing the residence with medication orders or medications. He said that about two weeks ago he discontinued external hospice services, however, his medication was still not administered as ordered. Resident #1 said that he had constant pain "everywhere". On 1/18/24 at approximately 3:30 p.m., the administrator said that Resident #1 had been under the care of three different hospice agencies. She said that each agency discontinued his care, which resulted in Resident #1 without a physician to write orders for his needed medications. She said that after the third hospice agency discontinued care, Resident #1 chose to return to the agency and doctors who worked with the residence. The administrator said that Resident #1 had been without many of his medications and orders for a while,which included when he was with the hospice agencies. She said it was difficult to get a physician's order and medications. She said that she was glad he decided to return to the residence agency and doctors so that he can get the medications and care he needed. Further, the administrator stated the resident was in pain constantly because he did not have his medications.d. ObservationOn 1/18/24 at 11:02 a.m., Resident #1 was slow to rise from his chair. The resident appeared to grimace and show expressions of pain when transferring and standing. 2. Chapter VII regulations governing assisted living residences, part 14.29, requires that all prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner.(C) 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. Residence PolicyThe undated medication record policy read in part, MAR were maintained for all medications poured and /or passed by qualified medication administration persons (QMAP). The undated medication refusal and /or missed doses policy read in part, missed/refused medications were documented in the resident ' s medication record and the prescribing physician notified immediately or according to physician parameters, which must be retained in writing and kept on file.b. Record reviewResident #5 was admitted to the residence on 6/28/22 with diagnosis including diabetes and illness unspecified. A written practitioner's order, dated 5/19/23, directed the residence to administer atorvastatin 40 mg one time daily. The December 2023 MAR read the medication was unavailable and was not administered on 12/19/23, for a total of one inaccurately documented medication administration. Residence #2 was admitted to the residence on 8/16/18 with diagnosis including migraines and muscle weakness. A written practitioner's order, dated 3/29/23, directed the residence to administer lidocaine 5% patch once daily. The December 2023 MAR read the medication was unavailable and not administered on 12/8/23, for a total of one inaccurately documented medication administration.c. InterviewsOn 1/18/24 at 12:36 p.m., Staff #10 stated the atorvastatin administration for Resident #5 was not accurately documented on 12/19/23. He said that it should have been documented as refused, not as unavailable. Staff #10 also stated the medication administration of the lidocaine patch for Resident #2 was not accurately documented on 12/8/23. He said that it should have been documented as refused, not as unavailable. On 1/18/24 at 3:30 p.m., the administrator said her expectation was that staff documented accurate information on the MAR and she expected refusals of medications would be documented accurately.

A recertification survey with complaint #CO32069 was completed on 1/18/24. Deficiencies were cited.

Based on record review, observation, and interview, the facility (residence) failed to maintain a comfortable temperature throughout the residence and participant (resident) rooms, sufficient to accommodate the use and needs of the residents, affecting one of five sample participants (residents) (#5). Findings include:1. ReferenceThe residence's Resident Agreement, dated May 2022, read, in part, "The community will furnish heat."2. ObservationOn 1/17/24 at approximately 4:00 p.m., the temperature inside Resident #5's room and bathroom was 67.5 degrees F (fahrenheit) and 67.8 F, respectively. 3. InterviewsOn 1/17/24 at 7:36 a.m., Resident #5 stated the thermostat in his room did not work and that he had a space heater because if he did not have one he would be cold. He added he left the space heater on during the night. On 1/17/24 at 4:00 p.m., Resident #5 stated someone removed the portable heater from his room the morning of the onsite visit. He stated he was cold and it would get even colder in his room later in the day. On 1/17/24 at approximately 4:15 p.m., the maintenance director confirmed the thermostat and heater in Resident #5's room was broken. On 1/18/24 at approximately 11:45 a.m., Resident #5 stated he notified staff a week prior to the onsite visit that the heat in his room was not working. He added he was provided a portable heater. On 1/18/24 at approximately 10:34 a.m., the administrator said the residence's boiler went out during the night in December 2023. She added the boiler was repaired the next day. The administrator said the maintenance director was responsible for ensuring that the heaters in resident rooms worked properly. She added that the staff should have notified the maintenance director when Resident #5 stated his heat was not working. She said she expected residents to have adequate heat in their rooms.

Based on observation, record review and interview, the facility (residence) failed to maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, Medication Administration Regulations affecting four of four sample participants (residents) requiring medication administration assistance (#1-#3, #5) and two of four participants with inaccurate medication administration records (MARs) (#2, #5). Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21, requires that 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, Resident #5 was admitted the residence on 2/10/21 with diagnosis including type 2 diabetes mellitus with other circulatory complications, hyperlipidemia epilepsy, old myocardial infarction, atherosclerosis of coronary artery bypass graft(s), chronic obstructive pulmonary disease, unspecified cirrhosis of the liver, transient ischemic attack and cerebral infarction without residual deficits. The resident stated he was in constant pain all over his body due to his medications not being available for approximately six weeks. Additionally, he was observed grimacing in pain during the onsite visit on 1/18/24.a. Residence Policy and ReferencesThe undated Medication Refill policy read in part, written physicians orders for all medications were maintained in the resident's record in the "physician's orders" section. Medication refills would be obtained in a timely manner (seven days prior to running out) to ensure residents had all physician ordered medication(s) available. Medications were never allowed to run out unless directed to by the physician. The resident agreement, dated 5/10/22, read in part, the residence qualified medication administration person (QMAP) would provide assistance to residents the physician deemed necessary. The residence bill of rights, dated 5/10/22, read in part, the resident had the right to expect the cooperation of the residence to achieve the maximum degree of benefit from the services made available by the residence. b. Record ReviewResident #1 was admitted to the residence on 2/10/21 with diagnosis including type 2 diabetes mellitus with other circulatory complications, hyperlipidemia epilepsy, old myocardial infarction, atherosclerosis of coronary artery bypass graft(s), chronic obstructive pulmonary disease, unspecified cirrhosis of the liver, transient ischemic attack and cerebral infarction without residual deficits. A written practitioner's order dated, 5/2/23, directed the residence to administer;Morphine sulfate extended release 30 mg two times daily Levothyroxine 200 mcg one time daily Atorvastatin 20 mg one time daily Glimepiride 4 mg tablet three times daily Sertraline Hd 50 mg one time daily Aspirin 81 mg one time daily Salonpas lidocaine 4% patch one time daily Symbicort 160-4.5 mcg inhaler one time daily Ezetimibe 10 mg tablet one time dailySenna plus doc 8.6/50 mg,trazodone 100 mg two times daily Dicyclomine 10 mg three times dailyDiclofenac sodium 1% gel one time daily However, the December 2023 medication administration record (MAR) read on 12/1-12/31/23, these medications were unavailable for 31 days. The January 2024 MAR read on 1/2-1/17/24, these medications were unavailable for 16 days. It was also revealed that the residence failed to comply with the authorized practitioner orders associated with medication administration for Residents #2, #3 and #5 according to their December 2023 MAR.c. InterviewsOn 1/18/24 at 11:02 a.m., Resident #1 said that many of his medications were not available because he had required hospice services and they were not providing the residence with medication orders or medications. He said that about two weeks ago he discontinued external hospice services, however, his medication was still not administered as ordered. Resident #1 said that he had constant pain "everywhere". On 1/18/24 at approximately 3:30 p.m., the administrator said that Resident #1 had been under the care of three different hospice agencies. She said that each agency discontinued his care, which resulted in Resident #1 without a physician to write orders for his needed medications. She said that after the third hospice agency discontinued care, Resident #1 chose to return to the agency and doctors who worked with the residence. The administrator said that Resident #1 had been without many of his medications and orders for a while,which included when he was with the hospice agencies. She said it was difficult to get a physician's order and medications. She said that she was glad he decided to return to the residence agency and doctors so that he can get the medications and care he needed. Further, the administrator stated the resident was in pain constantly because he did not have his medications.d. ObservationOn 1/18/24 at 11:02 a.m., Resident #1 was slow to rise from his chair. The resident appeared to grimace and show expressions of pain when transferring and standing. 2. Chapter VII regulations governing assisted living residences, part 14.29, requires that all prescribed and PRN medications shall be listed and recorded on a medication administration record (MAR) which contains the name and date of birth of the resident, the resident's room location, any known allergies, and the name and telephone number of the resident's authorized practitioner.(C) 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. Residence PolicyThe undated medication record policy read in part, MAR were maintained for all medications poured and /or passed by qualified medication administration persons (QMAP). The undated medication refusal and /or missed doses policy read in part, missed/refused medications were documented in the resident's medication record and the prescribing physician notified immediately or according to physician parameters, which must be retained in writing and kept on file.b. Record reviewResident #5 was admitted to the residence on 6/28/22 with diagnosis including diabetes and illness unspecified. A written practitioner's order, dated 5/19/23, directed the residence to administer atorvastatin 40 mg one time daily. The December 2023 MAR read the medication was unavailable and was not administered on 12/19/23, for a total of one inaccurately documented medication administration. Residence #2 was admitted to the residence on 8/16/18 with diagnosis including migraines and muscle weakness. A written practitioner's order, dated 3/29/23, directed the residence to administer lidocaine 5% patch once daily. The December 2023 MAR read the medication was unavailable and not administered on 12/8/23, for a total of one inaccurately documented medication administration.c. InterviewsOn 1/18/24 at 12:36 p.m., Staff #10 stated the atorvastatin administration for Resident #5 was not accurately documented on 12/19/23. He said that it should have been documented as refused, not as unavailable. Staff #10 also stated the medication administration of the lidocaine patch for Resident #2 was not accurately documented on 12/8/23. He said that it should have been documented as refused, not as unavailable. On 1/18/24 at 3:30 p.m., the administrator said her expectation was that staff documented accurate information on the MAR and she expected refusals of medications would be documented accurately.

A licensure complaint revisit was completed on 1/18/24 . Deficiencies were cited.

Based on observation, interview and record review, the residence failed to make available, either directly or indirectly through a resident agreement, a safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting two of five sample residents (#3, #11). This deficiency was cited previously during a state licensure complaint 9/22/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.34, defines "Personal services" as those services that an assisted living residence and its staff provide for each resident including, but not limited to:(A) An environment that is sanitary and safe from physical harmb. The residence's Resident Agreement, dated May 2022, read in part, "The resident will be entitled to occupancy and exclusive use (unless shared) of the apartment shall be entitled to use, in common with other residents, the community facilities and common areas. Inside common areas and apartments will be maintained as smoke-free environments."2. Physically Safe Environmenta. ObservationsOn 1/17/24 at 8:15 a.m., Resident #28 and Resident #11's room smelled like cigarette smoke. There was a stronger cigarette smell coming from the bathroom they shared. On 1/18/24 at 8:44 a.m., Resident #3 and #29's bathroom smelled like cigarette smoke.b. Record ReviewDecember 2023 and January 2024 progress notes for Resident #3 revealed Resident #3 was observed by staff smoking in his room on 12/29/23, 1/2, 1/6 , 1/10 and 1/16/24. January 2024 progress notes for Resident #11 revealed she was observed by staff, smoking in her room on 1/10 and 1/17/24.c. InterviewsOn 1/17/24 at 8:05 a.m., Resident #29 stated his roommate (Resident #3) has smoked cigarettes in their room on at least five occasions within the past week. On 1/17/24 at 8:15 a.m., Resident #28 stated her roommate (Resident #11) had just smoked a cigarette in their room. On 1/17/24 at 8:23 a.m., Resident #26 stated Resident #3 smoked a cigarette in the common area of the residence the evening prior to the onsite visit on 1/17/24. On 1/18/24 at approximately 10:45 a.m., the administrator stated residents should not be smoking in their rooms. 3. Sanitary Environmenta. ObservationsOn 1/17/24 at approximately 8:00 a.m., Resident #3 was observed scratching his right lower leg to the point it was bleeding. The white armchair in his room had bronze like colored spots near where Resident #3 scratched his lower leg. On 1/18/24 at approximately 8:45 a.m., the white armchair on Resident #3's side of the room had two stains on the seat cushion and front side of the chair.b. InterviewsOn 1/18/24 at approximately 9:00 a.m.., Staff #8 stated the stains on Resident #3's armchair was urine and blood. She added the urine stain had been there for a while and the blood stain was newer. On 1/18/24 at 9:08 a.m., the resident care coordinator confirmed Resident #3's armchair was stained with blood and urine. He added he was unsure how long the stains had been there but would expect them to be cleaned. On 1/18/24 at approximately 10:45 a.m., the administrator said housekeeping was responsible for cleaning resident rooms. She added if either care staff or housekeeping noticed a stain on a resident chair she expected the stain to be cleaned and did not expect blood or urine stains to be on resident furniture. The administrator said the reason the citation remained deficient was because it was something the residence had to continue to focus and improve.

Based on interview and record review, the residence failed to complete a comprehensive assessment whenever the resident had a change from baseline status, affecting one of five sample residents (#3) who experienced a change from baseline status. Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 12.7, requires that the comprehensive assessment shall include all the following items:(B) Information regarding the resident ' s overall health and physical functioning ability;(G) Individual bathroom routines(K) Safety awareness.b. The residence's Resident Agreement, dated May 2022, read in part, "Change in Resident Condition: If a resident's condition changes so that the previously assessed level of assistance is no longer appropriate, the community will reassess the residents needs, determine which level of service is appropriate and promptly notify the resident and any legal representative of such reassessment."2. Resident #3 was admitted to the residence on 2/1/21. December 2023 and January 2024 progress notes for Resident #3 revealed the following:On 12/2/23 staff found feces on the bathroom floor in Resident #3's bathroom. On 12/16/23 Resident #3 had a bandage on his right forearm to cover the wound he had from a burn. Resident #3 had bowel and bladder incontinence episodes and refused assistance. On 12/18/23 Resident #3 had an incontinent accident and staff were unsuccessful in their attempts to get him changed. On 12/27/23 Resident #3 had increased confusion. December 2023 and January 2024 practitioner progress notes for Resident #3 revealed the following:On 12/27/23 Resident #3 was seen for a wound on his left upper arm. On 1/4/24 Resident #3 was seen for increased behaviors due to dementia diagnoses. Specifically, Resident #3 was stealing items from other residents' rooms, main common areas and was inappropriately defecating in the shower. A care plan in Resident #3's record was last updated on 8/9/23. The care plan read Resident #3 was independent with toileting. The care plan did not address Resident #3's incontinence or wound care required. There were no other care plans or assessments in Resident #3's record. 3. InterviewsOn 1/17/24 at 1;17 p.m., Staff #8 said Resident #3 sustained the wound on his arm when he fell asleep with his heating pad on. On 1/17/24 at 3:30 p.m., Staff #7 stated Resident #3 had bowel and urine incontinence. On 1/18/24 at 9:08 a.m., the resident care coordinator said Resident #3 was being seen by an external wound care provider for the wounds on his leg and arm. On 1/18/24 at 10:34 a.m., the administrator said she expected a change in baseline condition assessment to be completed if a resident sustained a wound or had changes with their continence. She added she was responsible for completing reassessments and acknowledged she should have reassessed Resident #3, as required.

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A licensure complaint revisit was completed on 1/18/24. The residence is in compliance with all regulations surveyed.

A certification complaint revisit was completed on 1/18/24. The residence is in compliance with all regulations surveyed.