BEATRICE HOVER ASSISTED LIVING RESIDENCE

A revisit survey was completed on 5/8/26 for all previous deficiencies cited on 3/19/26. The facility is in compliance with all deficiencies that were cited.

An administrative relicensure survey was completed on 3/19/26. Deficiencies were cited.

Based on record review and interview, the residence failed to have policies and procedures to ensure the continuation of care to all residents for 72 hours following any emergency, affecting 48 current residents. (Cross-reference U0920)Findings include:On 3/11/26 at 2:18 p.m., the emergency preparedness policy for continuation of care for 72 hours was requested. 3/19/26 at 2:38 p.m. the emergency preparedness policy for continuation of care was requested a final time; however, it was not provided. On 3/19/26 at approximately 3:00 p.m., the administrator stated that he was unaware that a 72-hour plan was required under the regulations. He stated that he was unaware of a 72-hour plan ever having been put in place at the residence.

Based on record review and interview, the residence failed to have emergency policies addressing all required elements, affecting 48 current residents. (Cross-reference U0914)Findings include:On 3/11/26 at 2:18 p.m., the residence's emergency preparedness policies and procedures were requested. However, the policies provided failed to include the following:(D) A pre-determined means of communicating with residents, families, staff and other providers; (E) A plan that ensures the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids; (F) Storage and preservation of medications;(G) Assignment of specific tasks and responsibilities to the staff members on each shift including use of a triage system to assess the needs of the most vulnerable residents first; (H) Protection and transfer of health information as needed to meet the care needs of residents. On 3/19/26 at approximately 3:41 p.m., the administrator agreed the residence's emergency preparedness plan failed to include the required elements.

A revisit survey was completed on 4/2/25 for all previous deficiencies cited on 9/25/24. The facility is in compliance with all deficiencies that were cited.

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 relicensure survey with complaints #CO31569, #CO37102, and #CO37645 were completed on 9/25/24. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure appropriate routine staffing levels considering the acuity and needs of the residents, the services outlined in the care plan, and services set forth in the resident agreement, affecting 49 current residents. (Cross-reference S1192, S1194)Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 8.4, requires that staff shall be sufficient in number to help residents needing or potentially needing assistance, considering individual needs such as the risk of accident, hazards, or other challenging events.b. Chapter VII regulations governing assisted living residences, part 12.9, requires the comprehensive assessment shall be updated for each resident at least annually and whenever the resident's condition changes from baseline status.c. Chapter VII regulations governing assisted living residences, part 12.10, requires each resident care plan shall detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs.d. The residence's Staffing policy, dated 7/18/24, read in part that the residence provided staff sufficient in number to meet the care needs of the residents and maintain a safe and clean environment. The residence based their staffing needs on the acuity of residents, the services outlined in the residents' care plans, and the services set forth in the resident agreement. The residence reviewed staffing needs monthly.f. The January 2024 Resident Admission Agreement read in part that the residence reassessed the resident when the resident experienced a change in condition and updated the resident's care plan to reflect those changes. Further, it read that the residence provided activities of daily living to meet the residents needs, and lift assistance when a resident was not injured. 2. Record Reviewa. Staffing RecordsOn 9/24/24, documentation demonstrating the process the residence followed to establish routine staffing of the residence was requested; however, the residence provided no documentation aside from the residence policy. The residence's staff schedule, dated 9/1/24-9/24/24, revealed two staff worked at the residence from 11:00 p.m. until 7:00 a.m.b. Resident #2 was admitted to the residence on 4/13/22 with diagnoses including osteoarthritis and hemiplegia of the right side. Progress notes and incident reports read in part:On 8/16/24: "(Resident #2) pulled call light in the restroom. (Staff #4) went and found the resident on the floor by the toilet. The resident stated she was trying to transfer from her toilet to her wheelchair but missed and fell. Assisted per lift protocol with nurse, QMAP, and caregiver."On 8/12/24: "(Staff #6) was helping (Resident #2) get ready when she got up, (Staff #6) stepped away to grab (incontinence products) when (staff) came back (the resident) fell over her nightstand. (Staff #6) called for assistance, and (other unidentified staff members) came to help (Staff #6) get (Resident #2) up."On 7/21/24: "Got a call from (Resident #2). When (Staff #6) walked in, she was on the floor by her bed. (Staff #6) called (Staff #2 and #1) to help (Staff #6) lift (Resident #2) up."A comprehensive assessment, dated 8/19/24, read in part that Resident #2 was a fall risk due to the administration of four or more medications. Resident #2 required hands-on assistance with bed, chair, and toilet transfers. The assessment did not include the resident's needs regarding lift assistance, staff tasks to meet those needs, nor the number of staff members required to perform lift assistance. Further, the assessment read that the resident required assistance with incontinence care; however, the care plan did not include the frequency of the care. A care plan, dated 5/16/24, read in part that the resident required occasional assistance to get in and out of bed and wheelchair. Additionally, the resident was a fall risk due to hemiplegia. The care plan did not include the resident's needs regarding lift assistance, staff tasks to meet those needs, or the number of staff members required to perform lift assistance. Further, the care plan read that the resident required assistance with incontinence care; however, the care plan did not include the frequency of the care. 4. InterviewsOn 9/24/24 and 9/25/24 from approximately 7:00 a.m. until 4:00 p.m., Confidential Staff #8-#18 stated that there were approximately four instances when it took four staff members to provide lift assistance to Resident #2 when the resident fell and was not injured. Further, each staff member affirmed that Resident #1 required more than two staff members to lift her safely. Additionally, Confidential Staff #8-#18 stated that the staffing ratio did not allow for the staff to assist with incontinence care more than once per shift. On 9/25/24 at approximately 7:30 a.m., Resident #2 stated that she required four staff members to lift her after she fell to the floor. She affirmed that she required assistance from four staff members in approximately four instances. On 9/25/24 at 11:30 a.m., the administrator stated that the residence based staffing on the residents' acuity. She added that residence used assessments and levels of care from the care plan to establish residents' acuity. The administrator stated that she was not aware that Resident #2 required four staff members to provide lift assistance on approximately four occasions. She affirmed that the care plan did not reflect that need. The administrator stated that the residence had two staff members who worked from 11:00 p.m. until 7:00 a.m. daily and that if Resident #2 fell and was uninjured, the residence did not have enough staff to provide lift assistance from four staff members. She stated that the residence did not ensure the care plans captured the needs of the residents, including the frequency of incontinence care and the number of staff required for lift assistance. The administrator affirmed that the care plans did not accurately establish the acuity of the residents. 5. Additionally, the residence failed to ensure appropriate routine staffing levels considering the acuity and needs of Residents #1, #3, and #4. The staffing of the residence subsequently impacted all current residents.

Based on record review and interview, the residence failed to ensure staff were available to evaluate residents who had fallen to determine if the resident could be assisted in a safe manner, such as when the resident had no pain, or there was no change from baseline, affecting two of four sample residents with recurrent falls (#1 and #2). (Cross-reference S0720)Specifically, the residence staff lifted Resident #1 on 8/30/24 after she fell from her bed despite the resident experiencing pain. The resident continued to vocalize pain. Findings include: 1. Residence Policy The residence Lift Assistance policy, dated 12/1/20, read in part that the residence required staff to lift a resident if the resident had no pain and the residence staff was able to lift the resident safely. 2. Resident #1 was admitted to the residence on 2/9/16 with diagnoses including history of falls and muscle weakness. An incident report, dated 8/30/24, read: "(Staff #4) went to check up on (Resident #2) and found her face-planted on the floor at her bedside. The resident complained about knee pain; right eye was very pushed in (Resident #1) could hardly keep it open. (Staff #4) called (Staff #5) for assistance and assisted per lift protocol to get (Resident #1) on her bed."An external hospice provider (EHP) note, dated 8/30/24, read in part that the residence found Resident #1 on her stomach by her bed. She had redness on the right side of her face. 3. InterviewsOn 9/25/24 at 7:09 a.m., Staff #4 stated that Resident #1 fell from her bed approximately three weeks prior to the onsite visit. She added that Resident #1 fell on her face from her bed and was in pain when she and Staff #5 lifted her. Staff #4 stated that she and Staff #5 lifted the resident as the resident's EHP was unavailable to assist with lift assistance when contacted, and the resident would have had to wait on the floor for an hour for the EHP to arrive. She added that she and the other staff member chose to lift the resident as she appeared to be uncomfortable, and the resident cried out during the lift assist and continued to vocalize pain. Staff #4 added she was unaware that the residence's policy was to avoid lifting a resident when the resident experienced pain. She added the lift assistance was challenging for just two staff members. On 9/25/24 at 2:08 p.m., the administrator said that the staff should not have moved Resident #1 when the resident fell and expressed that she was in pain. She added that staff members were likely confused about whether they could contact emergency medical technicians, as the resident had an EHP.4. Additionally, the residence failed to ensure staff were available to evaluate residents who had fallen to determine if the resident could be assisted safely for Resident #2.

Based on record review and interview, the residence failed to document and implement effective actions that were to be taken by staff to prevent reoccurrence of falls for three of four sample residents (#1, #3, #4) with repeated falls. (Cross-reference S0720)Findings include:The residence's Lift Assistance policy, dated 12/1/20, read in part that after a resident fell, the residence staff documented the action taken by staff and ongoing efforts to prevent a reoccurrence of the situation in the future. Resident #3 was admitted to the residence on 9/14/22 with a diagnosis of cerebral palsy. A progress note, dated 9/15/24, read in part: "Resident stated she had a fall while getting (incontinence product) for her bed. She was sitting on her bed when (Staff #7) answered her call light. She had a cut to her chin and a skin tear on her left toe area." An incident report, dated 9/15/24, read in part: "Encourage resident to call staff for assistance." Fall risk assessments, dated 7/4/24 and 7/25/24, read the same approaches were to be taken by staff to address the resident's falls, including: "Remind to call for assistance."A care plan, dated 9/22/22, and revised on 7/31/24, read in part: "Will be encouraged to call for assistance when needed."On 9/25/24 at 2:15 p.m., the administrator stated the residence should have implemented effective actions that were to be taken by staff to prevent the reoccurrence of falls for Resident #3 instead of the same approach of encouraging her to call for assistance after she fell on 9/15/24. She affirmed that the residence should have implemented an action related to the precursor to the fall, such as increased staff assistance with putting an incontinence product on the resident's bed. Additionally, the residence failed to document and implement effective actions that were to be taken by staff to prevent the reoccurrence of falls for Resident #1 and #4.

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 7.12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents: A physically 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; 14.10 Unless otherwise allowed by statute, the assisted living residence shall not permit a qualified medication administration person to perform any of the following tasks: (A) Intravenous, intramuscular, or subcutaneous injections; (B) Gastrostomy or jejunostomy tube feeding; (C) Chemical debridement; (D) Administration of medication for purposes of restraint; (E) Titration of oxygen; (F) Decision making regarding PRN or "as needed" medication administration; (G) Assessment of residents or use of judgment including, but not limited to, medication effect; (H) Pre-pouring of medication; or (I) Masking or deceiving administration of medication including, but not limited to, concealing in food or liquid. 14.29 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. (A) The medication administration record shall reflect the name, strength, dosage, and mode of administration of each medication, the date the order was received, the date and time of administration, any special considerations related to administration, and the signature or initial of the person administering the medication.

A licensure complaint, prompted by complaint #CO29548, was completed on 1/10/23. No deficiencies were cited.