GARDENS CARE HOMESTEAD

A relicensure survey and complaint revisit was completed on 6/24/26 for the previous deficiencies cited on 1/13/26. A deficiency was cited.

Based on observations, records review, and interviews, the residence failed to provide a physically safe and sanitary environment and personal services either directly or indirectly, through a resident agreement, affecting 38 current residents. This deficiency was cited previously during a state licensure survey 1/13/26. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1 Observation and interviewDuring an environmental tour of the residence on 6/23/26 at approximately 9:00 a.m., Resident 8's room had a large amount of cat hair in the right corner of the room near the bed and oxygen concentrator. In the bathroom of Resident #8's room, there was discoloration at the base of the toilet and front of the sink. Resident #8's refrigerator had approximately 13 plastic and paper cups with various colors of liquids at various amounts and empty paper medication cups. Resident #8's freezer had approximately 8 black plastic containers and five opened, unfinished single-serve ice cream containers. The freezer also had food crumbs throughout it and spots, dark brown in color, stuck to the bottom shelf of the freezer. Staff #5 said Staff #6 had deep cleaned Resident #8's room on 6/21/26. Staff #5 observed the far right corner, near the resident's oxygen concentrator, and said the accumulation of cat hair was more than what would be present if the room had been swept in the last few days. Staff #5 said the discoloration in front of the toilet and sink was permanent stains on the linoleum floors and had gone away with the cleaning products she had used on them. Staff #5 demonstrated this with a mop in the bathroom, and the discoloration remained. Staff #5 said cleaning resident rooms, which included refrigerators, was primarily the responsibility of housekeeping staff (Staff #5 and Staff #6). Staff #6 confirmed she had cleaned Resident #8's room on 6/21/26 and was asked by Staff #5 to go back in and double-check cleanliness. During an environmental tour on 6/24/26 at approximately 9:30 a.m., Resident #8's refrigerator had approximately 13 plastic and paper cups with various colors of liquids at various amounts and empty paper medication cups. Resident #8's freezer had approximately 8 black plastic containers and five opened, unfinished single-serve ice cream containers. The freezer also had food crumbs throughout it and spots, dark brown in color, stuck to the bottom shelf of the freezer. 2. Record reviewThe housekeeping cleaning schedule, received on 6/23/26 at 8:42 a.m., read in part: "Expectations of cleaning included dusting, sweeping, mopping, organizing (throwing away anything that is clearly trash), and wiping down the inside of the refrigerator. Additionally, the housekeeping schedule revealed Resident #8's room was to be cleaned on Wednesday's, however, Staff #6 stated she cleaned the room on Sunday 6/21/26. 3. InterviewsOn 6/23/26 at approximately 9:30 a.m., Staff #5 said she was recently hired as a lead housekeeper and utilized "text messaging" with her coworkers regarding resident refusals or cleaning preferences. Staff #5 said she had not been informed Resident #8 refused or declined any housekeeping services on 6/21/26. Staff #6 said it was not uncommon for Resident #8 to ask that cups or containers be left in the refrigerator, but allow staff to clean surfaces and sweep. On 6/24/26 at 10:00 a.m., Staff #6 said she was aware that the expectation of cleaning duties included sweeping, mopping, organizing, to include throwing away obvious trash and wiping down the inside of the refrigerator. Staff #6 said she had not cleaned the freezer on 6/21/26 and went back on the morning of 6/23/26 to vacuum the cat hair s

A licensure complaint, prompted by #CO42134, was completed on 6/24/26. Deficiencies were cited.

Based on observations, records review, and interviews, the residence failed to provide a physically safe and sanitary environment and personal services either directly or indirectly, through a resident agreement, affecting 38 current residents. Findings include:1. Observation and interviewDuring an environmental tour of the residence on 6/23/26 at approximately 9:00 a.m., Resident 8's room had a large amount of cat hair in the right corner of the room near the bed and oxygen concentrator. In the bathroom of Resident #8's room, there was discoloration at the base of the toilet and front of the sink. Resident #8's refrigerator had approximately 13 plastic and paper cups with various colors of liquids at various amounts and empty paper medication cups. Resident #8's freezer had approximately 8 black plastic containers and five opened, unfinished single-serve ice cream containers. The freezer also had food crumbs throughout it and spots, dark brown in color, stuck to the bottom shelf of the freezer. Staff #5 said Staff #6 had deep cleaned Resident #8's room on 6/21/26. Staff #5 observed the far right corner, near the resident's oxygen concentrator, and said the accumulation of cat hair was more than what would be present if the room had been swept in the last few days. Staff #5 said the discoloration in front of the toilet and sink was permanent stains on the linoleum floors and had gone away with the cleaning products she had used on them. Staff #5 demonstrated this with a mop in the bathroom, and the discoloration remained. Staff #5 said cleaning resident rooms, which included refrigerators, was primarily the responsibility of housekeeping staff (Staff #5 and Staff #6). Staff #6 confirmed she had cleaned Resident #8's room on 6/21/26 and was asked by Staff #5 to go back in and double-check cleanliness. During an environmental tour on 6/24/26 at approximately 9:30 a.m., Resident #8's refrigerator had approximately 13 plastic and paper cups with various colors of liquids at various amounts and empty paper medication cups. Resident #8's freezer had approximately 8 black plastic containers and five opened, unfinished single-serve ice cream containers. The freezer also had food crumbs throughout it and spots, dark brown in color, stuck to the bottom shelf of the freezer. 2. Record reviewThe housekeeping cleaning schedule, received on 6/23/26 at 8:42 a.m., read in part: "Expectations of cleaning included dusting, sweeping, mopping, organizing (throwing away anything that is clearly trash), and wiping down the inside of the refrigerator. Additionally, the housekeeping schedule revealed Resident #8's room was to be cleaned on Wednesday's, however, Staff #6 stated she cleaned the room on Sunday 6/21/26. 3. InterviewsOn 6/23/26 at approximately 9:30 a.m., Staff #5 said she was recently hired as a lead housekeeper and utilized "text messaging" with her coworkers regarding resident refusals or cleaning preferences. Staff #5 said she had not been informed Resident #8 refused or declined any housekeeping services on 6/21/26. Staff #6 said it was not uncommon for Resident #8 to ask that cups or containers be left in the refrigerator, but allow staff to clean surfaces and sweep. On 6/24/26 at 10:00 a.m., Staff #6 said she was aware that the expectation of cleaning duties included sweeping, mopping, organizing, to include throwing away obvious trash and wiping down the inside of the refrigerator. Staff #6 said she had not cleaned the freezer on 6/21/26 and went back on the morning of 6/23/26 to vacuum the cat hair she missed on 6/21/26 after Staff #5 had asked her to. On 6/24/26 at 1:00 p.m., the administrator designee (AD) said she expected the cleaning duties listed on the housekeeping cleaning schedule to be completed. The AD said she was aware Resident #8 was particular about items being removed from her refrigerator; however, sweeping of floors and wiping down of surfaces needed to be done. The AD said Staff #5 and Staff #6 were recently hired because the previous housekeeping staff were not meeting expectations and the residence.

Based on observation, record review, and interviews, the residence failed to ensure each resident's care plan reflected the most current assessment information, promoted resident choice, and detailed specific personal service needs and preferences along with the staff tasks necessary to meet those needs affecting three of the six sampled residents (#1, #8, and #9). Findings include:1. ObservationOn 6/24/26 at 10:20 a.m., Resident #9 was leaving his room and was wearing his oxygen and carrying his portable concentrator with him. 2. Record reviewResident #9 was admitted to the residence on 8/15/24 with a diagnosis of schizoaffective disorder, nicotine dependence, and type II diabetes. Progress notes dated 2/1/26 to 6/23/26 documented Resident #9 going outside to smoke. The comprehensive assessment dated 5/15/26 for Resident #9 failed to mention anything regarding smoking and the use of oxygen. The care plan for Resident #9, last updated on 5/20/26, failed to include mention of smoking and the use of oxygen. 3. Similar deficient practice was found for Residents #1 and #8.4. InterviewsOn 6/23/26 at 10:00 a.m., Staff #8 said Resident #9 was on oxygen and was a smoker. Staff #8 said Resident #9 would leave his oxygen tank at the front desk before going outside to smoke. On 6/23/26 at 10:05 a.m., Staff #9 said Resident #9 was a smoker and was also on oxygen. Staff #9 said she would remind Resident #9 to leave his oxygen tank at the front desk before going outside to smoke. On 6/23/26 at 3:05 p.m., the administrator designee (AD) said smoking and oxygen were not listed as a task for residents. The AD acknowledged that smoking and oxygen should be added to the care plans. The AD said she did not know why smoking and oxygen were not on the care plans for residents who smoked and used oxygen.

A relicensure survey with complaint #CO39720 was completed on 1/13/26. Deficiencies were cited.

Based on records review and interviews, the residence failed to develop written policies and procedures to ensure the continuation of necessary care for all residents for at least 72 hours immediately following any emergency, affecting 32 current residents. (Cross-reference U0920)Findings Include:A review of the residence's "Emergency Preparedness Plan" that was undated revealed a section titled "72 Hour Continuation of Services" that read, "to provide continuation of care services to all residents in the event of an emergency in our assisted living location, for at least 72 hours, residents will be transported via the company vehicle to the nearest [sister community] site along with all medications and necessary medical equipment. Site consideration will be aligned with the level of care required."On 1/13/26 at 4:55 p.m., the administrator-designee explained that the residence had a stockpile of dry food, emergency water, oxygen tanks, and access to an emergency generator. She stated that she was unaware that the residence's policy did not include these parts of the plans. She agreed that the emergency plan should include all possible options available.

Based on records review and interviews, the residence failed to have emergency policies that addressed all minimum requirements, affecting 32 current residents. (Cross-reference U0914)Findings Include:On 1/13/26 at 7:30 a.m., the residence ' s Emergency Preparedness policy and procedures were requested and received. The following items were not included in the policy as required:(D) A pre-determined means of communicating with residents, families, staff, and other providers;(F) Storage and preservation of medications;(G) Assignment of specific tasks and responsibilities to the staff members on each shift, including the 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; andOn 1/13/26 at 4:55 p.m., the administrator-designee stated she expected there to be a plan for pre-determined means of communications with the residents, family members, staff, and other providers, the storage and preservation of medications, specific staff assignments during an emergency, as well as the protection and transfer of health information if the electronic medical record could not be used. The administrator-designee agreed on the importance of the specific missing elements.

Based on records review and interviews, the residence failed to ensure the resident agreement was signed and dated by both parties, affecting one (#3) of seven sample residents. (Cross-reference U1034)Findings Include:Resident #3 was admitted to the residence on 6/1/22. A resident agreement for Resident #3 dated 7/7/23, with a commencement date of 7/15/23, was only signed by the representative of the residence, the administrator, on 7/12/23. No evidence that Resident #3 or her legal representative had signed the resident agreement was provided. On 1/13/26 at 4:55 p.m., the administrator-designee stated that she was unaware that Resident #3 had not signed the resident agreement. She stated that she was aware that a representative from both parties was required to sign the resident agreement and agreed that this was a deficient practice.

Based on records review and interviews, the residence failed to review its resident agreements annually and amend, affecting five of seven sample residents (#2, #3, #4, #5, #1). (Cross-reference U1030)Findings Include:Resident #4 was admitted to the residence on 11/3/18. The resident agreement for Resident #4, dated 11/1/18, with a commencement date of 11/3/18, was signed by the resident's legal representative and the residence's representative. The agreement indicated that the resident would be charged a specific monthly fee. A review of the billing statements for Resident #4 from October 2025 to January 2026 revealed that Resident #4 was being charged and paid a higher fee than on the agreement. On 1/13/26 at 9:00 a.m., Resident #2 stated that the residence's billing practices were not clear and easy to understand. She explained that basic maintenance requests, such as hanging paintings or moving furniture, were being charged as an additional rate to the standard room and board rate. On 1/13/26 at 4:55 p.m., the administrator-designee stated that she was aware that the resident agreements were required to be reviewed annually, updated, and signed by both parties if any changes were to be made. She stated that she did not have a role in the billing process and was unaware that the monthly billing charges did not match the indicated monthly charges in each of the residents' agreements. She agreed that the monthly billing charges should match the indicated amount in each of the agreements. Similar deficient practice was found for Residents #1, #2, #3, and #5.

Based on observations, records review, and interviews, the residence failed to provide a physically safe and sanitary environment and personal services either directly or indirectly, through a resident agreement, affecting 32 current residents. (Cross-reference U1146, U1382, U1596, U2510, U2610, U2702, U2722)Findings Include:1. Physically safe and sanitary environmenta. ObservationsDuring an environmental tour of the residence on 1/13/26 from 7:30 a.m. to 5:40 p.m., An environmental tour of the residence on 1/13/26, beginning at 7:30 a.m., revealed that multiple areas of the residence were not maintained in a clean and unobstructed manner, the hallways leading to an exit, and the activities room contained flattened cardboard boxes stacked along the wall, a large trash receptacle, and an electric scooter stored within the walking path. In a narrow hallway leading to the kitchen, multiple rolling carts stacked with empty dish racks and trays were positioned along the wall. The stairwell carpeting and landing areas contained visible dark staining, debris, soiling, and a foul odor. Multiple stair treads and the landing area appeared discolored and not maintained in a sanitary condition. The rugs in the common area looked unvacuumed, and the wood flooring had visible liquid stains in certain areas. Multiple resident accessible interior and exterior areas were cluttered, disorganized, and not consistently maintained, including hallways, stairwells, common areas, resident rooms, laundry and utility spaces, and the exterior grounds of the residence. There were restricted pathways, reduced accessibility, and limited functional use of spaces. Medical equipment and assistive devices were observed throughout the residence, including oxygen cylinders and mobility equipment. There was excessive clutter, poor organization, and inconsistent use of storage. Observations of Resident #7 ' s room at 7:35 a.m. revealed that it had not been cleaned for over a couple of weeks; the bathroom floor had debris, wrappers, and toilet paper. The sink had toothpaste residue on it, and the bedroom was not maintained in a clean, orderly, or safe navigable condition. The room contained boxes, bags of clothes, loose trash on the floor, and surrounding furniture, including two half-eaten meals. Observations of a sitting area at 7:49 a.m. revealed an electrical socket in the floor in front of a couch. The electrical socket did not have a cover, and the live wires were accessible. Observations of the walking path along the side of the residence, beginning at 9:45 a.m., revealed a large patch of black ice that had formed from the downspout of the gutter leading directly to the walking path. This was a high-traffic walking path as it was one of the primary routes to the designated smoking area.b. Record reviewThe residence's "Cleaning Practices/Housekeeping Practices" policy, dated July 2019, read in part: "All resident rooms and common areas are kept clean and free of trip hazards. All floors are kept clean and dry. Smooth floors are dusted and wet mopped at least weekly and as needed. Floors are stripped, waxed, and buffed as needed. (Only non-slip polish is used on floors.) Carpets are vacuumed at least weekly, as needed, and are deep cleaned at regular intervals. ... The kitchen and dietary store rooms are cleaned at regular intervals. Resident beds are regularly observed during linen changes and bed making for any infection control concerns. Deep cleaning of resident rooms is done at least annually, as needed, or when a resident is discharged from the community. Walls, ceiling, light fixtures, and vents are cleaned at regular intervals. Trash is removed from all areas of the building as needed. Drapes, windows, and privacy curtains are cleaned as indicated. The laundry room is cleaned at regular intervals. ... A regular check is made of the building to check for sanitation, safety, and infection control hazards. ... Work surfaces will be cleaned and decontaminated with an appropriate disinfectant after completion of procedures and/or as soon as possible when surfaces are overtly contaminated with blood or other potentially infectious materials. All surfaces contaminated with blood or body fluids are cleaned with an approved blood spill clean-up kit."c. InterviewsOn 1/13/26 at 9:00 a.m., Resident #2 stated that the residence was not well-maintained by housekeeping or maintenance staff. She stated, "I was surprised there was nothing in the open space by the engagement". She explained that the only reason the staff had cleaned up was because of the state surveyors' presence. On 1/13/26 at 3:30 p.m., Resident #6 stated that she had "put up with" the cleanliness or lack thereof for four years. On 1/13/26 at 4:55 p.m., the administrator-designee stated she expected caregivers to complete the day-to-day tidying or cleaning of the common areas and the resident rooms. Housekeeping was responsible for weekly deep cleanings of the rooms and common areas. The administrator-designee stated the stairwell carpet, resident room, and common area floors were not considered sanitary. 2. Personal servicesa. ObservationsObservations of the residence's laundry room at 9:48 a.m. revealed a large pile of laundry on the work table that had not been dispersed or stored appropriately.b. Record reviewThe residence ' s resident care services policy dated 7/2019 read in part, the community makes available either directly, or indirectly, personal services including, but not limited to, a system for identifying and reporting resident concerns that require either an immediate individualized approach or ongoing monitoring and possible re-assessment. Resident #5 was admitted to the residence on 9/12/21 with diagnoses of schizophrenia and anxiety disorder. A care plan dated 6/12/25 read in part, provide supervision and monitoring to help manage/redirect abusive or destructivebehavior. Resident #5 ' s December 2026 Task Administration Record (TAR) read in part, on 12/23 and 12/24/25, staff did not monitor destructive behaviors. c. InterviewsOn 1/13/26 at 9:00 a.m., Resident #2 stated that the staff are unable to effectively manage the laundry to ensure that residents get their clothes returned and clean. She explained that she requested to do her own laundry because an expensive shirt of hers had gone missing when the staff were managing her laundry. Resident #2 stated that staffing was short on weekends. She explained that support staff, such as housekeepers, are inconsistently available to clean the residence. On 1/13/26 at 3:30 p.m., Resident #6 stated that she does not receive the care services she expects on weekends due to staffing shortages. She explained that she was supposed to have a cream applied to her legs between 7:00 a.m. and 8:00 p.m., and between 7:00 p.m. and 8:00 p.m. She stated that the cream had not consistently been applied on Saturdays and Sundays unless specific staff are scheduled. On 1/13/26 at 3:35 p.m., Staff #3 stated that her shift, second shift (2:00 p.m to 10:00 p.m.), had struggled to ensure that trash was taken out and laundry was completed because of staffing shortages. She also indicated that she had heard the same from the first shift staff. On 1/13/26 at 4:40 p.m., the administrator-designee stated staff required reeducation on all resident care plans to ensure required tasks were completed. The administrator-designee acknowledged tasks had been completed as expected. Similar deficient practice was documented for Residents #2, #3, #4, #5, #6, and #7. 3. Protective oversighta. ReferenceChapter 2 regulations governing assisted living residences, part 4.2.2(D), requires Any occurrence involving physical, sexual, or verbal abuse of a client, as described in sections 18-3-202, 18-3-203, 18-3-204, 18-3-206, 18-3-402, 18-3-403, as it existed before July 1, 2000, 18-3-404, or 18-3-405, C.R.S., by another client, an employee of the licensee or a visitor to the facility or agency to be reported to the Department within one business day after the occurrence or when the licensee becomes aware of the occurrence, in the format required by the Department.b. Record reviewThe residence ' s "Abuse/Neglect - Resident Abuse Resident Neglect" policy, dated 7/2019, read in part: Verbal abuse is defined as a threat or verbal assault upon a person. Verbal abuse includes cursing, insulting, threatening, and other forms of harmful (inappropriate) verbal exchanges that serve no legitimate purpose. An investigation will be carried out and will be documented according to regulations. The Administrator will notify the following individuals as soon as possible, within 24 hours of the occurrence. The Occurrence Reporting Line. Resident #5 was admitted to the residence on 9/12/21 with diagnoses of Schizophrenia and Anxiety disorder. A progress note, dated 10/31/25, read in part, Resident #1 had gone to the bank. On the way to the bank, he expressed to the driver that he wanted to purchase a firearm and kill his sister or power of attorney (POA). After returning to the residence, Resident #5 remained highly agitated, paced the hallways, slammed doors, removed hallway decorations, yelled at residents, and made repeated threats to kill his POA. Resident #5 aggressively confronted the Executive Director (ED) and threatened to punch the ED. Several residents expressed fear and remained in their rooms. A care plan, dated 10/31/25, read in part, Behavioral patterns; Resident #5 was very upset when he went to the bank and returned because he was not able to access his funds. He became agitated with everyone in the building. He was screaming at the executive director and threatened to punch the activities director in the face. He was kicking the walls and slamming his door. Causing picture frames to fall off the walls. He was going through the hallways yelling at other residents. Residents were very scared and upset.c. InterviewsOn 1/13/26 at approximately 3:30 p.m., Resident #6 stated she did not want to talk about Resident #5 now that he was not in the residence; she stated she had nothing positive to say about Resident #5. On 1/13/26 at 4:55 p.m., the administrator-designee stated Resident #5 had gone through a change in medication, which progressed his negative behavior and caused him to become more aggressive. The administrator-designee stated he threatened to purchase a firearm and often would pace in the hallways, yelling at staff and residents. She further stated that residents were afraid of Resident #5 and would stay in their rooms during his behavioral episodes. She agreed his actions were aligned with the definition of verbal abuse, and an investigation, as well as an occurrence report, should have been completed; however, she had not deemed his behavior as a reportable offense at the time.

Based on records review and interviews, the residence failed to update the comprehensive assessment for each resident annually, affecting two of four sample residents whose assessments were reviewed (#1, #3). (Cross-reference U1110)Findings Include:The residence ' s resident record forms policy, dated 7/2019 read in part that a comprehensive pre-admissions assessment would be completed on all residents who are admitted to this assisted living residence. The assessment shall be reviewed and updated at least yearly or more frequently, if necessary, to note significant changes from baseline in the resident ' s physical, mental, or social condition or needs. Resident #1 was admitted to the residence on 7/12/24 with diagnoses of depression, anxiety, prediabetes, respiratory disease, and cardiovascular disease. On 1/13/26 at approximately 8:30 a.m., Resident #1 ' s record was requested and received. Included in the record was a comprehensive assessment dated 7/17/24; no other assessment had been completed. Resident #3 was admitted to the residence on 6/1/22 with diagnoses of paranoid schizophrenia, depression, and anxiety. On 1/13/26 at approximately 8:30 a.m., Resident #3 ' s record was requested and received. Included in the record was the most recent comprehensive assessment dated 6/2/24; no other assessment had been completed since. On 1/13/26 at 4:55 p.m., the administrator-designee stated she was responsible for ensuring comprehensive assessments were updated and completed at least annually or after a change in the resident's baseline condition. She acknowledged that sample Residents #1 and #3 did not have updated comprehensive assessments and agreed there may be more residents whose assessments need updating.

Based on observations, records review, and interviews, the residence failed to list all possible actions to be taken by the residence if any house rules are knowingly violated by a resident, affecting 32 current residents. (Cross-reference U2510, U2702, U2722)Findings Include:A review of the posted house rules revealed no evidence of any possible actions that may be taken by the residence if any of the rules were knowingly violated by a resident. The residence's "House Rules/Resident Rules" policy dated July 2019 read in part: "The house rules list all possible actions which may be taken by the assisted living residence if any rule is knowingly violated by a resident."On 1/13/26 at 4:55 p.m., the administrator-designee stated that the house rules do not list all possible actions that may be taken by the residence if any rules were knowingly violated by a resident. She agreed that the policy on house rules did not include the possible actions either. She agreed that listing all possible actions to be taken would help support the staff in the enforcement of the rules.

Based on observations and interviews, the residence failed to ensure that qualified medication administration persons (QMAPs) apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications, affecting 32 current residents. (Cross-reference U1110)Findings Include:On 1/13/26, Staff #1 was observed administering medications from 7:35 a.m. to 8:13 a.m. to Residents #2, #3, and #7. Staff #1 began by unlocking and opening the medication cart, touching multiple keys and the drawer handle. He then retrieved two of the medication bubble packs, placed them on the medication cart, closed the drawer, and dispensed the medication into the medication cup. Staff #1 used the computer mouse, the keyboard, then the medication cart drawer, placed the two bubble packs back in the drawer, then retrieved three more medications. He closed the drawer, dispensed the medications, and then placed them back in the drawer. Staff #1 then used the computer mouse and keyboard, opened the top drawer, and retrieved eye drops. He then retrieved a water cup, took the water pitcher, and dispensed the water. Staff #1 then took the medications and water cup to Resident #7 ' s room. Staff #1 unlocked the bedroom door by using his keys, then entered the room and administered the medication. Staff #1 did not sanitize his hands, nor did he wash his hands. Staff #1 used the computer mouse and keyboard to begin the administration of Resident #2 ' s medications. He unlocked and opened the medication cart and retrieved Resident #2 ' s medication bubble packs. Again, he grabbed two bubble packs, dispensed the medication, took a water cup and pitcher, then filled the cup with water. He then opened the drawer and retrieved the rest of Resident #2 ' s morning medications. Staff #1 took his keys and touched multiple keys before finding the correct one to lock the medication cabinet. Staff #1 took the medication and water cup to Resident #2 ' s room, administered the medication, then went back to the medication cart. Staff #1 did not sanitize or wash his hands after administering the medication. Staff #1 used the computer mouse and keyboard to begin dispensing and administering Resident #3 ' s medications. He unlocked the medication cart, retrieved all bubble packs for Resident #3 ' s medications, and began dispensing them into a medication cup. Staff #1 then took the water pitcher and filled a water cup. He took the medication and water to Resident #3 ' s room, unlocked the door with his keys, and then administered the medication. After administration, Staff #1 went back to the medication cart and used the mouse and keyboard to initiate another medication administration process. Staff #1 did not sanitize or wash his hands after Resident #3 ' s medications were administered. The personnel file for Staff #1 revealed a hire date of 11/24/25 as qualified medication administration personnel (QMAP). On 1/13/26 at approximately 8:13 a.m., Staff #1 stated he was trained, and his competencies were checked before beginning work as a QMAP/ He stated he was trained in infection control and prevention measures; however acknowledged that there was no hand sanitizer on the cart, nor did he wash his hands after a total of three medication administrations. On 1/13/16 at 4:55 p.m., the administrator-designee stated she expected staff to use nationally recognized protocols for infection prevention and control while administering multiple residents' medications. She stated staff are required to sanitize their hands before dispensing medications and not touch anything other than the bubble pack, and after administering the medications to the residents. The administrator-designee further stated that staff were required to wash their hands after a total of three residents ' medications were administered or after administering eyedrops and creams. She acknowledged that Staff #1 had not used accurate infection prevention and control protocols before, during, and after his administration of multiple residents' medications.

Based on observations and interviews, the residence failed to keep the grounds free of garbage and rubbish, affecting 32 current residents. (Cross-reference U1110, U2610)Findings Include:Observations on 1/13/26 starting at 7:30 a.m. and ending at approximately 5:45 p.m of the exterior environment, both the front and back of the residence revealed that multiple exterior grounds were not maintained in a clean, orderly manner, free of garbage, rubbish, and accumulated unused items. Loose garbage, discarded materials, and miscellaneous items are stored directly on the ground throughout the exterior areas of the residence, including near entryways, patio spaces, the sheds, and the dumpster. Items observed included buckets, coolers, gardening materials, tools, folded furniture, and other discarded and unused items. There was an accumulation of leaves, debris, and rubbish on exterior walkways, patio area, and designated smoking area. This includes cigarette buds on the ground, all around the residence, not only in the smoking area. The dumpster was overflowing, causing garbage to be on the ground in front of the dumpster and all around outside the enclosed dumpster area. On 1/13/26 at 4:55 p.m., the administrator-designee agreed and acknowledged that the exterior environment of the residence was not maintained appropriately and was cluttered with rubbish and refuse.

Based on observations and interviews, the residence failed to ensure all interior areas were free from accumulations of extraneous materials, affecting 32 current residents. (Cross-reference U1110, U2510)Findings Include:Observations of the interior areas, both private and common, starting at 7:30 a.m. and ending at approximately 5:45 p.m., revealed that interior areas had accumulated with extraneous materials, including common areas, storage closets, utility rooms, dietary storage room, shelves, cabinets, hallways, the laundry, and vacant spaces. The residence ' s "Cleaning Practices/Housekeeping Practices - Cleaning and Sanitation Practices" policy, dated July 2019 read in part: "All interior areas, including attics, basements, and garages shall be free from accumulations of extraneous material such as refuse, unused or discarded furniture, and potential combustible materials. All resident rooms and common areas are kept clean and free of trip hazards. ... The kitchen and dietary store rooms are cleaned at regular intervals. ... Trash is removed from all areas of the building as needed. ... The laundry room is cleaned at regular intervals. All utility rooms and storage areas are kept clean and free from accumulation of extraneous materials. A regular check is made of the building to check for sanitation, safety, and infection control hazards. ... All work areas are kept clean and free from accumulation of extraneous materials."On 1/13/26 at 9:00 a.m., Resident #2 stated that the residence was always cluttered, adding "there is so much trash and so many boxes". On 1/13/26 at 10:05 a.m., Resident #2 stated that the pool table always had things piled on it, and residents do not use it. On 1/13/26 at 4:55 p.m., the administrator-designee agreed the residence was cluttered with extraneous materials throughout.

Based on observations, records review, and interviews, the residence failed to prohibit smoking in areas where oxygen was used, affecting 32 current residents. (Cross-reference U1110, U1382, U2722)Specifically, the residence failed to prohibit Resident #1 from bringing her portable oxygen concentrator (POC) to the designated smoking area (DSA) with open flames. On 1/13/26 at 7:50 a.m.and 9:45 a.m. Resident #1 had her portable oxygen and was in the DSA with two individuals who were smoking and there were no staff present. The DSA was directly next to the building with windows that led to the common areas of the residence. Staff was unaware they needed to monitor the smoking area and stated that Resident #1 would refuse to leave her oxygen at the front desk. Staff was unaware of what interventions were in place to ensure oxygen would not be in the smoking area while residents were smoking. This failure created an immediate jeopardy risk of serious harm or death affecting all 32 current residents, staff, contractors, and visitors. On 1/13/26, the department directed the residence to provide written evidence that the risk had been removed. Findings Include:1. ObservationsAn environmental tour of the residence, on 1/13/26 starting at 7:30 a.m., revealed 15 oxygen tanks in various locations throughout the residence in vacant spaces, and the laundry room; a conspicuous "No Smoking" sign was not observed in those areas. There were multiple oxygen cylinders stored together in an interior corner of the residence, including full and portable tanks placed in carts and unsecured cardboard holders. Observations of the (DSA) on 1/13/26 at 7:50 a.m. and 9:45 a.m., Resident #1 was observed in the DSA with her (POC) while using her electronic cigarette, and two other smokers were present within five feet of the resident. The DSA, while more than 25 feet from the entrance of the residence, was directly next to the building and windows into the residence's common spaces. The DSA was not monitored by staff. 2. Records reviewThe residence's "Oxygen Use, Handling And Storage" policy dated July 2019 read in part: "The assisted living residence must prohibit smoking in areas where oxygen is ... used."The residence's "Smoking" policy, dated July 2019, read in part: "Designated outdoor smoking areas must be monitored whenever residents are present."A "Memorandum Of Understanding" (MOU) was signed between the administrator and the resident on 3/4/25 that indicated that Resident #1 had previously violated DSA rules. 3. InterviewsOn 1/13/26 at 9:50 a.m., Staff #2 stated that he had only been working for the residence for a week and had not been taught about monitoring the DSA.On 1/13/26 at 9:55 a.m., Staff #4 stated that most residents who smoke and use oxygen would go to the reception desk first and leave oxygen bottles and concentrators inside. She explained that Resident #1 often did not comply with that requirement. She explained that Resident #1 used an electronic smoking device, adding that when Resident #1 was outside with others smoking, she was to switch to a liquid oxygen tank to prevent fires. On 1/13/26 at 10:05 a.m., the administrator-designee stated that it was her responsibility to ensure staff were trained and monitoring the DSA when residents were present. She explained she had seen Resident #1 with her POC in the DSA back in October. The administrator-designee explained that she counseled Resident #1 on oxygen safety. She added that a memorandum of understanding (MOU) had not been completed at that time. The administrator-designee stated that she had not been " on top of it" and expected staff to ensure all oxygen tanks are left inside and not taken outside to the designated smoking area. She also acknowledged that liquid oxygen was just as flammable as any other oxygen and that Staff #4 would need to be retrained. On 1/13/26 at 4:55 p.m., the administrator-designee agreed that no official process was in place to monitor the DSA, including staff reporting any noncompliance to the administrator-designee. 4. Immediate Jeopardy Risk - Written Evidence, Immediate CorrectionThe investigation and inspection established that the findings above placed the 32 current residents at immediate jeopardy risk for serious injury or death. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations requires residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 1/13/26 at 12:38 p.m., the administrator-designee submitted written evidence that read in part, the residence shall prohibit smoking in areas where oxygen was stored and/or used, and a conspicuous "No Smoking" sign will be hung in those areas. Education will be provided to staff, including 24-hour training for all staff, and new staff will be trained. Re-education will be provided to all staff on 1/14/26 at the home health staff's monthly meeting, and all staff will sign off on receiving the training. However, the written evidence did not indicate that the risk had been removed because the documentation did not identify where the oxygen was stored and/or used throughout the residence, did not specify how staff would ensure residents with oxygen were not smoking or around someone that was smoking while using oxygen and did not clearly define staff roles and responsibilities for monitoring the smoking area and compliance. Furthermore, the submission did not describe how the residence would enforce their smoking policy, when/if corrective actions would be implemented, and what actions would be taken if residents do not comply with the smoking policy. The residence had not demonstrated effective enforcement mechanisms for residents who have broken the house rules. On 1/13/26 at 1:50 p.m., the administrator-designee submitted written evidence that read in part, "No Smoking" signs had been placed in areas where oxygen tanks are stored. Education had been provided to staff, including the 24-hour training for all staff and new staff members to be trained. Re-education will be provided to all staff on 1/13/26 in the home. Everyone will sign off on the education, and a letter of notification will be sent to all residents, educating them of the smoking policy and designated areas. Staff will begin hourly checks to ensure residents who are outside smoking do not have their oxygen with them. A task had been added to the evening building tasks, along with checking the cameras that monitor the outside premises of the building. A Memorandum of Understanding (MUO) will be put in place immediately for Resident #1, and the executive director will review the smoking policy with the resident. If the resident does not comply with the policy, further action could be taken to issue a 30-day notice. However, the written evidence did not indicate that the risk had been removed because the submission did not demonstrate that corrective actions were duly implemented or effectively operational. Specifically, the residence did not identify all locations where oxygen was stored, did not specify when required "No Smoking" signage was installed or verified placement throughout the residence and did not provide evidence that all staff on shift had completed the referenced education, date by which all staff would be reeducated and did not include clarification on who was responsible for ensuing training was completed across all shifts. Furthermore, the residence did not define staff accountability for monitoring the designated smoking area, which staff were responsible for, and how compliance would be monitored during all shifts, and how monitoring would be documented. On 1/13/26 at 2:53 p.m., the administrator-designee submitted written evidence that read in part, "No Smoking" signs have been installed in all non-designated smoking areas, including areas where oxygen was stored, the front entrance, and the back door. The designated smoking area was located on the northeast corner of the building. Education was provided to staff, including 24-hour training for all staff and new staff members. Re-education was completed for staff not scheduled to work earlier in the day, and all staff signed off on the education. Staff assignments were implemented for daily monitoring and completion of daily tasks with executive director oversight. Staff began conducting hourly checks of the smoking area to ensure no residents were smoking with or around any oxygen. The appropriate storage location for oxygen tanks was identified on the second floor storage area in room 216. An MOU was implemented with the resident involved, and the executive director reviewed the smoking policy with residents. Additionally, enforcement actions, including the issuance of a 30-day notice, were identified for continued non-compliance. IJ was removed at 2:53 p.m.

Based on observations and interviews, the residence failed to ensure the outdoor smoking area was monitored when residents were present, affecting 32 current residents. (Cross-reference U1110, U1382, U2702)Findings Include:Observations of the designated smoking area (DSA) on 1/13/26 at 7:50 a.m. and 9:45 a.m., Resident #1 was observed in the DSA with her portable oxygen concentrator (POC) while using her electronic cigarette, and two other smokers were present within five feet of the resident. Staff was not present. The DSA, while more than 25 feet from the entrance of the residence, was directly next to the building and windows into the residence's common spaces. The residence's "Smoking" policy, dated July 2019, read in part: "Designated outdoor smoking areas must be monitored whenever residents are present."On 1/13/26 at 9:50 a.m., Staff #2 stated that he had only been working for the residence for a week and had not been taught about monitoring the DSA.On 1/13/26 at 9:55 a.m., Staff #4 stated that most residents who smoke and use 02 would go to the reception desk first and leave oxygen bottles and concentrators inside. She explained that Resident #1 often did not comply with that requirement. She explained that Resident #1 used an electronic smoking device, adding that when Resident #1 was outside with others smoking, she was to switch to a liquid oxygen tank to prevent fires. On 1/13/26 at 10:05 a.m., the administrator-designee stated that it was her responsibility to ensure staff were trained and monitoring the DSA when residents were present. She explained she had seen Resident #1 with her POC in the DSA back in October. The administrator-designee explained that she counseled Resident #1 on oxygen safety. She added that a memorandum of understanding (MOU) had not been completed at that time. The administrator-designee stated that she had not been " on top of it". She also acknowledged that liquid oxygen was just as flammable as any other oxygen and that Staff #4 would need to be retrained. On 1/13/26 at 4:55 p.m., the administrator-designee agreed that no official process was in place to monitor the DSA, including staff reporting any noncompliance to the administrator-designee.

A licensure complaint, prompted by #CO38051, was completed on 10/24/24. No deficiencies were cited.

A licensure complaint, prompted by #CO36445, was completed on 7/1/24. No deficiencies were cited.

A revisit survey was completed on 3/22/24 for all previous deficiencies cited on 7/31/23. 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 revisit survey was completed on 3/22/24 for all previous deficiencies cited on 7/31/23. 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 licensure revisit was completed on 7/31/23 for all previous deficiencies cited on 4/6/23. Deficiencies were cited.

Based on record review and interview, the residence failed to comply with conditions imposed by the department on the license, affecting 39 current residents. Findings include:The department completed a licensure complaint on 4/6/23. The event resulted in seven cited deficiencies. Tag Q722 C was cited at harm level for failure to ensure there was sufficient staffing. Tag Q1180 C was cited at harm level for failure to implement a fall management program. Tag Q1312 C was cited at harm level for failure to ensure residents received the right to be treated with dignity and respect and the right to be free from verbal/emotional abuse, humiliation and intimidation. The due date for the residence to request informal dispute resolution (IDR) was 6/15/23. The department imposed a $1,000 fine payable 7/5/23. The residence did not appeal the immediate condition. As of the morning of the 7/27/23 onsite visit, review of the department database revealed the residence had not yet paid the required fine of $1000 due by 7/5/23. On 7/27/23 at 6:10 a.m., a department representative confirmed the residence had not paid the civil fine as of 7/27/23. On 7/27/23 at approximately 2:41 p.m., the administrator stated that she had just paid the fine the day of the onsite investigation. The administrator stated that the reason the fine was not paid by the deadline of 7/5/23 was because she was going to request IDR of the deficiencies cited in April 2023.

Based on observation, interview and record review, the residence failed to ensure that residents rights included the right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services made available by the assisted living residence, affecting seven of nine sample residents (#5-#9, #12 and #14). This deficiency was cited previously during a state licensure survey 4/6/23. 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 Resident Rights Policy, read in part that residents had the right to choice and personal involvement regarding care and services, including the right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services made available by the assisted living residence. 2. Staff ScheduleThe residence's staff schedule revealed that staff worked at the residence as follows:Day shift: 6:00 a.m.-2:00 p.m. Evening shift: 2:00 p.m.-10:00 p.m. Night shift: 10:00 p.m.-6:00 a.m. 3. Resident #12 was admitted to the residence on 10/7/22 with diagnoses including atherosclerotic heart disease and idiopathic peripheral neuropathy. Documentation of call pendant response times from 7/1-7/27/23 revealed the following staff response times to be 15 minutes or longer for Resident #12 as follows:7/1/23 at 1:13 a.m.: 20 minutes7/2/23 at 5:38 a.m.: two hours and 26 minutes7/5/23 at 3:06 p.m.: 47 minutes7/10/23 at 3:02 p.m.: two hours and 48 minutes7/10/23 at 9:44 p.m.: two hours7/11/23 at 5:19 a.m.: one hour and 48 minutes7/14/23 at 12:35 a.m.: 27 minutes7/15/23 at 6:00 a.m.: 35 minutes7/17/23 at 10:35 p.m.: eight hours and 49 minutes7/18/23 at 11:01 a.m.: five hours and 43 minutes7/20/23 at 11:11 a.m.: 18 minutes7/22/23 at 7:29 p.m.: three hours and 39 minutes7/24/23 at 7:00 a.m.: 52 minutes7/25/23 at 9:44 a.m.: 15 minutesThe residence's care plan for Resident #12, dated 4/11/23, read in part: Resident #12 used a walker and a scooter for ambulation and staff were to monitor and assist with ambulation as necessary. Resident #12 was independent with toileting, and required nighttime safety checks at 12:00 a.m. and every two hours as needed. The care plan further read that Resident #12 was a fall risk and the resident was to use her call light for assistance. On 7/27/23 at 9:30 a.m., Resident #12 stated there were issues with residence staff not answering her call light and stated it was the worst during the night shift. Resident #12 stated she had weakness in her lower legs and required staff to provide her with her scooter to use the restroom at night. Resident #12 stated she had documented on her computer her pendant wait times since it was a frequent occurrence on night shift where staff would not respond to her call light timely. The resident stated the most recent instance when she waited for over an hour for staff to respond to her call pendant to provide care was on 7/2/23. Resident #12 stated on 7/2/23, staff did not respond even though she pressed her call pendant five times for staff to get her scooter from across the room so she could go to the restroom. Resident #12 stated Staff #4 was on shift and answered her call at 5:30 a.m.; however, at that point Resident #12 stated she had already urinated herself waiting. On 7/27/23 at 2:10 p.m., Staff #4 stated she worked the night shift in early July 2023 when Resident #12 had soiled herself. Staff #4 stated the resident's call pendant did not notify her, so instead Resident #12 pounded on the wall for assistance. Staff #4 stated that was how Resident #12 got her attention. Staff #4 stated she had experienced issues with not receiving call pendant notification from the residents who resided on the first floor. 4. Resident #14 was admitted to the residence on 2/25/23 with diagnoses that included macular degeneration, atherosclerotic heart disease, peripheral venous insufficiency and chronic respiratory failure. Documentation of call pendant response times from 6/14/23-7/27/23 revealed the following staff response times to be 15 minutes or longer for Resident #14 as follows:6/14/23 at 6:40 a.m.: eight hours and 27 minutes6/15/23 at 8:27 p.m.: 15 minutes6/27/23 at 12:56 p.m.: three hours and 36 minutes7/1/23 at 8:14 a.m.: 15 minutes7/2/23 at 8:53 p.m.: 15 minutes7/8/23 at 8:12 a.m.: 40 minutes7/12/23 at 8:10 p.m.: three hours and five minutesThe residence's care plan for Resident #14, dated 6/16/23, read in part: Resident #14 was independent with ambulation and used a walker for extended distances. The resident was incontinent of bowel and bladder; however, was capable of caring for her own incontinence needs. The care plan further read that Resident #14 required nighttime safety checks after 12:00 a.m. and every two hours as needed, and was encouraged to call for assistance due to frequent falls. An incident report, dated 6/14/23, read in part: paramedics arrived to Resident #14's room and alerted staff, and Resident #14 was observed on the floor with blood running down her legs. Paramedics stated the resident had sustained a skin tear on her back and when the resident fell the tear was enlarged. On 7/27/23 at 1:49 p.m., the receptionist stated Resident #14 had not waited eight hours on 6/14/23 for staff assistance. She stated, rather, the staff had not reset the resident's call pendant. The receptionist stated the call when Resident #14 has sustained a skin tear went through around 6:10 a.m. On 7/27/23 at 10:23 a.m., Resident #14 stated the morning of 6/14/23 she had sustained a skin tear on the edge of her bedframe that caused her to bleed. Resident #14 stated she pressed her call pendant numerous times with no staff response. The resident stated she had not continued to wait for staff since it was an emergency, so she had lowered herself off her bed onto the floor, reached for her personal phone on the counter and called 911 for herself. Resident #14 stated it was around 20-30 minutes before residence staff responded to her pendant. 5. Resident #9 was admitted to the residence on 12/21/22 with diagnoses including multiple sclerosis, muscle weakness, abnormalities of gait and mobility, lack of coordination, and urinary incontinence. A care plan for Resident #9, dated 7/16/23, read in part that the resident required full assistance which included both physical and verbal assistance with ambulation, and required staff to assist with her continence needs. The care plan further read the resident was encouraged to call for assistance as necessary. Documentation of call pendant response times from 7/1-7/27/23 revealed the following staff response times to be 15 minutes or longer for Resident #9 as follows:7/1/23 at 6:27 a.m.: one hour and 57 minutes7/2/23 at 8:58 a.m.: 15 minutes7/5/23 at 3:16 p.m.: 18 minutes7/6/23 at 9:03 a.m.: 15 minutes7/9/23 at 7:01 a.m.: 34 minutes7/9/23 at 8:29 p.m.: 30 minutes7/13/23 at 10:03 a.m.: 16 minutes7/14/23 at 6:18 p.m.: 50 minutes7/15/23 at 2:31 p.m.: one hour and 36 minutes7/15/23 at 5:58 p.m.: 49 minutes7/16/23 at 10:24 a.m.: three hours and 35 minutes7/17/23 at 5:25 p.m.: 28 minutes7/18/23 at 6:40 a.m.: 24 minutes7/22/23 at 6:04 p.m.: 28 minutes7/22/23 at 9:08 p.m.: one hour and 15 minutes7/24/23 at 3:52 a.m.: 52 minutesOn 7/27/23 at 9:12 a.m., Resident #9 stated she had frequently waited longer than 10 minutes for staff to respond to her call light. Resident #9 stated she tried to make sure to go to the bathroom before bed since she did not expect night shift staff to assist her to the bathroom since they would not answer her calls in a timely manner. Resident #9 stated although two staff now worked the night shift instead of one staff, she felt the night shift staff just did not want to work. Resident #9 stated a few nights prior to the onsite investigation she had called for pulled her call light in the middle of the night and had to wait to go to the bathroom for an extended amount of time. She further stated she had stopped timing how long it took staff to respond since it was such a frequent occurrence, especially with overnight staff. On 7/27/23 at 4:07 p.m., although the administrator was asked to confirm deficient practice for this resident, the administrator declined to comment. 6. Resident #8 was admitted to the residence on 5/23/22 with diagnoses including Parkinson's Disease and osteoarthritis in both shoulders. Documentation of call pendant response times from 7/1-7/27/23 revealed the following staff response times to be 15 minutes or longer for Resident #8 as follows:7/1/23 at 9:53 a.m.: 32 minutes7/3/23 at 3:24 p.m.: three hours and seven minutes7/4/23 at 5:56 p.m.: 42 minutes7/7/23 at 6:34 a.m.: 37 minutes7/7/23 at 8:26 a.m.: 18 minutes7/7/23 at 8:55 a.m.: 37 minutes7/8/23 at 8:01 a.m.: 40 minutes7/13/23 at 6:28 a.m.: one hour and three minutes7/13/23 at 9:50 a.m.: 16 minutes7/16/23 at 6:27 a.m.: three hours and 14 minutes7/17/23 at 7:49 a.m.: 18 minutes7/20/23 at 8:39 a.m.: 34 minutes7/25/23 at 7:05 a.m.: 38 minutes7/25/23 at 1:31 p.m.: one hour and 34 minutes7/27/23 at 7:20 a.m.: 23 minutes7/27/23 at 8:50 a.m.: 44 minutesThe residence's care plan for Resident #8, dated 5/31/23, read in part that Resident #8 required verbal prompts and cues with toileting needs, was independent with ambulation, required cues for transfers, was encouraged to call for assistance as necessary and staff were to assist and monitor. On 7/27/23 at 7:38 a.m., Resident #8 stated that she was not concerned with long call light times since she understood that the residence was short of staff help. 7. Resident #5 was admitted to the residence on 7/27/21 with diagnoses including macular degeneration, osteoporosis and venous insufficiency of both lower extremities. Documentation of call pendant response times from 7/1-7/27/23 revealed the following staff response times to be 15 minutes or longer for Resident #5 as follows:7/2/23 at 12:48 p.m.: 20 minutes7/3/23 at 8:27 a.m.: 21 minutes7/4/23 at 8:53 a.m.: 17 minutes7/4/23 at 11:09 a.m.: one hour and three minutes7/10/23 at 12:49 p.m.: two hours and 22 minutes7/12/23 at 1:59 p.m.: 22 minutes7/12/23 at 3:26 p.m.: 17 minutes7/13/23 at 7:39 a.m.: 23 minutes7/13/23 at 5:30 p.m.: 15 minutes7/17/23 at 12:56 p.m.: 27 minutes7/18/23 at 8:22 a.m.: one hour and one minute7/19/23 at 8:09 a.m.: 19 minutes7/20/23 at 7:49 a.m.: 15 minutes7/23/23 at 3:35 p.m.: 27 minutes7/23/23 at 7:09 p.m.: 35 minutes7/24/23 at 7:17 a.m.: 24 minutes7/24/23 at 5:39 p.m.: 44 minutes7/25/23 at 7:55 a.m.: 17 minutes7/27/23 at 11:35 a.m.: 18 minutesOn 7/27/23 at 7:24 a.m., Staff #3 transferred Resident #5 into her wheelchair which included placing the resident's legs on the wheelchair pedals for her. Staff #3 pushed the resident's wheelchair to assist the resident to the dining room for breakfast. 8. Resident #7 was admitted to the residence on 5/16/22 with diagnoses including gout and cervical disc degeneration in the cervical thoracic and lumbar regions. Documentation of call pendant response times from 7/1-7/27/23 revealed the following staff response times to be 15 minutes or longer for Resident #7 as follows:7/2/23 at 10:21 p.m.: 16 minutes7/13/23 at 5:28 a.m.: 16 minutes7/14/23 at 12:46 a.m.: 23 minutes7/19/23 at 8:44 p.m.: 21 minutesThe residence's care plan for Resident #7, dated 5/16/22, read in part that Resident #7 was able to ambulate independently with a walker, required assistance with medications, required standby assistance with transfers and required nighttime safety checks at 12:00 a.m. and as needed. On 7/27/23 at 5:11 p.m., Resident #7 stated she had to occasionally wait more than 10 minutes for staff to respond to her call pendant to request they apply her nighttime lidocaine patch. The resident stated this was one of the only reasons she called for staff assistance. Resident #7 stated although the residence was appropriately staffed with two staff on night shift, she felt she was still waited too long for staff response whenever she pushed her pendant. 9. Resident #6 was admitted to the residence on 9/28/20 with diagnoses including muscle weakness, dementia, and macular degeneration. Documentation of call pendant response times from 7/1-7/27/23 revealed the following staff response times to be 15 minutes or longer for Resident #6 as follows:7/23/23 at 8:20 p.m.: three hours and 9 minutesOn 7/27/34 at 10:47 a.m., Resident #6 stated she had no concerns about staff reponse times for call lights. Resident #6 stated, however, was that her only concern was there seemed to be less staff available on the weekend to help her out of bed. 10. InterviewsOn 7/27/23 at 7:23 a.m., Staff #3 stated all residence staff were responsible for answering call pendants. She further stated resident call lights should be answered in less than 10 minutes. On 7/27/23 at 8:11 a.m., Staff #6 stated she was trained to answer call lights in less than 10 minutes. On 7/27/23 at 2:10 p.m., Staff #4 stated the first floor pagers had not been notifying staff when a resident called. She stated she had reported the issue the week of the onsite investigation to the executive director (ED). Staff #4 also stated that staff forgot to reset the pendants after answering calls. On 7/27/23 at 2:41 p.m., the administrator stated she expected staff to respond to call lights within 10-15 minutes or as quickly as possible. The administrator stated that staff should be written up if a resident was waiting for their call light to be answered for more than an hour. On 7/27/23 at 4:07 p.m., the administrator stated that the long call light times were likely from staff members not resetting pendants and stated this deficiency should not be cited because she did not think it was due to staff not responding timely. The administrator further stated she thought this deficiency had been corrected. On 7/27/23 at 4:28 p.m., the ED stated she had been notified about the first floor call light pager not functioning properly and had replaced it the week prior to the onsite investigation. Contrary to the call pendant response time documentation, the ED stated there had been shorter call light times since the pager had been replaced.

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 7.10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations. 14.28 The assisted living residence shall ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications.

A licensure revisit was completed on 7/31/23 for the previous deficiency cited on 4/6/23. The facility is in compliance with all regulations surveyed.

A licensure complaint, prompted by #CO32988 and #CO33014, was completed on 7/31/23. Deficiences were cited.

Based on observation, interview and record review, the residence failed to ensure that residents rights included the right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services made available by the assisted living residence, affecting seven of nine sample residents (#5-#9, #12 and #14). Findings include:1. Residence PolicyThe residence's undated Resident Rights Policy, read in part that residents had the right to choice and personal involvement regarding care and services, including the right to expect the cooperation of the assisted living residence in achieving the maximum degree of benefit from those services made available by the assisted living residence. 2. Staff ScheduleThe residence's staff schedule revealed that staff worked at the residence as follows:Day shift: 6:00 a.m.-2:00 p.m. Evening shift: 2:00 p.m.-10:00 p.m. Night shift: 10:00 p.m.-6:00 a.m. 3. Resident #12 was admitted to the residence on 10/7/22 with diagnoses including atherosclerotic heart disease and idiopathic peripheral neuropathy. Documentation of call pendant response times from 7/1-7/27/23 revealed the following staff response times to be 15 minutes or longer for Resident #12 as follows:7/1/23 at 1:13 a.m.: 20 minutes7/2/23 at 5:38 a.m.: two hours and 26 minutes7/5/23 at 3:06 p.m.: 47 minutes7/10/23 at 3:02 p.m.: two hours and 48 minutes7/10/23 at 9:44 p.m.: two hours7/11/23 at 5:19 a.m.: one hour and 48 minutes7/14/23 at 12:35 a.m.: 27 minutes7/15/23 at 6:00 a.m.: 35 minutes7/17/23 at 10:35 p.m.: eight hours and 49 minutes7/18/23 at 11:01 a.m.: five hours and 43 minutes7/20/23 at 11:11 a.m.: 18 minutes7/22/23 at 7:29 p.m.: three hours and 39 minutes7/24/23 at 7:00 a.m.: 52 minutes7/25/23 at 9:44 a.m.: 15 minutesThe residence's care plan for Resident #12, dated 4/11/23, read in part: Resident #12 used a walker and a scooter for ambulation and staff were to monitor and assist with ambulation as necessary. Resident #12 was independent with toileting, and required nighttime safety checks at 12:00 a.m. and every two hours as needed. The care plan further read that Resident #12 was a fall risk and the resident was to use her call light for assistance. On 7/27/23 at 9:30 a.m., Resident #12 stated there were issues with residence staff not answering her call light and stated it was the worst during the night shift. Resident #12 stated she had weakness in her lower legs and required staff to provide her with her scooter to use the restroom at night. Resident #12 stated she had documented on her computer her pendant wait times since it was a frequent occurrence on night shift where staff would not respond to her call light timely. The resident stated the most recent instance when she waited for over an hour for staff to respond to her call pendant to provide care was on 7/2/23. Resident #12 stated on 7/2/23, staff did not respond even though she pressed her call pendant five times for staff to get her scooter from across the room so she could go to the restroom. Resident #12 stated Staff #4 was on shift and answered her call at 5:30 a.m.; however, at that point Resident #12 stated she had already urinated herself waiting. On 7/27/23 at 2:10 p.m., Staff #4 stated she worked the night shift in early July 2023 when Resident #12 had soiled herself. Staff #4 stated the resident's call pendant did not notify her, so instead Resident #12 pounded on the wall for assistance. Staff #4 stated that was how Resident #12 got her attention. Staff #4 stated she had experienced issues with not receiving call pendant notification from the residents who resided on the first floor. 4. Resident #14 was admitted to the residence on 2/25/23 with diagnoses that included macular degeneration, atherosclerotic heart disease, peripheral venous insufficiency and chronic respiratory failure. Documentation of call pendant response times from 6/14/23-7/27/23 revealed the following staff response times to be 15 minutes or longer for Resident #14 as follows:6/14/23 at 6:40 a.m.: eight hours and 27 minutes6/15/23 at 8:27 p.m.: 15 minutes6/27/23 at 12:56 p.m.: three hours and 36 minutes7/1/23 at 8:14 a.m.: 15 minutes7/2/23 at 8:53 p.m.: 15 minutes7/8/23 at 8:12 a.m.: 40 minutes7/12/23 at 8:10 p.m.: three hours and five minutesThe residence's care plan for Resident #14, dated 6/16/23, read in part: Resident #14 was independent with ambulation and used a walker for extended distances. The resident was incontinent of bowel and bladder; however, was capable of caring for her own incontinence needs. The care plan further read that Resident #14 required nighttime safety checks after 12:00 a.m. and every two hours as needed, and was encouraged to call for assistance due to frequent falls. An incident report, dated 6/14/23, read in part: paramedics arrived to Resident #14's room and alerted staff, and Resident #14 was observed on the floor with blood running down her legs. Paramedics stated the resident had sustained a skin tear on her back and when the resident fell the tear was enlarged. On 7/27/23 at 1:49 p.m., the receptionist stated Resident #14 had not waited eight hours on 6/14/23 for staff assistance. She stated, rather, the staff had not reset the resident's call pendant. The receptionist stated the call when Resident #14 has sustained a skin tear went through around 6:10 a.m. On 7/27/23 at 10:23 a.m., Resident #14 stated the morning of 6/14/23 she had sustained a skin tear on the edge of her bedframe that caused her to bleed. Resident #14 stated she pressed her call pendant numerous times with no staff response. The resident stated she had not continued to wait for staff since it was an emergency, so she had lowered herself off her bed onto the floor, reached for her personal phone on the counter and called 911 for herself. Resident #14 stated it was around 20-30 minutes before residence staff responded to her pendant. 5. Resident #9 was admitted to the residence on 12/21/22 with diagnoses including multiple sclerosis, muscle weakness, abnormalities of gait and mobility, lack of coordination, and urinary incontinence. A care plan for Resident #9, dated 7/16/23, read in part that the resident required full assistance which included both physical and verbal assistance with ambulation, and required staff to assist with her continence needs. The care plan further read the resident was encouraged to call for assistance as necessary. Documentation of call pendant response times from 7/1-7/27/23 revealed the following staff response times to be 15 minutes or longer for Resident #9 as follows:7/1/23 at 6:27 a.m.: one hour and 57 minutes7/2/23 at 8:58 a.m.: 15 minutes7/5/23 at 3:16 p.m.: 18 minutes7/6/23 at 9:03 a.m.: 15 minutes7/9/23 at 7:01 a.m.: 34 minutes7/9/23 at 8:29 p.m.: 30 minutes7/13/23 at 10:03 a.m.: 16 minutes7/14/23 at 6:18 p.m.: 50 minutes7/15/23 at 2:31 p.m.: one hour and 36 minutes7/15/23 at 5:58 p.m.: 49 minutes7/16/23 at 10:24 a.m.: three hours and 35 minutes7/17/23 at 5:25 p.m.: 28 minutes7/18/23 at 6:40 a.m.: 24 minutes7/22/23 at 6:04 p.m.: 28 minutes7/22/23 at 9:08 p.m.: one hour and 15 minutes7/24/23 at 3:52 a.m.: 52 minutesOn 7/27/23 at 9:12 a.m., Resident #9 stated she had frequently waited longer than 10 minutes for staff to respond to her call light. Resident #9 stated she tried to make sure to go to the bathroom before bed since she did not expect night shift staff to assist her to the bathroom since they would not answer her calls in a timely manner. Resident #9 stated although two staff now worked the night shift instead of one staff, she felt the night shift staff just did not want to work. Resident #9 stated a few nights prior to the onsite investigation she had called for pulled her call light in the middle of the night and had to wait to go to the bathroom for an extended amount of time. She further stated she had stopped timing how long it took staff to respond since it was such a frequent occurrence, especially with overnight staff. On 7/27/23 at 4:07 p.m., although the administrator was asked to confirm deficient practice for this resident, the administrator declined to comment. 6. Resident #8 was admitted to the residence on 5/23/22 with diagnoses including Parkinson's Disease and osteoarthritis in both shoulders. Documentation of call pendant response times from 7/1-7/27/23 revealed the following staff response times to be 15 minutes or longer for Resident #8 as follows:7/1/23 at 9:53 a.m.: 32 minutes7/3/23 at 3:24 p.m.: three hours and seven minutes7/4/23 at 5:56 p.m.: 42 minutes7/7/23 at 6:34 a.m.: 37 minutes7/7/23 at 8:26 a.m.: 18 minutes7/7/23 at 8:55 a.m.: 37 minutes7/8/23 at 8:01 a.m.: 40 minutes7/13/23 at 6:28 a.m.: one hour and three minutes7/13/23 at 9:50 a.m.: 16 minutes7/16/23 at 6:27 a.m.: three hours and 14 minutes7/17/23 at 7:49 a.m.: 18 minutes7/20/23 at 8:39 a.m.: 34 minutes7/25/23 at 7:05 a.m.: 38 minutes7/25/23 at 1:31 p.m.: one hour and 34 minutes7/27/23 at 7:20 a.m.: 23 minutes7/27/23 at 8:50 a.m.: 44 minutesThe residence's care plan for Resident #8, dated 5/31/23, read in part that Resident #8 required verbal prompts and cues with toileting needs, was independent with ambulation, required cues for transfers, was encouraged to call for assistance as necessary and staff were to assist and monitor. On 7/27/23 at 7:38 a.m., Resident #8 stated that she was not concerned with long call light times since she understood that the residence was short of staff help. 7. Resident #5 was admitted to the residence on 7/27/21 with diagnoses including macular degeneration, osteoporosis and venous insufficiency of both lower extremities. Documentation of call pendant response times from 7/1-7/27/23 revealed the following staff response times to be 15 minutes or longer for Resident #5 as follows:7/2/23 at 12:48 p.m.: 20 minutes7/3/23 at 8:27 a.m.: 21 minutes7/4/23 at 8:53 a.m.: 17 minutes7/4/23 at 11:09 a.m.: one hour and three minutes7/10/23 at 12:49 p.m.: two hours and 22 minutes7/12/23 at 1:59 p.m.: 22 minutes7/12/23 at 3:26 p.m.: 17 minutes7/13/23 at 7:39 a.m.: 23 minutes7/13/23 at 5:30 p.m.: 15 minutes7/17/23 at 12:56 p.m.: 27 minutes7/18/23 at 8:22 a.m.: one hour and one minute7/19/23 at 8:09 a.m.: 19 minutes7/20/23 at 7:49 a.m.: 15 minutes7/23/23 at 3:35 p.m.: 27 minutes7/23/23 at 7:09 p.m.: 35 minutes7/24/23 at 7:17 a.m.: 24 minutes7/24/23 at 5:39 p.m.: 44 minutes7/25/23 at 7:55 a.m.: 17 minutes7/27/23 at 11:35 a.m.: 18 minutesOn 7/27/23 at 7:24 a.m., Staff #3 transferred Resident #5 into her wheelchair which included placing the resident's legs on the wheelchair pedals for her. Staff #3 pushed the resident's wheelchair to assist the resident to the dining room for breakfast. 8. Resident #7 was admitted to the residence on 5/16/22 with diagnoses including gout and cervical disc degeneration in the cervical thoracic and lumbar regions. Documentation of call pendant response times from 7/1-7/27/23 revealed the following staff response times to be 15 minutes or longer for Resident #7 as follows:7/2/23 at 10:21 p.m.: 16 minutes7/13/23 at 5:28 a.m.: 16 minutes7/14/23 at 12:46 a.m.: 23 minutes7/19/23 at 8:44 p.m.: 21 minutesThe residence's care plan for Resident #7, dated 5/16/22, read in part that Resident #7 was able to ambulate independently with a walker, required assistance with medications, required standby assistance with transfers and required nighttime safety checks at 12:00 a.m. and as needed. On 7/27/23 at 5:11 p.m., Resident #7 stated she had to occasionally wait more than 10 minutes for staff to respond to her call pendant to request they apply her nighttime lidocaine patch. The resident stated this was one of the only reasons she called for staff assistance. Resident #7 stated although the residence was appropriately staffed with two staff on night shift, she felt she was still waited too long for staff response whenever she pushed her pendant. 9. Resident #6 was admitted to the residence on 9/28/20 with diagnoses including muscle weakness, dementia, and macular degeneration. Documentation of call pendant response times from 7/1-7/27/23 revealed the following staff response times to be 15 minutes or longer for Resident #6 as follows:7/23/23 at 8:20 p.m.: three hours and 9 minutesOn 7/27/34 at 10:47 a.m., Resident #6 stated she had no concerns about staff reponse times for call lights. Resident #6 stated, however, was that her only concern was there seemed to be less staff available on the weekend to help her out of bed. 10. InterviewsOn 7/27/23 at 7:23 a.m., Staff #3 stated all residence staff were responsible for answering call pendants. She further stated resident call lights should be answered in less than 10 minutes. On 7/27/23 at 8:11 a.m., Staff #6 stated she was trained to answer call lights in less than 10 minutes. On 7/27/23 at 2:10 p.m., Staff #4 stated the first floor pagers had not been notifying staff when a resident called. She stated she had reported the issue the week of the onsite investigation to the executive director (ED). Staff #4 also stated that staff forgot to reset the pendants after answering calls. On 7/27/23 at 2:41 p.m., the administrator stated she expected staff to respond to call lights within 10-15 minutes or as quickly as possible. The administrator stated that staff should be written up if a resident was waiting for their call light to be answered for more than an hour. On 7/27/23 at 4:07 p.m., the administrator stated that the long call light times were likely from staff members not resetting pendants and stated this deficiency should not be cited because she did not think it was due to staff not responding timely. On 7/27/23 at 4:28 p.m., the ED stated she had been notified about the first floor call light pager not functioning properly and had replaced it the week prior to the onsite investigation. Contrary to the call pendant response time documentation, the ED stated there had been shorter call light times since the pager had been replaced.

Based on record review and interview, the residence failed to ensure that all qualified medication administration persons (QMAPs) were trained in and adhered to medication procedures that included identification of the right resident for each medication administration or monitoring by asking for the resident's name or comparing the resident to a photograph maintained specifically for medication administration identification, affecting one of four sample residents whose medications were reviewed (#14). Findings include:1. Residence PolicyThe residence's undated Medication Administration Policy, read in part that all qualified medication administration persons are trained in and adhere to the following medication administration procedures ... identification of the right resident for each medication administration or monitoring by asking for the resident's name or comparing the resident to a photograph maintained specifically for medication administration identification. 2. Resident #14 was admitted to the residence on 2/25/23 with a diagnosis of hypothyroidism. A written practitioner's order, dated 3/1/23, directed the residence to administer levothyroxine 50 mcg daily. The May 2023 electronic medication administration record (eMAR), read that on 5/12/23, levothyroxine 50 mcg was administered. However, a progress note dated 5/12/23, read in part: "Staff had administered a resident (Resident #14) another resident's dose of levothyroxine 175 mcg the morning of 5/12/23, instead of the practitioner-ordered dose of 50 mcg. Resident #14's family member, practitioner and administrator were notified. Resident #14 was feeling okay and vitals were taken."The residence's incident report investigation, read that on 5/12/23 contracted Staff #5 had mistaken Resident #14 for Resident #15. Both residents were prescribed the same medication; however at different doses. 3. InterviewsOn 7/27/23 at 10:00 a.m., Resident #14's family member stated that she had been notified through a text message from the former executive director, that Resident #14 was administered another resident's thyroid medication in May 2023. On 7/27/23 at 10:23 a.m., Resident #14 stated she was unaware staff had administered to her the incorrect dose of another resident's thyroid medication in May 2023. On 7/27/23 at 4:28 p.m., the executive director stated the residence had removed contracted Staff #5 from the residence's staff schedule after that staff had administered to Resident #14 another resident's medication on 5/12/23 and stated that was contracted Staff #5's first and only time working at the residence.. On 7/27/23 at 4:07 p.m., the administrator stated the residence had terminated contracted Staff #5 after investigating the medication error in which contracted Staff #5 had administered another resident's medication to Resident #14. On 7/31/23 at 4:31 p.m., the administrator acknowledged that the residence trained staff to use at least one personal identifier prior to medication administration. The administrator stated the resident's name was listed on their profile in the electronic health record system for medication administration. She acknowledged she would expect staff to ensure they used one personal identifier such as verification of the resident's name prior to administering medication to ensure the correct dose of medication was administered to the right resident.

Based on record review and interview, the residence failed to ensure each qualified medication administration person (QMAP) accurately documented each medication administration or monitoring event at the time the event was completed for each resident along with each of their signatures and, if used, their initials, affecting three of four sample residents whose medications were reviewed (#7, #13, #14). Findings include:1. Residence PolicyThe residence's undated Medication Administration Policy, read as part of the medication administration record, the community maintained a legible list of the names of the persons utilizing the record for medication administration, along with each of their signatures and, if used, their initials ... each qualified medication administration person, nurse, or practitioner must accurately document each medication administration or monitoring event at the time the event was completed for each resident. 2. Resident #13 was admitted to the residence on 10/30/21 with diagnoses including hypertension, osteoarthritis and osteopenia. Written practitioner orders, dated 4/24/23, directed the residence to administer the following medications:a. Atenolol 25 mg dailyb. Spironolactone 50 mg once dailyc. Acetaminophen 1000 mg twice dailyd. Diclofenac 1% four grams twice dailye. Meloxicam 7.5 mg dailyA written practitioner's order, dated 5/8/23, directed the residence to administer furosemide 20 mg daily. However, the July 2023 electronic medication administration record (eMAR) contained no evidence of documentation for the above medications for the morning medication administration on 7/7/23.3. Resident #7 was admitted to the residence on 5/16/22 with a diagnosis of cervical disc degeneration in the cervical thoracic and lumbar regions. A written practitioner's order, dated 1/30/23, directed the residence to administer lidocaine 4% patch twice daily and remove. However, the July 2023 eMAR contained no evidence of documentation on 7/14/23 in the evening for application, and 7/15/23 in the evening for both application and removal. Additionally, on 7/16/23 in the morning, the eMAR was marked with an exception code under lidocaine application. However, there was no documentation as to why the medication was marked or what the exception code meant. 4. Resident #14 was admitted to the residence on 2/25/23 with a diagnosis of atherosclerotic heart disease. A written practitioner's order, dated 3/1/23, directed the residence to administer Prevident 1.1% twice daily. However, the July 2023 eMAR contained no evidence of documentation on 7/7/23 in the morning. Additionally, on 7/7/23 in the evening, the eMAR was marked with an exception code for Prevident. However, there was no documentation as to why the medication was marked besides "other" or what the exception code meant. 5. InterviewsOn 7/27/23 at 4:07 p.m., the administrator stated she was not aware of eMAR documentation issues and stated she would expect staff to document with their initials or provide an exception code and explaination in the eMAR notes if not administered. The administrator said the executive director (ED) who would be able to answer specifically regarding what may have occurred since she was unable to see the eMARs to verify for Resident #7, #13 and #14. On 7/27/23 at 4:28 p.m., the ED acknowledged she would expect the eMARs to contain complete and accurate documentation including the reason a medication was not administered, and to be completed at the time a medication was administered. The ED further stated she did not know why there were blank spaces where staff did not document on 7/7/23 for Resident #13 and #14 or 7/14 and 7/15 for Resident #7, since the only time she had been aware of blank spaces in the eMAR was on 7/25/23 when their system went down and staff had to initial medication administrations on a paper chart. The ED further acknowledged she was unaware why a staff had not documented why Resident #14's eMAR for Prevident contained "other" or why staff had documented "out" on 7/16/23 for Resident #7's lidcoaine, and stated she would expect there to be a note to reference whether it was administered.

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 7.10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations. 14.28 The assisted living residence shall ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications.