ARGYLE, THE

A licensure complaint, prompted by #CO41607 was completed on 2/12/26. Deficiencies were cited.

Based on observation, interview, and record review, the residence failed to require all staff certified in cardiopulmonary resuscitation (CPR) to provide CPR services promptly in accordance with their training, affecting 125 current residents. (Cross-reference U2722)Specifically, Former Resident #1 was admitted to the residence on 8/18/22 with a diagnosis of hypertension. On 1/6/26 at 8:37 p.m., Former Resident #1 had gone out to the unmonitored designated smoking area. Approximately two minutes later, the resident had begun to slump over in his wheelchair, and he fell out of the wheelchair onto his head. The former resident had been on the ground for approximately eight minutes with no staff present before another resident found him and obtained staff assistance. Former Staff #3 and Staff #5 went outside to the designated smoking area to evaluate Former Resident #1. Former Staff #3 was unaware of how to respond and called for staff assistance while Staff #5 telephoned Emergency Medical Services (EMS). After receiving Former Staff #3's call for assistance, Staff #4 and #6 responded, and Staff #5 asked they move Former Resident #1 out of the rocks. After moving the former resident, Staff #4 and #6 asked about the former resident's advance directive. Former Staff #3 was unaware of where to locate an advance directive, and Staff #5 had not confirmed. Staff #5 then went to the former resident's room and confirmed the resident was a full code and wanted life-saving measures performed. While Staff #5 was looking for an advance directive, Staff #4 and #6 checked for a pulse and confirmed there wasn't one. A total of 13 minutes had passed since Former Resident #1 had fallen and lost consciousness, until CPR was initiated by Staff #5. Staff #5 continued CPR until EMS arrived and took over; however, resuscitation was unsuccessful, and the former resident was pronounced dead by EMS. Additional interviews with Staff #1 and #2, who were CPR-certified, revealed they had not received training on what to do if a resident becomes unresponsive. Additional interviews with Staff #1 and #2, who were CPR-certified, revealed they had not received training on what to do if a resident becomes unresponsive. This failure created an immediate jeopardy risk for failure to follow residents' advance directives, with injury and death to Former Resident #1, and risk of injury or death to 125 current residents. On 2/12/26, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. Reference and Residence Policya. According to the National Institute on Aging, medical orders for scope of treatment (MOST) form provides guidance about your medical care that health care professionals can act on immediately in an emergency. These forms may also be called portable medical orders or physicians' orders for scope of treatment. National Institute on Aging (2022). Advance Care Planning: Advance Directives for Health Care retrieved from: https://www.nia.nih.gov/health/advance-care-planning/advance-care-planning-advance-directives-health-care#:~:text=Physician%20orders%20for%20life%2Dsustaining,scope%20of%20treatment%20b. The residences CPR directive policy, undated, read that information about the residences CPR directive policy will be given to each resident as part of the admission paperwork. At the time of admission the residence shall inform the resident or the residents legal representative regarding the residents right to receive CPR or have a written CPR directive refusing CPR.However, there was no direction for when staff are to perform CPR.2. Record Review Former Resident #1 was admitted to the residence on 8/18/22 with a diagnosis of essential primary hypertension. The record for Former Resident #1 contained a MOST form, dated 5/25/21, which read that he wanted CPR to be conducted. An incident report written by the Associate Executive Director for Former Resident #1, dated 1/6/26 at 8:37 p.m., read in part, at approximately 8:37 p.m. on 1/6/26, a resident went inside the residence and requested assistance. The resident reported that another resident had fallen outside on the smoking area. When the caregiver and the qualified medication administration person (QMAP) arrived at the scene, they found the resident on the floor with their head facing downward. The resident had fallen from their wheelchair and was unresponsive, exhibiting no observable signs of life or movement. EMS was telephoned immediately for emergency assistance. Per EMS dispatcher instructions, QMAP/caregiver began cardiopulmonary resuscitation (CPR) and continued until EMS arrived. Upon arrival, EMS assumed care of the resident and were given a summary of the observed events and interventions. EMS transported the resident inside the facility to continue advanced life support measures. After approximately 30 minutes of interventions, EMS pronounced the resident deceased. EMS advised that they would notify law enforcement and, per protocol, no further details would be released until law enforcement arrived. An internal investigation, dated 1/22/26, revealed the following: Staff #4's written statement read that the night of Former Resident #1's death, Staff #4 was in another resident's room and was called by another caregiver who told her they believed a resident had passed away. Staff #4 ran to assist, where she called other caregivers to meet. Once Staff #4 made it to the location where Former Resident #1 was at, Staff #5 requested they move Former Resident #1 out of the rocks. After moving him, Staff #4 asked whether or not Former Resident #1 was a do-not-resuscitate (DNR). Staff #5 then ran inside the residence to confirm the MOST form. Staff #4 then checked for a pulse on Former Resident #1. No pulse was felt. EMS then instructed the staff to perform CPR, and Staff #5 performed it on Former Resident #1. At that time EMS arrived. Staff #6's written statement read on 1/22/26, he was working with another resident when he heard over the radio, "staff to the smoking area." When Staff #6 arrived, he saw Former Resident #1 on the ground with a cut on his forehead and unconscious. Staff #6 then checked for a pulse and confirmed Former Resident #1 did not have one. Staff #6 asked if Former Resident #1 had a MOST form. Staff #5 ran to Former Resident #1's room where the MOST form was kept. Once confirmed that Former Resident #1 was a full code, Staff #5 began CPR, and the EMS arrived three minutes later. The investigation revealed no evidence that Staff #3 and #5 was interviewed by the residence to provide a statement. On 2/12/26 at approximately 10:00 a.m., CPR certifications for all sampled staff were requested. CPR certifications for Staff #1, #2, #5, and #6 were provided and were current. There were no CPR certifications provided for Former Staff #3 and Staff #4. On 2/12/26 at approximately 10:30 a.m., the administrator and associate executive director provided surveillance footage of the incident. After review of the footage, it had revealed Former Resident #1 had gone out to the designated smoking area at 8:37 p.m., where he exited the doors in his wheelchair. After approximately two minutes, Former Resident #1 begins to hunch over in his wheelchair with his head hanging off the side of the chair. Approximately three minutes later, another resident comes out to the designated smoking area using a walker, walks by Former Resident #1, and has to maneuver past Former Resident #1. After Former Resident #1 had been outside for one minute and fifty seconds he flips out of the chair, headfirst onto the concrete. After approximately three minutes, the other resident in the designated smoking area walks back into the residence and notices Former Resident #1 on the ground. She maneuvers past the Former Resident #1 and has to leave her walker. Another four minutes and fifty-two seconds go by when Former Staff #3 and Staff #5 come outto assess the situation. Former Staff #3 is seen assessing Former Resident #1 when he throws his hands up in shock. Staff #5 is then seen telephoning EMS. Staff #3 is then seen on the telephone and walking away from Former Resident #1. Former Staff #3 then comes back after a few seconds and stands above Former Resident #1. Another four and a half minutes pass when you see two other staff members come out to the area and stand over Former Resident #1. Staff #5 then moves Former Resident #1's body with the additional staff member. Staff #5 then goes back into the residence and returns one minute later to assess Former Resident #1 and then starts CPR, a total of approximately 13 minutes. 3. InterviewsOn 2/12/26 at approximately 9:30 a.m., Staff #1 and Staff #2 stated they had both never received any training at the residence on what to do if they were to ever come across an unresponsive resident, to ensure they received prompt services. On 2/12/26 at approximately 10:45 a.m., contrary to Staff #1 and #2's interview, the administrator stated all staff received training on CPR response protocol, and he believed the staff followed protocol on 1/6/26. He added that after the residence's investigation was completed, he believed his staff did the right thing and followed procedure by telephoning EMS and starting CPR when they did. On 2/12/26 at approximately 2:20 p.m., Former Staff #3 stated that he and Staff #5 were told by another resident that a resident was on the ground in the designated smoking area. When Former Staff #3 arrived to the smoking area, he and Staff #5 had found Former Resident #1 on the ground and unresponsive. Former Staff #3 stated he rolled Former Resident #1 over onto his back and was in shock to find Former Resident #1 unresponsive. Former Staff #3 stated he then got on his phone to telephone other staff members for assistance, while Staff #5 telephoned EMS. Former Staff #3 stated, "I did not respond very well, I'm sorry". Former Staff #3 stated he was not sure if he was CPR certified at the time of the incident. He also added that he had not been through any training to help a resident who was unresponsive while working at the Residence. Former Staff #3 also stated he was not aware of where the residence kept the MOST forms for its Residents. 4. Immediate Jeopardy Risk - Written Evidence, Immediate Correction The investigation established that the findings above placed the 125 current residents at immediate jeopardy risk for harm, injury or death. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations requires residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 2/12/26 at 4:15 p.m., the administrator submitted written evidence that read in pertinent part: "Unresponsive Resident Response Policy, dated 2/12/26. The purpose, to ensure immediate and appropriate response when a resident is found unresponsive, including rapid verification of the MOST form and prompt initiation of CPR in accordance with American Heart Association."On 2/12/26 at 4:15 p.m., the administrator submitted written evidence that read in pertinent part: "Plan of Correction CPR Training Implementation Plan. The plan was to train the entire staff on emergency CPR training effective immediately 2/12/26. The plan included, assess responsiveness, rapid MOST form verification, immediate CPR initiation if MOST is not confirmed, simultaneous 911 activation, Automated External Defibrillator (AED) retrieval and use."

Based on observations, record review, and interviews, the residence failed to ensure the outdoor smoking area was monitored when residents were present, affecting 125 current residents. (Cross-reference U0740)Findings Include:The residence's undated "Smoking" policy, had no mention of the DSA being monitored by staff when residents were present. Observations of the designated smoking area (DSA) on 2/12/26 from approximately 7:45 a.m. to 4:15 p.m. revealed as follows:Two different residents were observed smoking. No staff were present during both times. On 2/12/26 at approximately 10:00 a.m., Staff #1 and Staff #2 stated they had never been told they needed to monitor residents when residents were present in the DSA. They stated they had never done so. On 2/12/26 at approximately 10:30 a.m., the administrator confirmed that no official process was in place to monitor the DSA. He stated he was not aware of the state regulation, and confirmed the residence did not monitor the DSA. He added he did not have enough staff to monitor the DSA.

A licensure complaint, prompted by #CO41454, #CO41455, and #CO41456, was completed on 2/4/26. A deficiency was cited.

Based on record review and interviews, the residence failed to comply with authorized practitioner orders associated with medication administration for one of four sample residents whose medications were reviewed (#27). Findings include:1. Record reviewResident #27 was admitted to the residence on 10/13/25, with diagnoses including epilepsy and hypothyroidism. A signed practitioner's order, dated 9/17/25, instructed the residence to administer hydralazine oral tablets 100 mg three times a day. The December 2025 and January 2026 medication administration record (MAR) read hydralazine oral tablets were to be administered to Resident #27 daily at 6:00 a.m., 2:00 p.m., and 8:00 p.m. The December 2025 MAR read in part: Resident #27 was not administered hydralazine oral tablets at 2:00 p.m. on 11 of 31 days in December of 2025, only receiving two of the three doses, because she [Resident #27] was absent from the home without medication. The January 2026 MAR read in part: Resident #27 was not administered hydralazine oral tablets at 2:00 p.m. on 10 of 31 days in January of 2026, only receiving two of the three doses, because she [Resident #27] was absent from the home without medication. 2. InterviewsOn 2/4/26 at 3:30 p.m., the clinical manager said Resident #27 went to dialysis three days a week and was not administered the 2:00 p.m. dose of hydralazine on those days she was absent from the residence. The clinical manager said the residence was not following the practitioner's order for the medication consistently due to Resident #27 only receiving two of the scheduled three doses of hydralazine on dialysis days. The clinical manager said she had contacted the practitioner to discuss missing doses on dialysis days, but was not able to provide documentation. On 2/4/26 at approximately 4:00 p.m., the administrator said he [administrator] was not in agreement that the residence was not following practitioner orders; however, acknowledged the residence could document conversations with the practitioner better about changing the order. The administrator said Resident #27 was not able to self-administer medication, so it was not given to her by the residence prior to her leaving for dialysis appointments, and the residence could not give her the medication if she was not at the residence, which resulted in her [Resident #27] missing her 2:00 p.m., hydralazine consistently.

A complaint revisit was completed on 2/4/26 for all previous deficiencies cited on 5/8/25. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 7/1/25.

Based on record review and interviews, the residence failed to comply with authorized practitioner orders associated with medication administration for one of four sample residents whose medications were reviewed (#27). This deficiency was cited previously during a state licensure survey 5/8/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Record reviewResident #27 was admitted to the residence on 10/13/25, with diagnoses including epilepsy and hypothyroidism. A signed practitioner's order, dated 9/17/25, instructed the residence to administer hydralazine oral tablets 100 mg three times a day. The December 2025 and January 2026 medication administration record (MAR) read hydralazine oral tablets were to be administered to Resident #27 daily at 6:00 a.m., 2:00 p.m., and 8:00 p.m. The December 2025 MAR read in part: Resident #27 was not administered hydralazine oral tablets at 2:00 p.m. on 11 of 31 days in December of 2025, only receiving two of the three doses, because she [Resident #27] was absent from the home without medication. The January 2026 MAR read in part: Resident #27 was not administered hydralazine oral tablets at 2:00 p.m. on 10 of 31 days in January of 2026, only receiving two of the three doses, because she [Resident #27] was absent from the home without medication. 2. InterviewsOn 2/4/26 at 3:30 p.m., the clinical manager said Resident #27 went to dialysis three days a week and was not administered the 2:00 p.m. dose of hydralazine on those days she was absent from the residence. The clinical manager said the residence was not following the practitioner's order for the medication consistently due to Resident #27 only receiving two of the scheduled three doses of hydralazine on dialysis days. The clinical manager said she had contacted the practitioner to discuss missing doses on dialysis days, but was not able to provide documentation. On 2/4/26 at approximately 4:00 p.m., the administrator said he [administrator] was not in agreement that the residence was not following practitioner orders and believed the deficiency had been corrected; however, acknowledged that the residence could document conversations with the practitioner better about changing the order. The administrator said Resident #27 was not able to self-administer medication, so it was not given to her by the residence prior to her leaving for dialysis appointments, and the residence could not give her the medication if she was not at the residence, which resulted in her [Resident 27] missing her 2:00 p.m., hydralazine consistently.

A relicensure survey and complaint revisit were completed on 2/4/26 for the previous deficiency cited on 5/8/25. The residence is in compliance with all regulations surveyed. The regulations governing Assisted Living Residences were revised. The new regulation Chapter VII was implemented on 7/1/25.

A revisit survey was completed on 1/13/26 for all previous deficiencies cited on 9/11/25. The facility is in compliance with all deficiencies that were cited.

A complaint survey, prompted by #CO40918, #CO40324 and #CO40250, was completed on 9/11/25. A deficiency was cited.

Based on observation, interview and record review, the residence failed to ensure qualified medication administration personnel (QMAP) did not pre-pour medication, affecting four of four sample residents (#29-#31 and #33). Observation and interviewOn 9/11/25 at 8:26 a.m., a drawer within a portable work station contained a stack of three small, clear cups, labeled with various numbers on them. Each cup contained one medication each. Staff #9, who was utilizing the work station for med pass, said the cups contained medications for residents with correlating room numbers Resident's (#29, #30 and #31). Staff #9 said he had pre-poured medications because he was running behind on med pass. Staff #9 said pre-pouring medication was not allowed. On 9/11/25 at 3:30 p.m., the executive director (ED) said it was not acceptable for QMAPS to pre-pour any medications and that staff were aware. Similar deficient practice was found for Resident #33.

A licensure complaint, prompted by #CO38225 and #CO40011, was completed on 5/8/25. Deficiencies were cited.

Based upon interview and record review, the residence failed to ensure new orders from an authorized practitioner were obtained when three of six sample resident (#2, #18, #21) returned to the residence after an inpatient hospitalization. (Cross-reference T1068 and T1568). Findings include:Resident #2 was admitted to the residence on 2/28/23 with diagnoses including spinal stenosis, pain, and later a history of overdose of opiates. Progress notes, dated 12/22/24-4/16/25, read in part:On 12/22, the residence sent the resident to the hospital. On 12/23, the hospital emergency department (ED) admitted the resident. On 2/21, the residence re-admitted the resident. On 3/15, the residence sent the resident to the hospital. On 4/16, the resident was at the residence. The residence's census, dated 5/6/25, read in part that the resident was sent to another healthcare entity and returned to the residence on the following dates:Discharged from the residence on 12/22/24 to the hospital, and re-admitted to the residence on 2/21/25. Discharged from the residence on 3/15/25 to the hospital, and re-admitted to the residence on 4/11/25. The residence had no practitioner orders from the resident's inpatient hospital stays or from a practitioner aware of the details of those stays at the time of readmission to the residence. On 5/6/25-5/7/25, during the onsite survey, Staff #7 and #8 stated Resident #2 had frequent hospitalizations and readmissions to the residence. On 5/7/25 at approximately 4:00 p.m., the assistant administrator (AA) stated the residence did not ensure they had practitioner orders for residents after they returned to the residence post-hospitalization including Resident #2. Additionally, the residence failed to ensure new orders from an authorized practitioner were obtained when residents returned to the residence after an inpatient hospitalization for Residents #18 and #21.

Based on record review and interview, the residence failed to evaluate a resident transferred to another healthcare entity prior to re-admission, affecting three of three sample residents who were transferred to another healthcare entity and then re-admitted to the residence (#2, #18, and #31). (Cross-reference B0710, T1568, T2230) Findings include:1. Residence PolicyThe residence's undated Hospital/Rehab Re-Admission policy read that the residence reassessed the resident prior to the resident's return to the residence. 2. Resident #2 was admitted to the residence on 2/28/23 with a diagnosis of epilepsy and later with a diagnosis of a history of overdose of opiates. Progress notes, dated 12/22/24-4/16/25, read in part:On 12/22, the residence sent the resident to the hospital. On 12/23, the hospital emergency department (ED) admitted the resident to the intensive care unit (ICU). The resident was on a ventilator and under sedation. The hospital monitored for seizure activity, with no recent seizure activity observed. The hospital medical team planned to begin weaning the resident off sedation, and if she demonstrated the ability to follow commands, they planned to proceed with ventilator removal. The resident's current diagnoses include acute-on-chronic hypoxic respiratory failure, acute kidney injury, and shock. On 1/10, the hospital discharged the resident to a skilled nursing facility (SNF). On 1/23, the resident was transferred from the SNF to the hospital on an undetermined date due to an unspecified illness. Then on 1/23, the resident was transferred from the hospital to a SNF for rehabilitation. On 1/31, the resident's practitioner reported that the hospital discharged the resident to a different SNF on 1/29. On 2/21, the residence re-admitted the resident. On 3/15, the residence sent the resident to the hospital. On 4/15, the resident was confused and reported having memory loss. The resident's practitioner visited the resident and sent her to the ED due to a possible stroke. On 4/16, the note indicated the resident was at the residence. The residence's census, dated 5/6/25, read in part that the resident was sent to another healthcare entity and returned to the residence on the following dates:Discharged from the residence on 12/22/24 and re-admitted to the residence on 2/21/25. Discharged from the residence on 3/15/25 and re-admitted to the residence on 4/11/25. Discharged from the residence on 4/15/25 and re-admitted to the residence on 4/16/25. The residence conducted no documented assessments of Resident #2 since 8/27/24.3. InterviewsOn 5/6/25-5/7/25, during the onsite survey, Staff #7 and #8 stated Resident #2 had frequent hospitalizations and readmissions to the residence. On 5/6/25 at 1:05 p.m., the assistant administrator (AA) stated that the residence did not assess Resident #2 after her hospitalizations or SNF stays, they should have to determine if the residence could continue to meet her needs. In a later interview on 5/8/25 at 10:17 a.m., the AA stated the residence was required to reassess residents prior to their re-admission to the residence and had not. She added that the prior health and wellness director (HWD) was no longer working at the residence as of 4/17/25 due to medication and care concerns, and the former HWD was responsible for completing re-admission assessments after a resident transferred to another healthcare entity. On 5/6/25 at 2:40 p.m., Resident #2 stated she did not recall anyone from the residence assessing her prior to her return from the hospital or SNF stays since January 2025. On 5/8/25 at 10:32 a.m., the administrator stated the residence was required to reassess residents prior to their re-admission to the residence, and the residence had not completed the assessments. 4. Additionally, the residence failed to evaluate a residents transferred to another healthcare entity prior to re-admission for Residents #18 and #31.

Based on record review and interview, the residence failed to either directly or indirectly, through a resident agreement, provide personal services sufficient to meet the needs of the resident, affecting one sample resident (#20) (Cross-reference T1142 and T1568)Specifically, the residence identified through assessments that Resident #20 required assistance donning and doffing compression hose. On 10/17/24, the resident's practitioner directed the residence to assist the resident with donning and doffing compression hose due to edema with wounds; however, the residence repeatedly failed to assist the resident, and she arrived at her external service provider (ESP) day program wearing no compression hose. The resident was hospitalized due to cellulites on 1/11/25 due to noncompliance with donning and doffing compression hose. The residence continued to periodically not assist the resident with her compression hose, and on 5/7/25, the resident continued to experience edema and had recently developed a new wound. Findings include:1. Reference and Residence Policiesa. Chapter VII regulations governing assisted living residences:Part 2.3 defines "Activities of daily living (ADLs)" as those personal functional activities required by an individual for continued well-being, health, and safety. Activities of daily living include, but are not limited to, dressing and personal hygiene (skin care). Part 2.45 defines "Personal services" as those services that an assisted living residence and its staff provide for each resident, including, but not limited to: (D) Assistance with activities of daily living.b. The residence's undated lease agreement read in part that residents received care and services identified by the residence's assessment of the resident.c. The residence's Resident Handbook, dated April 2025, read that the resident had the right to receive services in accordance with the resident agreement and the care plan. 2. Resident #20 was admitted to the residence on 8/7/24 and was diagnosed on 10/17/24 with edema and on 1/11/25 with cellulitis. Assessments, dated 8/7/24 and 9/14/24, read that the resident required staff assistance with donning and doffing of compression hose daily; however, the electronic medication administration record (eMAR) did not include the task. 3. InterviewsOn 5/7/25 at 10:53 a.m., a registered nurse (RN) from the resident's practitioner's office stated that the residence did not assist the resident with donning and doffing compression stockings beginning in October 2024. She stated that the lack of assistance led to increased edema, wounds, and on 1/11/25, a hospitalization due to cellulitis. She added that the resident arrived at her ESP day program a few times a week without the compression stockings for several months. She stated that the residence improved slightly in April 2025; however, the resident continued to show up at least once a week without her compression stockings on. The RN added that the resident had continued edema and had developed a wound due to the edema within the last three weeks. On 5/7/25 at 3:43 p.m., Staff #6 stated that Resident #20 no longer wore compression stockings but wraps that the ESP day program may apply. She added that compression stocking assistance was typically added to the eMAR for residents so that staff were aware that the task was required in addition to the task list. On 5/7/25 at 4:00 p.m., the assistant administrator (AA) stated that she became aware that the residence failed to add assistance with donning and doffing compression hose to the task list for the resident until approximately mid-April 2025. She affirmed the residence had not yet added the task to the resident's eMAR. In a later interview, on 5/8/25 at 10:03 a.m., the AA stated she was unaware that the residence's failure to assist with donning and doffing compression stockings led to the resident having increased edema and wounds. On 5/7/25 at 4:24 p.m., Resident #20 stated that the residence did not assist her with donning compression hose several times a week for months and her legs became more swollen and painful. She added that currently the residence did not assist her at least once a week, and routinely did not complete the task unless she reminded them. She stated that she currently donned compression stockings with velcro compression, which some staff referred to as wraps.

Based on interview and record review the residence failed to ensure residents' comprehensive assessment included information regarding the resident's overall health and physical functioning ability, reactions to the environment and others, safety awareness and the types of physical, mental, and social support required by the resident, affecting seven of eight sample residents (#2, #12, #16-#20). (Cross-reference T1068, T1110, T1568, T1433). Findings include:The residence's undated Resident Assessment Policy read in part that the residence completed a comprehensive assessment annually, or when a resident had a change in condition. Resident #12 was admitted to the residence on 6/3/19 with diagnoses including unspecified pain in the hip and neuropathy. Progress notes, dated 3/8/25-4/25/25, read in part:On 3/8, a representative from the resident's practitioner's office reported the resident experienced increased pain between 2:00 a.m. and 4:00 a.m., and asked the residence if they were administering medications correctly. On 4/25, the resident experienced pain that woke him. The most recent comprehensive assessment, dated 4/17/24, contained no information regarding the resident's history of pain other than his most recent pain level, dated 3/29/22, which was a six on an undisclosed scale. 3. InterviewsOn 5/6/25 at 9:28 a.m., the assistant administrator (AA) stated that the former health and wellness director (HWD) completed most assessments. She stated that the residence became aware in mid-April 2025 of multiple failures by the former HWD, and she no longer worked at the residence. The AA stated that the former HWD failed to address Resident #12's uncontrolled pain. In a later interview, on 5/8/25 at 10:06 a.m., the AA stated that the residence was required to ensure all assessments contained all of the resident's care needs, behavioral expressions, and all staff support needed by the resident and the residence may have not updated them. On 5/7/25 at 1:43 p.m., Resident #12 stated that he had unmanaged pain beginning in January 2025 until a slight improvement approximately mid-April 2025. He added he did not recall the residence assessing him after his pain increased. On 5/8/25 at 10:40 a.m., the administrator stated that the residence was required to include when a resident experienced a change in behavior, care, falls, or resident-reported changes in the resident's comprehensive assessment. He added that the residence had not corrected this citation due to the failures of the former HWD, who no longer worked at the residence. 4. Additionally, the residence failed to ensure residents comprehensive assessment included information regarding the resident's overall health and physical functioning ability, reactions to the environment and others, safety awareness and the types of physical, mental, and social support required by the resident for Residents #2 and #16-#20.

Based on interview and record review the residence failed to comply with practitioner's orders, affecting six of six sample residents for whom medications were reviewed (#2, #12, #16, #17, #20, and #21). (Cross-Reference T1110, T1142, T1604, B0710)Specifically, a practitioner's order for Resident #12, dated 1/17/25, directed the residence to administer Cymbalta 30 mg once daily for pain; however, the residence failed to administer the medication on 1/18/25-2/26/25, for 40 missed doses. The practitioner was unaware that the residence failed to administer the medication and wrote an order, dated 2/26/25, directing the residence to administer Cymbalta 60 mg once daily. On 4/7/25, the practitioner became aware that the residence failed to administer the medication and directed the residence to administer Cymbalta 30 mg once daily; however, the residence failed to administer the medication as it was out of stock until 4/9/25. Due to these multiple failures, the resident experienced significant pain for approximately three months. Specifically, a practitioner's order for Resident #2, dated 4/17/25, directed the residence to administer Xtampza ER 9 mg for opioid abuse deterrent twice daily; however, the residence failed to administer the medication 4/16/25-5/6/25 for 31 doses. On 5/6/25, the resident reported that the residence refused to give her the medication as there was no reason listed on the order, despite there being a reason for administration included in the order. She added that the medication was central to managing her pain, and she had experienced significant pain since the residence had not administered it to her. Specifically, a practitioner's order for Resident #20, dated 4/21/25, directed the residence to administer two Lasix 20 mg tabs twice daily; however, the residence administered one Lasix 20 mg tablet twice daily. Subsequently, the resident experienced increased edema in her legs that led to the development of a new wound. Findings include:1. Resident #12 was admitted to the residence on 6/3/19 with diagnoses including unspecified pain in the hip and neuropathy. a. CymbaltaA written practitioner's order, dated 1/17/25, directed the residence to administer Cymbalta 30mg once daily; however, the January and February 2025 electronic medication administration record (eMAR) read in part that the residence failed to administer the medication on 1/18/25-2/26/25, for a total of 40 missed doses. A practitioner's order dated 2/26/25 directed the residence to administer Cymbalta 60 mg once daily because the 30 mg dose failed to control the resident's pain; however, the February-April 2025 eMAR read in part that the residence failed to administer the medication on 2/27/25-4/7/25, for a total of 40 missed doses. A practitioner's note, dated 4/7/25 read that the practitioner contacted the residence, and the residence affirmed they had not administered Cymbalta to the resident since the order on 1/17/25, as they failed to add it to the eMAR. A practitioner's order, dated 4/7/25, directed the residence to administer Cymbalta 30 mg once daily for pain; however, the April 2025 eMAR read in part that the residence failed to administer the medication on 4/7/25-4/9/25, for a total of three missed doses, as the medication was out of stock.b. Lidocaine OintmentA practitioner's order, dated 1/31/25 directed the residence to administer Lidocaine 5% ointment to both lower legs three times daily; however, the February and March 2025 eMAR read in part that the residence failed to administer one of the three doses of the medication on 2/1/25-2/7/25, for a total of seven missed doses. A practitioner's order dated 2/26/25 directed the residence to administer Lidocaine 5% ointment to both lower legs once daily as needed for pain; however, the as-needed dose of the medication was not added to the eMAR until 3/8/25. Further, the residence did not administer the medication on 3/8/25 despite the resident reporting pain. A progress note, dated 3/8/25 at 4:09 p.m., read in part that a representative from the resident's practitioner's office reported the resident experienced increased pain between 2:00 a.m. and 4:00 a.m. The representative stated to the residence that the practitioner wrote an order for the resident to get Lidocaine ointment once a day as needed in addition to his scheduled doses. 2. InterviewsOn 5/6/25-5/7/25, during the onsite survey, Staff #6 and #7 stated that they administered the medications entered into the residents' eMARs by the former health and wellness director (HWD). On 5/6/25 at 9:28 a.m., the assistant administrator (AA) stated that the residence became aware in mid-April 2025 of multiple failures by the former HWD, and she no longer worked at the residence. The AA stated that the former HWD failed to address Resident #12's uncontrolled pain, and the residence failed to administer Cymbalta for months because the former HWD did not add it to the eMAR. In a later interview, on 5/8/25 at 10:06 a.m., the AA stated that the residence was not compliant with the practitioner's orders as they did not administer several medications correctly, which resulted in pain for some residents. On 5/7/25 at 1:43 p.m., Resident #12 stated that he had unmanaged pain beginning in January 2025 until a slight improvement approximately mid-April 2025. He added that the residence did not give him his Lidocaine correctly for some time in the prior two or three months, and they failed to give him a medication that assisted with pain management from January until mid-April 2025. He stated he was in significant pain from January 2025 until April 2025. On 5/8/25 at 10:40 a.m., the administrator stated that the residence was not compliant with the practitioner's orders due to failures of the former HWD.3. Additionally, the residence failed to comply with authorized practitioners' orders associated with medication administration for Residents #2, #16, #17, #20, and #21.

Based on interview and record review, the residence failed to on a quarterly basis audit the accuracy and completeness of the medication administration records, affecting six of six sample residents for whom medications were reviewed (#2, #12, #16, #17, #20, and #21). (Cross-Reference T1568)Findings include:On 5/6/25-5/8/25, during the onsite visit, quarterly medication audits were requested from the assistant administrator (AA). However, the residence provided no audits. On 5/6/25 at 1:05 p.m., the AA stated that the former health and wellness director (HWD) failed to document completed quarterly medication audits and that her documentation was inaccurate. On 5/8/25 at 10:43 a.m., the administrator stated that the former HWD conducted the medication audits, which were not accurate and did not meet the residence's expectations.

Based on record review and interview, the residence failed to ensure that residents' practitioner was promptly notified of a residents' pattern of refusal; or a resident's repetitive request for and use of pro nata (PRN) medication, affecting three of six sample residents for whom medications were reviewed (#2, #17, and #21). (Cross-reference T1142, T1568, T2230)Findings include:Resident #2 was admitted to the residence on 2/28/23 with diagnoses including spinal stenosis, pain, and later a history of overdose of opiates. A written practitioner's order, dated 2/25/25, directed the residence to administer oxycodone HCL 5 mg, one tablet every six hours as needed for pain. The April 2025 electronic medication administration record (eMARs) read that the residence administered the medication on 4/12-4/15, 4/17-4/20, 4/26, 4/29, and 4/30, for a total of 10 times. A written practitioner's order, dated 4/16/25, directed the residence to administer methocarbamol 500 mg two tablets every 12 hours as needed for pain. The April and May 2025 eMARs read that the residence administered the medication on 4/12, 4/18, 4/19, 4/21, 4/24, 4/26, 4/30, 5/1-5/3, and 5/5, for a total of 11 times. Progress notes, dated 4/12/25-5/5/25, failed to contain notes regarding the residence's contact with the practitioner regarding repetitive requests for and use of PRN medication. On 5/6/25 at 2:40 p.m., Resident #2 stated she routinely requested medication for pain. On 5/8/25 at 10:11 a.m., the assistant administrator (AA) stated the residence was required to notify the practitioner when a resident requested as-needed medication for seven doses. She added that the residence required communication with the practitioner in the resident's progress notes. On 5/8/25 at 10:45 a.m., the administrator stated that the residence was required to contact a resident's practitioner and representative when they requested as-needed medications several days in a row and that the residence was required to document such communication in the resident's progress notes. Additionally, the residence failed to ensure that the residents' practitioner was promptly notified of the residents' pattern of refusal for Residents #17 and #21.

Based on interview and record review, the residence failed to require staff members to document, before the end of their shift, any out of the ordinary event or issue regarding a resident. Further, the residence failed to ensure that the residents' records contained practitioner orders and documentation provided by external service providers (ESP), affecting eight of eight sample residents (#2, #12, #16-#21) and one former resident (#22). (Cross-reference T1068, T1110, T1568, T1612, and B0710). Findings include:Resident #21 was admitted to the residence on 6/21/23. Progress notes, dated 3/28/25-4/12/25, read in part:On 3/28, the residence sent the resident to the hospital via ambulance. On 4/12, the resident returned to the residence and appears to be at her baseline. On 5/7/25 at 2:34 p.m., Resident #21 stated she went to the hospital in March 2025 as she had back pain. On 5/7/25 at approximately 4:00 p.m., the assistant administrator (AA) stated that she was not sure of the reason that Resident #21 was sent to the hospital; however, she thought the resident had a distended stomach and pain. She added that there was no progress note, and there should have been as the event was out of the ordinary. In a later interview on 5/8/25 at 10:21 a.m., the AA stated that the residence required staff to document events before the end of their shifts and did not do so for several residents, including Resident #21. On 5/8/25 at 10:47 a.m., the administrator stated the residence required staff to document any specific incident impacting a resident at the end of their shifts or as soon as they can. Additionally, the residence failed to ensure that staff documented, before the end of their shift, any out-of-the-ordinary event or issue regarding a resident. It failed to ensure that the residents' records contained practitioner orders, and documentation provided by ESP for Residents #2, #12, #16-#20, and Former Resident #22.

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 7.14.11 Only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents. 14.20 The assisted living residence shall contact the authorized practitioner for clarification of any orders which are incomplete or unclear and obtain new orders in writing. 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(B) As part of the medication administration record, the assisted living residence shall maintain 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.(C) Each qualified medication administration person, nurse, or practitioner shall accurately document each medication administration or monitoring event at the time the event is completed for each resident.(D) Each qualified medication administration person, nurse, or authorized practitioner shall document accurate information in the medication administration record including any medication omissions, refusals, and resident reported responses to medications.

A relicensure survey with complaint revisit was completed on 5/8/25 for the previous deficiencies cited on 9/24/24. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new regulation Chapter 7 was implemented on 3/17/25.

Based on interview and record review the residence failed to ensure residents' comprehensive assessment included information regarding the resident's overall health and physical functioning ability, reactions to the environment and others, safety awareness and the types of physical, mental, and social support required by the resident, affecting seven of eight sample residents (#2, #12, #16-#20). (Cross-reference T1068, T1110, T1568, T1433). This deficiency was cited previously during a state licensure survey on 9/24/24. Although the residence corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:The residence's undated Resident Assessment Policy read in part that the residence completed a comprehensive assessment annually, or when a resident had a change in condition. Resident #12 was admitted to the residence on 6/3/19 with diagnoses including unspecified pain in the hip and neuropathy. Progress notes, dated 3/8/25-4/25/25, read in part:On 3/8, a representative from the resident's practitioner's office reported the resident experienced increased pain between 2:00 a.m. and 4:00 a.m., and asked the residence if they were administering medications correctly. On 4/25, the resident experienced pain that woke him. The most recent comprehensive assessment, dated 4/17/24, contained no information regarding the resident's history of pain other than his most recent pain level, dated 3/29/22, which was a six on an undisclosed scale. 3. InterviewsOn 5/6/25 at 9:28 a.m., the assistant administrator (AA) stated that the former health and wellness director (HWD) completed most assessments. She stated that the residence became aware in mid-April 2025 of multiple failures by the former HWD, and she no longer worked at the residence. The AA stated that the former HWD failed to address Resident #12's uncontrolled pain. In a later interview, on 5/8/25 at 10:06 a.m., the AA stated that the residence was required to ensure all assessments contained all of the resident's care needs, behavioral expressions, and all staff support needed by the resident and the residence may have not updated them. On 5/7/25 at 1:43 p.m., Resident #12 stated that he had unmanaged pain beginning in January 2025 until a slight improvement approximately mid-April 2025. He added he did not recall the residence assessing him after his pain increased. On 5/8/25 at 10:40 a.m., the administrator stated that the residence was required to include when a resident experienced a change in behavior, care, falls, or resident-reported changes in the resident's comprehensive assessment. He added that the residence had not corrected this citation due to the failures of the former HWD, who no longer worked at the residence. 4. Additionally, the residence failed to ensure residents comprehensive assessment included information regarding the resident's overall health and physical functioning ability, reactions to the environment and others, safety awareness and the types of physical, mental, and social support required by the resident for Residents #2 and #16-#20.

A complaint revisit was completed on 9/24/24 for all previous deficiencies cited on 2/1/23. The residence is in compliance with all regulations surveyed.

A relicensure survey with complaint #CO31250, #CO32996, #CO33104, #CO33232, #CO33742, #CO35414, #CO36269, and #CO37142 was completed on 9/24/24. Deficiencies were cited.

Based on observation, interview and record review, the residence failed to ensure residents' comprehensive assessments included a history and circumstances of recent falls and any known approaches to prevent future falls, affecting one sample resident (#8) who had recent falls. Findings Include: 1. References The residence's undated Resident Assessment Policy read in part: an updated resident assessment will be completed when a change of condition is noted and a new care plan would be initiated. 2. Record ReviewResident #8 was admitted to the residence on 2/29/24 with diagnoses including heart disease, chronic obstructive pulmonary disease, hyperlipidemia, major depressive disorder, and type II diabetes. An assessment dated 3/31/24, read in part that Resident #8 was at risk for falls due to impaired balance with foot sensation and high blood pressure. Interventions on 3/22/24 were that Resident #8 would call for assistance when needed and remain free of injury. Resident #8 required staff to lace up her lace up shoes, to pause when standing when she felt lightheaded, and to always be aware of the oxygen hose as a tripping hazard. A 30 day assessment had been updated by the director of resident services on 4/20/24 and signed by a physical therapist on 5/16/24 but failed to contain new or updated interventions for increased falls. An assessment, dated 4/20/24, read Resident #8 required escorts to meals, activities, and appointments. No further assessments were documented for Resident #8. Progress notes regarding falls for Resident #8 read as follows:4/6/24 at 10:35 a.m., the resident fell in the bathroom; maintenance staff picked her up. 4/16/2024 at 8:47 p.m., the resident slid out of a chair. Emergency medical services (EMS) were called to assist the resident off the floor. 5/3/2024 8:44 a.m., the resident fell after getting up from her chair. The resident was transported to the emergency department (ED) due to high blood sugar. 5/15/24 9:04 p.m., the resident required a wheelchair so she would not fall. 5/22/24 at 1:27 p.m., the resident fell and sustained knee pain. 5/31/23 at 3:52 p.m., the resident fell, and staff contacted 911 for lift assistance. 6/13/24 at 12:50 p.m., the resident had an unwitnessed fall. 6/15/24 at 4:07 p.m., the resident had an unwitnessed fall at approximately 3:35 p.m.; she sustained bruises on her right knee. 06/20/2024 at 4:18 p.m., the resident had an unwitnessed fall; her ankle gave out. 07/4/2024 at 5:44 p.m., the resident had an unwitnessed fall. 07/5/2024 at 10:16 p.m., the resident fell at about 8:30 p.m. EMS was called, and the resident was transported to the ED. A progress note from the clinical licensed practical nurse (CLPN), dated 7/6/24 at 3:30 p.m., read: "Resident continues on follow up S/P (status post) fall. Resident with frequent falls recently. Provider and POA (power of attorney) notified of increase and frequency in falls. Provider spoke with residents about getting down to the wellness center for strengthening and endurance. Residents were reminded and educated on the importance of going down to the wellness center for exercise. Resident verbalizes understanding. Resident denies pain at this time. No injuries observed. No concerns verbalized at this time." 7/12/2024 at 12:21 p.m., the resident had an unwitnessed fall in front of the dining room. 7/24/2024 at 09:04 p.m., the resident had an unwitnessed fall and hit her head. 3. InterviewsOn 9/24/24 at 12:00 p.m., the associate executive director said that when a resident fell three times within six to eight weeks, the residence should reassess the resident and implement new interventions to their care plan. On 9/24/24 at 1:50 p.m., the administrator stated that when a resident's baseline change was related to falls, the residence completed an assessment and a change of condition.

Based on record review and interview, the residence failed to ensure staff were trained to provide lift assistance when appropriate instead of relying on emergency medical responders, affecting 138 current residents. Findings Include: 1. Residence PolicyThe residence's undated Fall Management Program policy read in part that after finding a resident that had fallen, staff notified the service coordinator or director of nursing (DON). If the service coordinator or DON are out of the building, staff called 911 and requested assistance to assess the resident and to provide lift assistance. The residence's undated emergency response training read in part that when a resident fell or injured themselves: 1. Do not touch the resident. 2. Call a nurse immediately via the radio or ask another employee for assistance. 3. A nurse or QMAP [qualified medication administration personnel] will call 911. 2. Interviews On 9/23/24 at approximately 3:00 p.m., Resident #8 stated staff had difficulty assisting her after she had a fall; it took three to four staff members to lift her so staff decided to just call 911 and the emergency medical responders came to lift her. On 9/24/24 at 1:28 p.m., the associate executive director stated staff are trained to call 911 for lift assist if a resident that had fallen, were uninjured and staff were unable to assist the resident up. On 9/24/23 at 1:50 p.m., the administrator stated he expected staff to follow the residence's fall management policy of calling 911 when a resident fell and could not be assisted up by the current staff.

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 7.22.32 The assisted living residence shall ensure that oxygen tanks are secured upright at all times in a manner that prevents tanks from falling over, being dropped, or striking each other. 22.34 The assisted living residence shall ensure that oxygen tanks are not placed against electrical panels, live electrical cords, or near radiators or heat sources. If stored outdoors, tanks shall be protected from weather extremes and damp ground to prevent corrosion. 10.6 Each assisted living residence ' s emergency policies shall address, at a minimum, all of the following items:(A) Written instructions for each identified risk that includes persons to be notified and steps to be taken.(C) When to evacuate the premises and the procedure for doing so; (D) A pre-determined means of communicating with residents, families, staff and other providers;(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; (I) In the event relocation of residents becomes necessary, written agreements with other health facilities and/or community agencies."