A CHANGE OF SEASONS ASSISTED LIVING LLC

A revisit survey was completed on 2/10/25 for all previous deficiencies cited on 11/6/24. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 2/10/25 for all previous deficiencies cited on 11/6/24. The facility is in compliance with all deficiencies that were cited.

A recertification survey revisit was completed on 11/6/24 for the previous deficiency cited on 12/28/23. The facility is in compliance with all regulations surveyed. The regulations governing Alternative Care Facilities were revised and the new regulations were implemented on 11/30/23. The deficiency cited for Event 0OQ911 was cited prior to the regulation revision that was implemented 11/30/23.

A certification complaint, prompted by #CO38017, was completed on 11/6/24. A deficiency was cited.

Based on record review and interview the residence failed to comply with Chapter 7, Part 11 by not providing a written notice of involuntary discharge, affecting one former member (#4). References:11.17 Written notice of involuntary discharge must include the following: (A) A detailed explanation of the reason or reasons for the discharge, including, at a minimum: (1) Facts and evidence supporting each reason given by the residence, and (2) A recounting of events leading to the involuntary discharge, including interactions with the resident over a period of time prior to the notice and actions taken to avoid discharge, specifying the timing of the events and actions. (B) Statements conveying the following information: (1) That the individual receiving the notice has the right to file a grievance with the residence challenging the involuntary discharge within 14 days of the written notice, regardless of whether the resident has already been removed from the assisted living residence, (2) That if a grievance is filed, the assisted living residence must provide a response to the grievance within five business days, and (3) If the resident or person filing the grievance is dissatisfied with the response, that the resident or person filing the grievance may appeal to the executive director of the Colorado Department of Public Health and Environment or their designee. (C) Names and contact information, including phone numbers, physical addresses, and email addresses, for the state long-term care ombudsman, the designated local ombudsman, and the Colorado Department of Public Health and Environment. (D) If the involuntary discharge is initiated due to a medical or physical condition resulting in a required level of care that cannot be treated with medication or services routinely provided by the residence ' s staff or an external service provider, the notice must also include an assessment by the resident ' s applicable health-care or behavioral health provider of the resident ' s current needs in relation to the resident ' s medical and physical condition. 11.18 A copy of any involuntary discharge notice shall be sent to the state long-term care ombudsman and the designated local ombudsman, within five (5) calendar days of the date that it is provided to the resident and the resident's legal representative. Findings include:Former Member #4 was admitted to the facility on 8/24/24 with a diagnosis of dementia. A progress note dated 9/17/24 read in part, communication from former Member #4's legal representative about an appointment. Former Member #4 and legal representative left the facility at 11:30 a.m. The facility did not document anything further for former Member #4. On 11/6/24 at approximately 8:45 a.m., Staff #2 stated that an emergency care conference was held the week former Resident #4 was discharged. She also stated that in the care conference, an agreement was reached to start a new medication to help alleviate some of the challenging behaviors. Staff #2 reported at the time of the conference the legal representative was on board with the changes, however, the next day was when the residence received communication from the external hospice provider that the legal representative was discontinuing hospice care services. She further stated that the following day the hospice social worker and nurse arrived at the residence to meet with the legal representative to complete the discharge. Staff #2 stated that it was at this time the residence learned of a practitioner's appointment for former Resident #4 which was scheduled without the residence's knowledge. She stated later that day, the residence was contacted by an unknown practitioner to get their fax number to send over new prescriptions. Staff #2 stated, the residence did not have the medications ordered nor did they have a pharmacy agreement with the legal guardian to fill the prescriptions. Staff #2 elaborated explaining the new practitioner was not informed that former Resident #4 was not using external hospice services as of that morning. Finally, Staff #2 recalled the interaction when the legal guardian returned to the residence with former Resident #4, the administrator told the legal representative because you had discontinued hospice care and former Resident #4 was unsafe and the residence could not safely meet her needs. On 11/6/24 at 12:30 p.m., the administrator stated due to the rushed and difficult nature of the ending of services she did not complete any reports or discharge summaries. She said she did not send a copy of the written involuntary discharge notice to the local or state long-term ombudsman because one was never written. She did explain that she was not aware this was a requirement. She stated she called the local ombudsman after this instance to inform them of what was going on and the local ombudsman recorded the information.

A licensure complaint, prompted by #CO38016, was completed on 11/6/24. Deficiencies were cited.

Based on record review and interview the residence failed to develop and implement an involuntary discharge grievance policy which included all required elements, affecting 10 current residents. Findings include:The residence's involuntary discharge section of the resident agreement failed to include the following required elements:1. The individual designated by the assisted living residence to receive involuntary discharge grievances. 2. The ability of any of the persons in the assisted living residence is required to notify under Part 11.16 to file a grievance challenging the involuntary discharge and reasons for the discharge with the individual designated in subpart (A), above, within 14 calendar days after the assisted living residence provides written notice of the involuntary discharge. 3. The ability for the resident, or other person allowed to file a grievance to receive assistance in preparing and filing a grievance without interference from the assisted living residence. 4. A requirement that grievances related to involuntary discharge be submitted to the individual designated by the facility under subpart (A) as follows: A. In writing, or B. Orally submitted to the individual designated under subpart (A), above. In the case of an oral submission, the assisted living residence shall ensure the individual submitting the grievance retains proof of the oral submission through a witness or other evidence. a. If the grievance is orally submitted and witnessed, the assisted living residence shall ensure that the resident or other person filing the grievance has the witness ' s name and contact information, and shall keep that information as part of the grievance documentation. 5. A requirement that no later than 5 business days after the submission of a grievance under subpart (D), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall respond to the grievance as follows: B. An oral explanation of the written response shall be provided to the resident and person filing the grievance, as appropriate. C. The written response shall include the following statement regarding the filing of an appeal: "If the resident, or other person that submitted this grievance is dissatisfied with this response, they may file an appeal to the executive director of the Colorado Department of Public Health and Environment within 5 business days after receiving this written response. The appeal must include the original grievance, the original notice of involuntary discharge and supporting documentation given to the resident as part of that notification, and any additional information or documentation." 6. Acknowledgement that if the resident, the individual filing the grievance, or the assisted living residence is dissatisfied with the findings and recommendations of the Department related to an appeal, they may request a hearing conducted by the Department under Section 24-4-105, C.R.S. 7. A requirement that the assisted living residence does not take any punitive or retaliatory action against a resident due to the resident filing a grievance or appeal under this Part. 8. A requirement that the assisted living residence continue to assist with planning a discharge or transfer of the resident while the grievance or appeal to the Department is pending. 9. A requirement that the resident be allowed to return to the assisted living residence if all of the following apply: A. The stated reason for the involuntary discharge in the notice of involuntary discharge provided under Part 11.17 is nonpayment of monthly services or room and board, B. The assisted living residence discharged the resident on or after the 31st day after the written notice of involuntary discharge was provided to the resident and C. The resident substantially complied with payments due to the residence, as determined through the grievance and appeal process. On 11/6/24 at approximately 8:00 a.m., the administrator stated the residence did not have any admissions or discharge policies. She provided the resident agreement as it had a section that covered termination of the agreement and discharge. She acknowledged the policy did not include all of the required elements.

Based on record review and interview the residence failed to provide a written notice of involuntary discharge which includes all required elements, affecting one former resident (#4). (Cross-reference S1074)Findings include:Former Resident #4 was admitted to the residence on 8/24/24 with a diagnosis of dementia. A progress note dated 9/17/24 read in part, communication from former Resident #4's legal representative about an appointment. Former Resident #4 and her legal representative left the residence at 11:30 a.m. The residence did not document anything further for former Resident #4. On 11/6/24 at 8:15 a.m., the administrator stated former Resident #4 only lived at the residence for a few weeks. She also stated the former resident was admitted to the residence with external hospice services to support her for various reasons; especially difficult behaviors, which include but are not limited to physical aggression, verbal aggression, refusal of care and treatment, and urinating and defecating on the floor. The administrator explained when she agreed to admit former Resident #4 to the residence she was warned, by the administrator of former Resident #4's prior residence, that the legal representative had a pattern of past behaviors of admitting former Resident #4 to a residence and external hospice then oppose the recommendation, become combative and insulting, then terminate everyone and leave without any notice. The administrator continued by stating that it did not take long for the legal representative to start dictating the care and services without offering any help or support and then started refusing medication recommendations from the hospice provider. She stated in the last few days, the legal representative discontinued the external hospice provider and scheduled an appointment with a new practitioner unknown to the residence to change all of the medication orders for former Resident #4. On 11/6/24 at approximately 8:45 a.m., Staff #2 stated that an emergency care conference was held the week former Resident #4 was discharged. She also stated that in the care conference, an agreement was reached to start a new medication to help alleviate some of the challenging behaviors. Staff #2 reported at the time of the conference the legal representative was on board with the changes, however, the next day was when the residence received communication from the external hospice provider that the legal representative was discontinuing hospice care services. She further stated that the following day the hospice social worker and nurse arrived at the residence to meet with the legal representative to complete the discharge. Staff #2 stated that it was at this time the residence learned of a practitioner's appointment for former Resident #4 which was scheduled without the residence's knowledge. She stated later that day, the residence was contacted by an unknown practitioner to get their fax number to send over new prescriptions. Staff #2 stated, the residence did not have the medications ordered nor did they have a pharmacy agreement with the legal guardian to fill the prescriptions. Staff #2 elaborated explaining the new practitioner was not informed that former Resident #4 was not using external hospice services as of that morning. Finally, Staff #2 recalled the interaction when the legal guardian returned to the residence with former Resident #4, the administrator told the legal representative because you had discontinued hospice care and former Resident #4 was unsafe and the residence could not safely meet her needs. On 11/6/24 at 11:45 a.m., the external hospice nurse stated former Resident #4 was transferred to her care when former Resident #4 was admitted to the residence. The nurse explained that the nurse who was working the case prior to her informed her the resident has been transferred several times between different residences and external hospice providers. The nurse explained the case was very challenging becauseformer Resident #4 was very combative and agitated. The nurse explained that during the emergency care conference, the legal guardian agreed to a new order for seroquel at a low dose to help with anxiety and emotional regulation. The nurse stated she got a communication from the administrator at 8:00 p.m. that evening that the legal guardian had scheduled a practitioner's appointment at 11:00 a.m. the following day. The nurse pointed out how unusual that was as the hospice provider was the primary care provider for anyone in hospice care. The nurse recalled the next day after receiving communication from the hospice social worker that the legal guardian was discontinuing hospice care. The nurse and the social worker met the administrator and the legal guardian at the residence prior to the practitioner's appointment at which time the legal representative signed the forms to discontinue hospice care services. The nurse clarified that she learned later that the legal guardian was taking former Resident #4 to a new doctor who was unaware of the recent change in treatment services. On 11/6/24 at 12:30 p.m., the administrator stated after the ending of external hospice services and changing of medications the residence could not effectively meet her needs and immediately discharged the former resident. She further stated she did not complete an involuntary discharge summary due to the rushed and difficult nature of the ending of services she did not complete any reports or discharge summaries. On 11/7/24 at 10:00 a.m., an external hospice social worker stated former Resident #4 was transferred to the residence from another residence after a disagreement with the legal representative and the prior residence. The social worker explained that former Resident #4 was a difficult resident with challenging behaviors. He stated the legal guardian was oppositional or resistant to medical interventions to reduce these concerns. Further, he stated the legal guardian ended services with hospice care services with no notice.

Based on record review and interview the residence failed to provide a copy of an involuntary discharge notice to the state long-term care ombudsman, affecting one former resident (#4). (Cross-reference S1072)Findings include:Former Resident #4 was admitted to the residence on 8/24/24 with a diagnosis of dementia. A progress note dated 9/17/24 read in part, communication from former Resident #4's legal representative about an appointment. Former Resident #4 and the legal representative left the residence at 11:30 a.m. The residence did not document anything further for former Resident #4. On 11/6/24 at 12:30 p.m., the administrator stated she did not send a copy of the written involuntary discharge notice to the local or state long-term ombudsman because one was never written. She did explain that she was not aware this was a requirement.

A relicensure survey revisit was completed on 11/6/24 for all previous deficiencies cited on 12/28/23. The residence is in compliance with all regulations surveyed. The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24. The deficiencies cited for Event Z1VN11 were cited prior to the regulation revision that was implemented on 1/14/24.

A recertification survey was completed on 12/28/23. A deficiency was cited.

Based on observation, record review and interview, the facility (residence) failed to follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII medication administration regulations, affecting eight current participants (residents). Findings include: Chapter VII regulations governing assisted living residences, part 14.31, requires the administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence's Quality Management Program assessment and review. On 12/28/23 at 7:45 a.m., the administrator was requested to provide the residence's quarterly medication cart audits; however, she was unable to provide the documentation. On 12/28/23 at 8:30 a.m., the administrator stated she conducted medication cart audits; however, she had not documented the results of the audits. The administrator confirmed there was no documentation for the medication cart audits.

A relicensure survey was completed on 12/28/23. Deficiencies were cited.

Based on record review and interview, the residence failed to show compliance with the Colorado Adult Protective Services Data System (CAPS Check), prior to hiring staff who provided direct care to at-risk residents for two of three sample staff (#1, #2), affecting eight current residents. Findings include: 1. References a. According to Colorado Revised Statutes (2020) Title 26 Human Services Code, " ... individuals receiving care and services from persons employed in programs or facilities ... are vulnerable to mistreatment, including abuse, neglect, and exploitation. It is the intent of the general assembly to minimize the potential for employment of persons with a history of mistreatment of at-risk adults in positions that would allow those persons unsupervised access to these adults. As a result, the general assembly finds it necessary to strengthen protections for vulnerable adults by requiring certain employers to request a CAPS check by the state department to determine if a person who will provide direct care to an at-risk adult has been substantiated in a case of mistreatment of an at-risk adult." Justia US Law (2018), 2018 Colorado Revised Statutes Title 26 - Human Services Code Article 3.1 - Protective Services for Adults at Risk of Mistreatment or Self-Neglect Part 1 - Protective Services for At-Risk Adults § 26-3.1-111. Access to CAPS - employment checks - confidentiality - fees - rules - legislative declaration - definitions, retrieved from: https://law.justia.com/codes/colorado/2018/title-26/article-3.1/part-1/section-26-3.1-111/b. C.R.S. 26-3.1-101 (1.8) reads a "CAPS check" means a check of the Colorado adult protective services data system pursuant to section 26-3.1-111.c. Chapter VII regulations governing assisted living residences, part 2.7, defines an "At-risk person" as any person who is 70 years of age or older, or any person who is 18 years of age or older and meets one or more of the following criteria: (D) Is a person with an intellectual and developmental disability as defined in Section 25.5-10-202, C.R.S.; (E) Is a person with a mental health disorder as defined in Section 27-65-102(11.5), C.R.S.2. Observation On 12/28/23 from 7:15 a.m. to 11:30 a.m., Staff #1 was observed working at the residence. 3. Record ReviewThe personnel files for Staff #1 and Staff #2 revealed they were hired on 4/5/20 and 11/19/22, respectively. However, the files contained no evidence a CAPs check had been completed. Review of the December 2023 staff schedule, revealed Staff #1 worked at the residence on the following dates: 12/1/2312/6-12/8/2312/13-12/16/2312/20-12/22/2312/25-12/28/23Review of the December 2023 staff schedule, revealed Staff #2 worked at the residence on the following dates:12/1-12/2/2312/4/2312/6/2312/9-12/11/2312/13/2312/17-12/18/2312/20/2312/23/2312/25/2312/27/234. InterviewOn 12/28/23 at 10:11 a.m., the administrator stated she had assumed the administrator role in July, 2020, and was unaware that CAPs checks were required for new employees. She stated she had not been made aware of the requirement until sometime in 2021 which was why a CAPs check had not been completed for Staff #1. However, she could not explain why a CAPs check had not been completed for Staff #2 who was hired on 11/19/22. The administrator confirmed that a CAPs check had not been completed for Staff #1 and #2.

Based on record review and interview, the residence failed to ensure medication audits were completed and documented by the administrator and qualified medication administration person (QMAP) supervisor on a quarterly basis, affecting eight current residents. Findings include:On 12/28/23 at 7:45 a.m., the administrator was requested to provide the residence's quarterly medication cart audits; however, she was unable to provide the documentation. On 12/28/23 at 8:30 a.m., the administrator stated she conducted medication cart audits; however, she had not documented the results of the audits. The administrator confirmed there was no documentation for the medication cart audits.

A revisit survey was completed on 12/15/2023 for all previous deficiencies cited on 3/24/22. The facility is in compliance with all deficiencies that were cited.