PARK HILL RESIDENCE

A complaint revisit was completed on 2/5/25 for all previous deficiencies cited on 10/21/24. A deficiency was cited.

Based on observation and interview the residence failed to make available a physically safe environment sufficient to meet the needs of residents, affecting 24 residents who resided on the second floor. This deficiency was cited previously during a state licensure survey on 10/21/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 2/5/25 at 7:13 a.m., observation of the residence's bathroom E (one of five and a half bathrooms on the second floor) had dislodged tiles from the outside corner of the shower. The tiles were sharp and located next to the entrance of the shower which presented a partial risk of injury. On 2/5/25 at 2:45 p.m., the administrator stated, she was unaware that bathroom E had a dislodged tile from the corner of the shower. She stated she agreed that this posed a risk of injury.

A relicensure survey with complaints #CO35460, #CO36485, #CO37121, and #CO37793 was completed on 10/21/24. Deficiencies were cited.

Based on observation, record review, and interview, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting one of five sample residents (#2). Findings include:Resident #2 was admitted to the residence on 10/21/21 with diagnoses including hypertension. A written practitioner's order, dated 6/21/24, directed the residence to administer lisinopril 30 mg daily. However, the October 2024 medication administration record read that the residence failed to administer the medication on 10/2/24 because the medication was unavailable. On 10/21/24 at 3:45 p.m., the resident service coordinator and the director of operations acknowledged that the residence had failed to administer one dose of lisinopril.

Based on record review and interview, the residence failed to, on a quarterly basis, audit the controlled substance list, medication error reports and medication disposal records, affecting 28 current residents. Findings include:On 10/21/24 at approximately 7:50 a.m., medication audits were requested; however, they were never provided. On 8/8/24, at approximately 1:15 p.m., the resident service coordinator (RSC) stated she had contacted the wellness coordinator, who stated the medication audits had not been completed. The RSC stated she was unaware of the requirement to conduct quarterly medication audits of the controlled substance lists, medication error reports, and medication disposal records. On 10/21/24, at approximately 3:45 p.m., the RSC and director of operations acknowledged the residence's failure to complete quarterly audits.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents: (A) A physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population.

A recertification survey with complaint #CO35461, #CO36486, #CO37122, and #CO37794 was completed on 10/21/24. A deficiency was cited.

Based on record review and interview, the facility failed to provide sufficient support to members in the use on prescription medications, affecting one member (#2). Findings include:Member #2 was admitted to the residence on 10/21/21 with diagnoses including hypertension. A written practitioner's order, dated 6/21/24, directed the facility to administer lisinopril 30 mg daily. However, the October 2024 medication administration record read that the facility failed to administer the medication on 10/2/24 because the medication was unavailable. On 10/21/24 at 3:45 p.m., the resident service coordinator and the director of operations acknowledged that the facility had failed to administer one dose of lisinopril.

A relicensure survey was completed on 10/25/23. No deficiencies were cited.

A recertification survey was completed on 10/25/23. No deficiencies were cited.

A revisit survey was completed on 7/24/23 for all previous deficiencies cited on 3/9/23. No deficiencies were cited.

A revisit survey was completed on 7/24/23 for all previous deficiencies cited on 3/9/23. No deficiencies were cited.

A certification complaint, prompted by #CO30218, was completed on 3/9/23. A deficiency was cited.

Based on interview and record review, the residence (facility) failed to conduct an assessment whenever there was a significant change in physical, cognitive, or behavioral needs. Additionally, the residence failed to document in the assessment that the residence was able to support a resident's needs, along with the resident's physical, behavioral and social needs, affecting one current resident (participant) (#1). Findings include:1. Residence PolicyThe residence's comprehensive resident assessment policy, dated March 2022, read in part that the comprehensive resident assessment was updated whenever a resident's condition changed from baseline status to determine if additional needs had emerged and whether the residence could fully meet them. 2. Record ReviewResident #1 was admitted to the residence on 7/26/22 with diagnoses including major depressive disorder, anxiety disorder, and post-traumatic stress disorder. An assessment, dated 9/28/22, read in part that Resident #1 used available resources to cope with stress. The assessment did not address that the resident required periodic interventions to facilitate expressions of feeling or resolve conflict. A progress note, dated 2/16/23, read in part that Resident #1 stated, "she just wants to take all of her (medications) so this all will be over." Staff noted that it appeared as though the resident had been cutting her wrists. Staff telephoned a crisis hotline, and a therapist spoke with Resident #1. The staff then spoke with the therapist who stated that staff should check on her more frequently. A 24 hour communication note, dated 2/16/23, read in part that Resident #1 was upset at everyone. She stated that no one cared. Resident #1 tried to cut her wrist with her razor; she just scratched her wrists. Staff telephoned a crisis hotline, and a therapist spoke with the resident on the telephone. A progress note, dated 2/25/23, read in part that Resident #1 telephoned 911 from her room and told the responder that "she was going to kill herself and her blood would be on the administrator's hands." The resident was transported to the emergency department (ED). 3. InterviewsOn 3/9/23 at approximately 8:40 a.m., the administrator confirmed the residence had not completed a comprehensive assessment since 9/28/22, and she stated that the resident services director (RSD) should have completed a comprehensive assessment when Resident #1 experienced changes in her baseline status. On 3/9/23 at 9:08 a.m., the RSD acknowledged Resident #1's self harming behaviors began within 30 days prior to the on site investigation, and she stated that this was considered a change in condition. The RSD stated she should have completed a comprehensive assessment but did not do so. On 3/9/23 at 9:34 a.m., Staff #1 stated he was aware that Resident #1 recently attempted to cut her wrists and acknowledged this was a change in her baseline status because he had not seen her do this before.

A licensure complaint, prompted by #CO30217, was completed on 3/9/23. A deficiency was cited.

Based on interview and record review, the residence failed to update the comprehensive assessment whenever the resident's condition changed from baseline status, affecting one current resident (#1). Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 12.7, requires that the comprehensive assessment shall include all the following items:(D) Communication ability and any specific needs to facilitate effective communication;(E) Current diagnoses and any known or anticipated need or impact related to the diagnoses;(H) Reactions to the environment and others, including changes that may occur at certain times or in certain circumstances;(K) Safety awareness;(L) Types of physical, mental, and social support required.b. The residence's comprehensive resident assessment policy, dated March 2022, read in part that the comprehensive resident assessment was updated whenever a resident's condition changed from baseline status to determine if additional needs had emerged and whether the residence could fully meet them. 2. Record ReviewResident #1 was admitted to the residence on 7/26/22 with diagnoses including major depressive disorder, anxiety disorder, and post-traumatic stress disorder. An assessment, dated 9/28/22, read in part that Resident #1 used available resources to cope with stress. The assessment did not address that the resident required periodic interventions to facilitate expressions of feeling or resolve conflict. A progress note, dated 2/16/23, read in part that Resident #1 stated, "she just wants to take all of her (medications) so this all will be over." Staff noted that it appeared as though the resident had been cutting her wrists. Staff telephoned a crisis hotline, and a therapist spoke with Resident #1. The staff then spoke with the therapist who stated that staff should check on her more frequently. A 24 hour communication note, dated 2/16/23, read in part that Resident #1 was upset at everyone. She stated that no one cared. Resident #1 tried to cut her wrist with her razor; she just scratched her wrists. Staff telephoned a crisis hotline, and a therapist spoke with the resident on the telephone. A progress note, dated 2/25/23, read in part that Resident #1 telephoned 911 from her room and told the responder that "she was going to kill herself and her blood would be on the administrator's hands." The resident was transported to the emergency department (ED). 3. InterviewsOn 3/9/23 at approximately 8:40 a.m., the administrator confirmed the residence had not completed a comprehensive assessment since 9/28/22, and she stated that the resident services director (RSD) should have completed a comprehensive assessment when Resident #1 experienced changes in her baseline status. On 3/9/23 at 9:08 a.m., the RSD acknowledged Resident #1's self harming behaviors began within 30 days prior to the on site investigation, and she stated that this was considered a change in condition. The RSD stated she should have completed a comprehensive assessment but did not do so. On 3/9/23 at 9:34 a.m., Staff #1 stated he was aware that Resident #1 recently attempted to cut her wrists and acknowledged this was a change in her baseline status because he had not seen her do this before.