DAYSPRING VILLA

A certification complaint, prompted by #CO34286, #CO34501, was completed on 1/18/24. A deficiency was cited.

Based on interview and record review, the facility (residence) failed to maintain and follow written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII Medication Administration Regulations, affecting two of six sample participants (residents) (#5, #13). Findings include:1. Chapter VII regulations governing assisted living residences, part 14.21, requires that the assisted living residence comply with authorized practitioner's orders associated with medication administration except for those medications which a resident self-administers.a. Residence PolicyThe residences medication policy, dated December 2022, read in part that the residence trained staff to provide medication administration services to residents according to state regulations. Staff administered medications to residents as ordered.b. Resident #13 was admitted to the residence on 1/20/23 with diagnoses including type II diabetes. A written practitioner's order, dated 12/5/23, directed the residence to administer dapagliflozin propanediol 10 mg daily. However, the January 2024 medication administration record read that the residence failed to administer the medication on 1/2, 1/3, and 1/7-1/10/24 because the medication was unavailable, for a total of six missed doses. On 1/18/24 at 12:10 p.m., Resident #13 stated that the residence did not have the medication because the pharmacy did not deliver it before she ran out of the medication. She stated that the staff tried their best to get the medication delivered timely, but they were unable to. On 1/18/24 at 12:47 p.m., the administrator stated that when staff documented that a medication was unavailable in the MAR, it meant that the residence did not administer the medication as ordered. On 1/18/24 at 12:47 p.m., the resident care coordinator stated that the pharmacy did not deliver the medication timely because of complications with Resident #13's insurance, so the medication was not in stock and the residence was unable to administer it as ordered. She stated that this deficiency which was previously cited was not corrected because the pharmacy sometimes was unable to send the medications due to orders, payment, or other extenuating circumstances.c. Additional evidence gathered during the on site investigation revealed the residence also failed to comply with authorized practitioner's orders for Resident #5.

A relicensure revisit was completed on 1/18/24 the previous deficiency cited on 10/31/23. The residence is in compliance with all regulations surveyed.

A relicensure survey was completed on 10/31/23. A deficiency was cited.

Based on observation and interview, the residence failed to ensure resident rooms occupied by smokers had fire resistant wastebaskets, affecting six of 10 residents who smoked (#7-#12). Findings include:On 10/31/23 at 9:55 a.m., the administrator provided a list of residents who smoked. Resident #7-#12 were identified as smokers. On 10/31/23 at approximately 1:00 p.m., an environmental tour of the residence revealed Resident #7-#12's wastebaskets were not fire resistant and were either made of plastic or wood. On 10/31/23 at approximately 2:30 p.m., the administrator said she was not aware the wastebaskets were required to be fire resistant for residents who were identified as smokers.

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 7.14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers. 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. (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 recertification survey was completed on 10/31/23. A deficiency was cited.

Based on interview, and record review, 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 two of three sample participants (residents) (#3, #5). 1. Chapter VII regulations governing assisted living residences, part 14.21, requires that the assisted living residence comply with authorized practitioner's orders associated with medication administration except for those medications which a resident self-administers.a. Residence PolicyThe Medication Administration policy, dated 12/2021, read in part "Community shall provide medication administration services to assisted living residents according to Colorado Department of Health and Environment (CDPHE) 6 CCR 1011-1 Chapter 24 and Chapter 7 regulations and current standards of Nursing Practice."b. Resident # 5 was admitted to the residence on 10/27/14. A written practitioner ' s order, dated 8/8/23, directed the residence to administer two famotidine tablets 20 mg two times daily. However, the October 2023 medication administration record (MAR) read that on 10/16/23 in the morning, 10/17/23 in the morning and evening, and 10/18/23 in the morning Resident #5 was not administered the medication because the medication was out of stock. On 10/31/23 at 12:13 p.m., the resident care coordinator (RCC) stated from 10/16 to 10/18/23 the famotidine was out of stock due to a complication with the pharmacy. She confirmed that Resident #5 was not administered her medication. 2. Chapter VII regulations governing assisted living residences, part 14.29, requires that the assisted living residence ensure that each qualified medication administration person (QMAP), nurse, or practitioner accurately document each medication administration or monitoring event at the time the event is completed for each resident.a. Residence PolicyThe residence ' s Medication Errors policy, dated December 2022, read in part "associates administering medication to residents are expected to follow right documentation."b. Resident #3 was admitted to the residence on 2/4/21. A written practitioner ' s order, dated 10/6/23, directed the residence to hold the administration of Lidocaine 4% patch until provided by the family. The October MAR on 10/22, 10/23, 10/25 through 10/29 and 10/31/23 Resident #3 refused the medication. On 10/24 and 10/31/23 the medication was documented as administered to Resident #3. c. ObservationOn 10/31/23 at 1:08 p.m., a medication cart audit revealed Lidocaine (4% patch) was out of stock.d. InterviewOn 10/31/23 at 12:13 p.m., the RCC stated that the hold for Lidocaine 4% patch was requested because the family had not brought in the medication. She confirmed that from 10/22/23 through 10/31/23 the Lidocaine 4% patch was out of stock and the MAR was incorrect. She stated that her expectation was for the QMAPs to have documented out of stock on the MAR.On 10/31/23 at approximately 12:30 p.m., the health and wellness coordinator confirmed the Lidocaine 4% patch was not in the medication cart. On 10/31/23 at 2:22 p.m., the administrator stated her expectation was for QMAPs to document accurate information in the medical administration record.

A certification revisit was completed on 10/31/23 for all previous deficiencies cited on 6/5/23. The facility is in compliance with all regulations surveyed

A licensure revisit was completed on 10/31/23 for all previous deficiencies cited on 6/5/23. The residence is in compliance with all regulations surveyed.

A certification complaint, prompted by #CO30104 and #CO30115, was completed on 6/5/23. A deficiency was cited

Based on record review and interview, the facility (residence) failed to ensure special health needs that support the individual's needs were documented in the care plan, affecting three of three participants (residents) who had falls (#2-#4). Findings include: 1. Resident #3 was admitted to the residence on 2/4/21 with diagnoses including Type 2 diabetes and neuropathy. Residence incident reports for Resident #3, dated 3/12/23-6/2/23, read: On 3/12/23, Resident #3 had a fall without injury. On 3/14/23, Resident #3 had a fall which resulted in severe pain from her lower back, which radiated into her hip. Additionally, she had shoulder pain and was struggling to stand up and walk. On 4/20/23, Resident #3 had a fall without injury. On 6/1/23, Resident #3 had a fall without injury. On 6/2/23, Resident #3 had a fall without injury. A practitioner's note, dated 3/16/23, read Resident #3 had a numerous fall that week, including the fall on 3/14/23. The note read Resident #3 was sent to the hospital due to complaints of severe left hip and right shoulder pain. The note read as of 3/16/23, Resident #3 had still been in pain and had refused to go to a rehabilitation center, as recommended. The residence's assessment for Resident #3, dated 5/11/23, read Resident #3 was a high fall risk. The residence's care plan for Resident #3, dated 11/1/22, read staff were expected to encourage Resident #3 to call for assistance ands read she was under safety checks. The care plan read Resident #3 was at risk for falls due to neuropathy. The care plan for Resident #3 was not updated to include individualized approaches necessary to address fall risks after Resident #3's falls on 3/12/23, 3/14/23, 4/20/23, 6/1/23, and 6/2/23. On 6/5/23 at 11:06 a.m., Resident #3 stated she had falls because she was diabetic and her legs swelled, which caused them to give out on her. She added she was unsure what staff did to help prevent her from falling. On 6/5/23 at 12:27 p.m., the health and wellness coordinator (HWC) stated the residence had requested physical and occupational for Resident #3 but stated she had only completed it once. She added, staff were expected to declutter Resident #3's room if she agreed. On 6/5/23 at approximately 12:27 p.m., the resident care coordinator (RCC) stated the residence had requested physical and occupational therapy for Resident #3 but stated she had only completed it once. She added, the family had gotten a wheelchair for Resident #3 but stated she did not use it. The RCC stated the resident had a fall in March, which resulted in the resident having pain and she was recommended to go to a rehabilitation center; however, the resident had declined. The RCC stated she had told the family that due to Resident #3's falls, the residence could not meet Resident #3's needs unless she agreed to physical and occupational therapy. On 6/5/23 at approximately 12:27 p.m., the administrator stated the residence had gotten a new walker for Resident #3 as an intervention for falls. She added she believed when Resident #3 was found after the fall on 3/14/23, she did not report pain until a couple of days later. 2. Resident #2 was admitted to the residence on 5/21/21 with a diagnosis of hypertension. Residence incident reports for Resident #2, dated 9/23/23-2/8/23, read: On 9/23/22, Resident #2 had a fall with no injury. On 2/8/23, Resident #3 had a fall with no injury. The residence's assessment for Resident #2, dated 11/15/22, read Resident #2 was a high fall risk. The residence's care plan for Resident #2, dated 11/22/22, read staff would encourage Resident #2 to call for assistance. Additionally, it read Resident #2 was at risk for falls. The care plan for Resident #2 was not updated to include individualized approaches necessary to address fall risks after Resident #2's fall on 2/8/23. On 6/5/23 at 10:55 a.m., Resident #2 stated she had a fall when she was trying to get something off the ground, and put her hand on her rolling storage container. She stated the container had rolled, which caused her to fall. She stated when she fell, she was unable to get up on her own because of her fibromyalgia. Resident #2 stated she lived at the residence because when she lived at home, she had repeated falls. Further, she stated her stepdaughter had removed the wheels on the storage container to prevent additional falls but was unaware what staff were doing to help prevent falls. On 6/5/23 at 12:25 p.m., the RCC, HWC and administrator all stated they were unaware of Resident #2's fall on 2/8/23. On 6/5/23 at approximately 12:25 p.m., the HWC stated when Resident #2 had a fall, she would contact Radiant #2's practitioner and suggest ideas of what to do as an intervention but stated it was the practitioner's choice. On 6/5/23 at approximately 12:25 p.m., the administrator stated staff were expected to remove clutter in Resident #2's room and remind her to use her walker. 3. Resident #4 A residence progress note for Resident #4, dated 3/21/23, read Resident #4 had a fall and did not want the staff to use the razor lift to assist her back up. Residence incident reports for Resident #4, dated 3/20/23-4/27/23, read: On 3/20/23, Resident #4 had a slip from bed without injury. On 3/21/23, Resident #4 had a fall without injury. On 4/21/23, Resident #4 slipped, without injury. On 4/27/23, Resident #4 had a fall without injury. The residence's assessment for Resident #4, dated 8/26/22, read Resident #4 was a moderate fall risk. The residence's care plan for Resident #4, dated 12/7/22, read Resident #4 was expected to call for staff assistance when needed. The care plan read Resident #4 was receiving physical therapy and used a wheelchair and a walker. Further, the care plan read Resident #4 was at a risk for falls due to a history of falling. The care plan for Resident #4 was not updated to include individualized approaches necessary to address fall risks after Resident #2's falls on 3/20/23, 3/21/23, 4/21/23, and 4/27/23. On 6/5/23 at 12:32 p.m., the HWC stated Resident #4 got tired at night, so staff were expected to help Resident #4 to get into bed. She added most of the time Resident #4 refused the help or would fall asleep in her chair then attempt to transfer herself. She added she believed the intervention was in Resident #4's care plan. On 6/5/23 at approximately 12:32 p.m., the administrator stated Resident #4 did not remember to call for help and tried to transfer on her own and fell. On 6/5/23 at approximately 12:32 p.m., the RCC stated Resident #4 was working with physical and occupational therapy as much as she could. Further, she stated Resident #4 had recently gotten an electric wheelchair, which helped her reserve energy. 4. Interview On 6/5/23 at 12:36 p.m., the HWC stated she was responsible for updating resident care plans. She added, resident care plans should have been updated after falls. Further, the HWC confirmed after Resident #2-#4's falls, their care plans should have been updated to include interventions. She added she was not aware Resident #2-#4's care plans were not updated to include fall interventions. On 6/5/23 at approximately 12:36 p.m., the administrator stated resident care plans were expected to be completed after each resident fall to include interventions. She added she was not aware Resident #2-#4's care plans had not been updated after their falls to include new interventions. The administrator confirmed the care plans for Resident #2-#4 should have been updated after each of their falls.

A licensure complaint, prompted by #CO30103 and #CO30114, was completed on 6/5/23. Deficiencies were cited

Based on record review and interview, the residence failed to have a roster of current residents, their room assignments and emergency contact information, along with a residence diagram showing room locations, affecting 70 current residents. Findings include: On 6/5/23 at approximately 8:00 a.m., the residence's roster was provided. The roster did not include emergency contact information or a residence diagram showing room locations. On 6/5/23 at 8:36 a.m., the administrator confirmed the roster provided was the residence's roster. On 6/5/23 at approximately 12:30 p.m., the administrator stated the residence's roster was expected to have resident names and room numbers. The administrator acknowledged the roster was required to include emergency contact information and stated she was not aware the roster was expected to be provided along with a residence diagram showing room locations.

Based on record review and interview, the residence failed to establish a fall management program that included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting three of three sample residents who had falls (#2-#3). Specifically, Resident #3 was admitted to the residence on 2/4/21 with diagnoses including Type 2 diabetes and neuropathy. Resident #3 had falls on 3/12/23, 3/14/23, 4/20/23, 6/1/23, and 6/2/23. The fall on 3/14/23 resulted in Resident #3 having severe pain in her left hip and right shoulder. The resident went to the hospital but refused to seek further care at a rehabilitation center, as suggested by the hospital The residence did not update the care plan for Resident #3 with individualized approaches to prevent future falls after the falls on 3/12/23, 3/14/23, 4/20/23, 6/1/23, and 6/2/23. Findings include: 1. Residence Policy The residence's falls policy, dated February 2023, read in part: "Intervene to prevent falls for at-risk individuals which may include notifying primary care physician and/or requesting a therapy evaluation. Maintain routine falls intervention efforts ..." 2. Resident #3 was admitted to the residence on 2/4/21 with diagnoses including Type 2 diabetes and neuropathy. Residence incident reports for Resident #3, dated 3/12/23-6/2/23, read: On 3/12/23, Resident #3 had a fall without injury. On 3/14/23, Resident #3 had a fall which resulted in severe pain from her lower back, which radiated into her hip. Additionally, she had shoulder pain and was struggling to stand up and walk. On 4/20/23, Resident #3 had a fall without injury. On 6/1/23, Resident #3 had a fall without injury. On 6/2/23, Resident #3 had a fall without injury. A practitioner's note, dated 3/16/23, read Resident #3 had a numerous fall that week, including the fall on 3/14/23. The note read Resident #3 was sent to the hospital due to complaints of severe left hip and right shoulder pain. The note read as of 3/16/23, Resident #3 had still been in pain and had refused to go to a rehabilitation center, as recommended. The residence's assessment for Resident #3, dated 5/11/23, read Resident #3 was a high fall risk. The residence's care plan for Resident #3, dated 11/1/22, read staff were expected to encourage Resident #3 to call for assistance ands read she was under safety checks. The care plan read Resident #3 was at risk for falls due to neuropathy. The care plan for Resident #3 was not updated to include individualized approaches necessary to address fall risks after Resident #3's falls on 3/12/23, 3/14/23, 4/20/23, 6/1/23, and 6/2/23. On 6/5/23 at 11:06 a.m., Resident #3 stated she had falls because she was diabetic and her legs swelled, which caused them to give out on her. She added she was unsure what staff did to help prevent her from falling. On 6/5/23 at 12:27 p.m., the health and wellness coordinator (HWC) stated the residence had requested physical and occupational for Resident #3 but stated she had only completed it once. She added, staff were expected to declutter Resident #3's room if she agreed. On 6/5/23 at approximately 12:27 p.m., the resident care coordinator (RCC) stated the residence had requested physical and occupational for Resident #3 but stated she had only completed it once. She added, the family had gotten a wheelchair for Resident #3 but stated she did not use it. The RCC stated the Resident had a fall in March, which resulted in the resident having pain and she was recommended to go to a rehabilitation center; however, the resident had declined. The RCC stated she had told the family that due to Resident #3's falls, the residence could not meet Resident #'s needs unless she agreed to physical and occupational therapy. On 6/5/23 at approximately 12:27 p.m., the administrator stated the residence had gotten a new walker for Resident #3 as an intervention for falls. She added she believed when Resident #3 was found after the fall on 3/14/23, she did not report pain until a couple of days later. 3. Resident #2 was admitted to the residence on 5/21/21 with a diagnosis of hypertension. Residence incident reports for Resident #2, dated 9/23/23-2/8/23, read: On 9/23/22, Resident #2 had a fall with no injury. On 2/8/23, Resident #3 had a fall with no injury. The residence's assessment for Resident #2, dated 11/15/22, read Resident #2 was a high fall risk. The residence's care plan for Resident #2, dated 11/22/22, read staff would encourage Resident #2 to call for assistance. Additionally, it read Resident #2 was at risk for falls. The care plan for Resident #2 was not updated to include individualized approaches necessary to address fall risks after Resident #2's fall on 2/8/23. On 6/5/23 at 10:55 a.m., Resident #2 stated she had a fall where she was trying to get something off the ground, and put her hand on her rolling storage container. She stated the container had rolled, which caused her to fall. She stated when she fell, she was unable to get up on her own because of her fibromyalgia. Resident #2 stated she lived at the residence because when she lived at home, she had repeated falls. Further, she stated her stepdaughter had removed the wheels on the storage container to prevent additional falls but was unaware what staff were doing to help prevent falls. On 6/5/23 at 12:25 p.m., the RCC, HWC and administrator all stated they were unaware of Resident #2's fall on 2/8/23. On 6/5/23 at approximately 12:25 p.m., the HWC stated when Resident #2 had a fall, she would contact Radiant #2's practitioner and suggest ideas of what to do as an intervention but stated it was the practitioner's choice. On 6/5/23 at approximately 12:25 p.m., the administrator stated staff were expected to remove clutter in Resident #2's room and remind her to use her walker. 4. Resident #4A residence progress note for Resident #4, dated 3/21/23, read Resident #4 had a fall and did not want the staff to use the razor lift to assist her back up. Residence incident reports for Resident #4, dated 3/20/23-4/27/23, read: On 3/20/23, Resident #4 had a slip from bed without injury. On 3/21/23, Resident #4 had a fall without injury. On 4/21/23, Resident #2 slipped, without injury. On 4/27/23, Resident #4 had a fall without injury. The residence's assessment for Resident #4, dated 8/26/22, read Resident #4 was a moderate fall risk. The residence's care plan for Resident #4, dated 12/7/22, read Resident #4 was expected to call for staff assistance when needed. The care plan read Resident #4 was receiving physical therapy and used a wheelchair and a walker. Further, the care plan read Resident #4 was at a risk for falls due to a history of falling. The care plan for Resident #4 was not updated to include individualized approaches necessary to address fall risks after Resident #2's falls on 3/20/23, 3/21/23, 4/21/23, and 4/27/23. On 6/5/23 at 12:32 p.m., the HWC stated Resident #4 got tired at night, so staff were expected to help Resident #4 to get into bed. She added most of the time Resident #4 refused the help or would fall asleep in her chair then attempt to transfer herself. She added she believed the intervention was in Resident #4's care plan. On 6/5/23 at approximately 12:32 p.m., the administrator stated Resident #4 did not remember to call for help and tried to transfer on her own and fell. On 6/5/23 at approximately 12:32 p.m., the RCC stated Resident #4 was working with physical and occupational therapy as much as she could. Further, she stated Resident #4 had recently gotten an electric wheelchair, which helped her reserve energy. 5. Interview On 6/5/23 at 12:36 p.m., the HWC stated she was responsible for updating resident care plans. She added, resident care plans should have been updated after falls. Further, the HWC confirmed after Resident #2-#4's falls, their care plans should have been updated to include interventions. She addedshe was not aware Resident #2-#4's care plans were not updated to include fall interventions. On 6/5/23 at approximately 12:36 p.m., the administrator stated resident care plans were expected to be completed after each resident fall to include interventions. She added she was not aware Resident #2-#4's care plans had not been updated after their falls to include new interventions. The administrator confirmed the care plans for Resident #2-#4 should have been updated after each of their falls.