JUNIPER VILLAGE AT AURORA

A relicensure survey with complaint #CO41692 was completed on 6/10/26. Deficiencies were cited.

Based on record review and interviews, the residence failed to obtain a name-based criminal history report conducted by the Colorado Bureau of Investigation (CBI) for two of the three personnel files sampled (#2, #3), affecting 48 current residents. Findings Include:Review of the personnel files for Staff #2 and #3 revealed no evidence of CBI checks being conducted prior to the staff being hired. On 6/9/26 at approximately 1:45 p.m., the administrator stated that the previous business office manager failed to run CBI checks before hire. She explained that when she became administrator, she had implemented this requirement for all staff hired.

Based on record review and interviews, the residence failed to ensure each personnel file contained written documentation of orientation and training for one of three personnel files sampled (#3). Findings Include:A review of the personnel file for Staff #3 revealed no evidence of documentation of orientation and training or proof of portable training accepted by the residence. On 6/10/26 at 8:15 a.m., the administrator stated that she was unaware of the lack of documentation in Staff #3's personnel file. She acknowledged that this should be part of the record and confirmed that Staff #3 did receive orientation and training.

Based on record review and interview, the residence failed to develop and follow written policies and procedures to ensure the continuation of necessary care to all residents for at least 72 hours immediately following any emergency, affecting 48 current residents. (Cross-reference U0920)Findings include:On 6/9/26 at approximately 7:40 a.m., a 72-hour continuation of care policy and procedure was requested; however, it was not provided. On 6/10/26 at approximately 8:30 a.m., the administrator stated the residence did not have a specific 72-hour plan as part of the residence's emergency policies. She acknowledged the need for the plan to be in place.

Based on observations, record review, and interviews, the residence failed to have emergency preparedness policies (EPP) addressing each identified risk, a schematic plan of the building including all required elements, instructions on when and how to evacuate the premises, and assignment of specific tasks and responsibilities of the staff members on each shift, affecting 48 current residents. (Cross-reference U0914, U3144) Specifically, the administrator stated that she was unaware the residence had no plan and or training in place for evacuating 48 current residents. Additionally, four staff members could not state the procedure to use a triage system to assess the needs of the most vulnerable residents first during an evacuation. Residence staff also confirmed there were four residents who required two person assistance. The local fire authority stated the residence was mandated to be a full evacuation and not a defend-in-place residence. This failure created an immediate jeopardy (IJ) risk of serious harm or death to all 48 current residents residing in the residence. On 6/9/26, the Department directed the residence to provide written evidence that the risk had been removed. Findings Include: 1. Record Review The residence's "Evacuations" undated policy and procedures revealed that it failed to include written instructions for each identified risk, including persons to be notified and steps to be taken. Along with the plan to be posted in public areas. Additionally, failed to include assignment of specific tasks and responsibilities to the staff members on each shift, including the use of a triage system to assess the needs of the most vulnerable residents first. 2. Interviews At approximately 8:00 a.m. on 6/9/26, Staff #2 stated she was unfamiliar with when to evacuate residents in an emergency situation and the procedures for doing so along with where to take residents. On 6/9/26 at 8:15 a.m., Staff #3 stated that four residents required two-person assistance and was unfamiliar with how to evacuate in an emergency situation. At approximately 9:20 a.m. on 6/9/26 Staff #1 stated she had worked at the residence for seven months and was unfamiliar with the evacuation plan of residents if needed in an emergency situation. She added she did not know where to take residents or where the meeting place was. Staff #5 stated in an interview on 6/9/26 at 3:00 p.m., he would evacuate residents outside but did not know where to gather residents and or where the meeting place was. He was unsure if staff were to evacuate residents to the front of the residence or into the secured courtyard. On 6/9/26 at 4:00 p.m., during a phone interview with the local fire authority stated the residence was mandated to be a full evacuation and not a defend in place residence. He stated the residence is required to have policies and procedures on emergency evacuation and training of such policies. At approximately 2:40 p.m., on 6/9/26 an interview with the regional maintenance director, he stated fire drills are to be conducted monthly at the residence and that they are to be tracked and documented. He stated he did not know that the residence was a full evacuation and not a defend in place residence. He added that he did not know that resident and staff responses to the drills were required to be monitored during the drills. He stated he did not know why drills were not being followed per regulation. 3. Observations Observations conducted throughout the residence on 6/9/26 revealed the schematic plan of the building plaques throughout the residence failed to include the required elements, including evacuation routes, smoke stop and fire doors, exit doors, and the location of fire extinguishers and fire alarm boxes. 4. Immediate Jeopardy Risk (IJR) - Written Evidence, Immediate Correction The investigation established that the findings above placed the 48 current residents at IJR in serious harm or death. The residence was directed to provide the Department with written evidence that the risk had been removed. Part 3.13 of the Chapter VII regulations requires residences to immediately correct the circumstances that gave rise to the IJ situation. On 6/9/26 at 5:05 p.m., the administrator submitted written evidence that read in part: "The residence identified the need to strengthen staff training, emergency staffing preparedness, evacuation competency validation, and documentation practices related to fire emergency response and resident evacuation procedures. All current staff will complete mandatory fire emergency resident evacuation training that includes: Fire prevention and hazard identification, alarm activation procedures, resident evacuation techniques, accountability procedures, emergency communication protocols, dementia-specific evacuation considerations, evacuation equipment use and demonstration. Training will be conducted on all shifts: 2:00 p.m. – 10:00 p.m., 10:00 p.m., – 6:00 a.m., 6:00 a.m., – 2:00 p.m.,A completion date of 6/9 and 6/10/26 and ongoing. The residence had developed and implemented an emergency staffing plan to ensure adequate staffing coverage during emergencies, severe weather events, and disasters. All staff members will demonstrate competency through: Written testing-relias training added 6/9/26, participation in fire drills- mandatory for all staff, direct observation by leadership. Staff unable to demonstrate competency will receive immediate retraining and reassessment. The facility will conduct fire drills on all shifts quarterly, including: Alarm activation, resident accountability, staff performance evaluation, post-drill review. Leadership will complete an after-action review following each drill and document opportunities forimprovement. A resident accountability process has been implemented to ensure: Resident census is updated daily, resident emergency face sheets are readily available, headcounts are conducted immediately following evacuation, missing residents are reported immediately to emergency responders. To ensure ongoing compliance: Monthly audits of fire drill documentation will be completed, training records will be reviewed monthly, emergency staffing plans will be reviewed quarterly, annual review of fire evacuation and emergency preparedness policies will be completed, results will be reviewed during leadership meetings. The facility has implemented the following measures to prevent recurrence: Emergency staffing plan posted and available in designated emergency binders, mandatory annual fire evacuation competency validation for all staff, quarterly fire drills conducted on every shift, leadership participation in all fire drills, annual review and revision of fire emergency resident evacuation policy, documentation audits added to the monthly review process." However, the written evidence did not indicate the risk had been removed because it did not contain an acceptable plan for updating the emergency preparedness plan to include community specific evacuation plan, specifically the predetermined areas of evacuation and triage areas along with who conducts a head count of the residents and who conducts one if the administrator is not present. The administrator was directed to submit additional written evidence. On 6/9/26 at 6:14 p.m., the administrator submitted written evidence that read in part: "Based on the review of the residences fire emergency resident evacuation training policy and emergency preparedness program, the following plan of correction has been implemented to ensure compliance with fire safety requirements, emergency preparedness standards, and staff competency expectations". Evacuation will include moving residents to the secured courtyard by the gazebo. Exit through any exit door away from fire to the courtyard. We will do a headcount/at gazebo by the administrator or who is designated by the administrator. The residence corrected the circumstances that gave rise to the IJ situation, as required on 6/9/26 at 6:23 p.m.

Based on record review and interview, the residence failed when qualified medication administration personnel (QMAP) made judgements on medication administration, affecting three of seven sample residents (1, #3, #6) and one former resident (#7). Findings Include:1. Record ReviewResident #1 was admitted to the residence on 7/1/23 with a diagnosis including dementia, mood disturbance, and anxiety. A written practitioner's order, dated 4/23/26, directed the residence to administer 5mg/0.25mL of lorazepam 2mg/mL by mouth every six hours as needed for anxiety and agitation. The May 2026 medication administration record (MAR) for Resident #1 read on 5/22/26, at 2:15 p.m., 7:35 p.m., and 9:19 p.m., qualified administration personnel (QMAP) staff administered lorazepam 0.5 mg/0.5mL to Resident #1.2. Similar deficient practice was found for Resident #3, #6, and Former Resident #7. 3. InterviewsOn 6/9/26 at 11:45 a.m., the director of nursing (DON) stated residents are allowed to be given as needed medications by the QMAP staff. The DON also stated she was aware that QMAP staff cannot assess residents or use their own judgement to determine a resident ' s medication effect. The DON also stated nursing staff have not always been at the residence to assess whether any as needed medication should be administered to a resident. The DON stated QMAP staff received approval to administer as needed medications to residents by an on call off-site nurse via telephone. On 6/10/26, at approximately 8:45 a.m., the administrator stated she was aware QMAP staff cannot assess residents or use their own judgement to determine a resident ' s medication effect. The administrator acknowledged nursing staff do not work night shifts and are not always available on-site to determine administration of as needed medications. The administrator stated she was unaware QMAP staff cannot receive verbal authorization to administer as needed medication to residents over the phone with nursing staff authorization. The administrator acknowledged QMAP staff made judgments without a nursing staff present for the administration of as needed medications for Resident #1, #3, #6, and Former Resident #7. The administrator also acknowledged that failure to prohibit a qualified medication administration person from performing assessment of residents and use of judgment that included medication effect was non-compliant with Chapter VII, 14.10.

Based on record review and interviews, the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting two of seven sample residents ( #4 and #6) and one former resident (#7). (Cross-reference U1528, U1600)Findings include:1. Record Reviewa. Resident #6 was admitted to the residence on 9/22/23 with a diagnosis including seizures and Alzheimer ' s disease. I. Oxycodone 5mg TabletA written practitioner's order, dated 12/20/25, directed the residence to administer one tablet of 5 mg oxycodone by mouth three times a day to Resident #6. The June 2026 medication administration record (MAR) displayed a "9" code that indicated the medication was not administered to Resident #6 at 5:00 p.m. on 6/5/26. II. Olanzapine 5mg TabletA written practitioner's order dated 4/26/24, directed the residence to administer 5mg of olanzapine by mouth twice daily to Resident #6. The May 2026 MAR displayed a "5" code that indicated the medication was not administered Resident #6 for the morning dose on 5/4 and 5/5/26.b. Former Resident #7 was admitted to the residence on 8/15/25 with a diagnosis including dementia with agitation and spondylosis. I. Alprazolam 0.25 mg Tablet A written practitioner's order dated 9/24/26, directed the residence to administer one tablet of 0.25 mg alprazolam to Former Resident #7 by mouth once daily in the evening. The December 2025 MAR displayed a "9" code that indicated the medication was not administered to Former Resident #7 on 12/25 and 12/26/26. II. Depakote 125mg TabletA written practitioner's order dated 8/18/25, directed the residence to administer one tablet of 125 mg Depakote by mouth twice daily to Former Resident #7. The December 2025 MAR displayed a "9" code that indicated the medication was not administered to Former Resident #7 on 12/9, and 12/10/26. III. Meloxicam 15mg TabletA written practitioner's order dated 10/27/25, directed the residence to administer one tablet of 15 mg Meloxicam by mouth once daily to Former Resident #7. The December 2025 MAR displayed a "9" code that indicated the medication was not administered to Former Resident #7 on 12/1/25. 2. There was similar deficient practice for Resident #4.3. InterviewsOn 6/9/26, at approximately 9:20 a.m., the resident care coordinator (RCC) stated she was responsible for assisting nursing staff and qualified medication personnel (QMAP)'s with ensuring bubble packets of resident medications match to the residents record on the electronic health record system. The RCC stated Former Resident #7's medications may have been out of stock at times due to pharmacy discrepancies. On 6/9/26, at approximately 9:30 a.m., the wellness director (DON) stated QMAPS staff are responsible for ordering medications unless there are discrepancies with medications due to delivery, order delay, or pharmacy. The DON stated nursing staff are responsible for following up on concerns with medications, and that these issues would escalate to her if not resolved. The DON acknowledged there have been discrepancies with resident medications due to delivery, order delay, and pharmacy. On 6/9/26, at approximately 11:50 a.m., the DON stated "5" and "9" codes on resident MAR's indicated medication had not been administered to the resident, and QMAP staff are expected to write a progress note to document the reason. On 6/10/26, at approximately 8:45 a.m., the administrator acknowledged medication was not administered per the practitioner's order for Resident #4, #6, and Former Resident #7. The administrator acknowledged that this was non-compliant with Chapter VII, 14.21.

Based on a record review and interviews, the residence failed to ensure that each qualified medication administration person (QMAP) accurately documented each medication administration event, affecting two current (#3, #4) sample residents. (Cross-reference U1528, U1568)Findings include:1. Record Review Resident #4 was admitted to the residence on 7/22/25 with a diagnosis of unspecified pain.a. Oxycodone 5mgA written practitioner's order dated 1/29/26, directed the residence to administer oxycodone 5 mg once daily at bedtime. However, the June 2026 medication administration record (MAR) contained a blank space on 6/6/26. Resident #3 was admitted to the residence on 4/17/26 with a diagnosis including insomnia.a. Melatonin 3mgA written practitioner's order dated 4/17/26, directed the residence to administer melatonin 3 mg once daily at bedtime. However, the June 2026 MAR contained a blank space on 6/6/26. 2. InterviewsOn 6/9/26, at approximately 11:50 a.m., the DON stated QMAP staff are expected to document medication administration in the resident MAR, and document medications not administered to a resident. The DON acknowledged MAR records for Resident #3 and #4 contained blanks, and were inaccurate. On 6/10/26, at approximately 8:45 a.m., the administrator acknowledged MAR records for Resident #3 and #4 contained blanks, and were inaccurately documented. The administrator acknowledged that failure to list and record medication administration on a resident MAR was non-compliant with Chapter VII, 14.29.

Based on record review, and interviews, the residence failed to ensure each resident's care plan in a secure environment included all required elements, affecting four of six current sample residents (#1, #3, #4, #5). Findings include: 1. Record Review Resident #5 was admitted to the residence on 2/11/26, with diagnoses of Alzheimer ' s disease. A progress notes dated 4/27/26 read in part, Resident #5 was found on the floor during shift change. Blood stains were seen on the floor by staff. Resident #5 has new skin tears to both elbows. A progress note dated 4/28/26 read in part, Resident #5 was found on the floor with skin tears to both arms. Wound care done by an external service provider, dressings and arm sleeves intact, mentation comparable to his baseline. An incident report dated 5/19/26 at 1:00 a.m., read in part, Resident #5 was found on the floor of his bedroom and assisted back to bed. Around 2:00 a.m., during another round check Resident #5 was found in the dining room under the table completely unclothed. Another staff was notified and came to assist Resident #5 in cleaning his wounds. A care plan dated 5/2/23, read under fall risk that Resident #5 would have a care plan updated at admission, quarterly and an as needed fall assessment. Resident #5 resided in a secure environment and had diagnoses including dementia, documented confusion, and fall risk. However, the care plan did not include a description of fall risk and patterns, nor did it include individualized interventions to address the fall risks. Also, the care plan did not identify the type or level of staff oversight, monitoring, or accompaniment necessary to meet the resident ' s fall risk needs within the secure environment. 2. Interviews On 6/9/26 at approximately 9:30 a.m., the director or nursing stated that after a resident sustains even one fall the resident is reassessed and an update to the care plan is made. She stated that wheelchairs are often ordered as an intervention, along with the use of a hospital bed, a floor mat and physical therapy and occupational therapy is ordered. On 6/9/26 at 4:40 p.m., Staff #4 and Staff #6 both stated Resident #5 falls at times and would benefit from using a wheelchair instead of a walker. She stated the staff finds Resident #5 without his walker often. The staff stated Resident #5 was in need of a care plan adjustment. On 6/10/26 at approximately 8:30 a.m., the administrator stated care plans should be updated after residents sustain falls and or with injuries due to falls. The administrator acknowledged that care plans should reflect resident needs and or updated interventions. She also acknowledged that care plans should be enhanced to identify the level of staff oversight and monitoring those residing within the secured environment. 3. Similar deficient practice was identified for Residents #1, #3, and #4.

Based on observations and interviews, the residence failed to ensure all staff assigned to the secure environment have a readily available means of unlocking the gate in case of emergency, affecting 47 current residents. (Cross-reference U0920)Findings Include:Observations of the residence's enclosure around the perimeter of the outdoor area revealed multiple gated access points in the fence. Each had a release that was locked with a padlock on the outside of the fence and inaccessible to staff on the inside of the fence. On 6/9/26 at 3:00 p.m., Staff #5 stated that a key to the gate was located in the medication storage closet, but could not locate it when requested. On 6/9/26 at 3:10 p.m., the administrator confirmed that the front desk had a key to the gates as well as maintenance, and did not mention that staff had access to the keys. On 6/10/26 at 8:15 a.m., the administrator confirmed that she was aware that all staff were required to have a readily available means of unlocking the gate. She confirmed that because the padlocks were on the outside of the gate, staff on the inside would not have access to open the gate in an emergency. She confirmed that because it was part of the emergency evacuation plan for staff to evacuate into the gated outdoor area, staff should have access to unlock the gate inside the gate in the event of an emergency.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised to review and maintain the following processes in accordance with the existing program regulations at 6 CCR 1011-1, Chapter 7.(U0666) 7.14 If the employee or volunteer is a qualified medication administration person, the following shall also be retained in the employee's or volunteer's personnel file:(B) A signed disclosure that the individual has not had a professional medical, nursing, or pharmacy license revoked in this or any other state for reasons directly related to the administration of medications.(U1542) 14.13 The assisted living residence shall designate a QMAP supervisor who is a nurse, practitioner, or meets the definition of a qualified medication administration person at Part 2.52.(A) The QMAP supervisor shall, before initial assignment of each qualified medication administration person, conduct a competency assessment with direct observation of all medication administration tasks that the QMAP will be assigned to perform.(1) Whenever a QMAP is assigned additional medication administration tasks, the QMAP supervisor shall conduct a competency assessment with direct observation of each new task that the QMAP will be assigned.(U1590) 14.25 The assisted living residence shall maintain medication storage and preparation areas which are clean and free of clutter.(U1596) 14.28 The assisted living residence shall ensure that qualified medication administration persons are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications.(U2220) 18.5 The assisted living residence shall have a means of securing resident records that preserves their confidentiality and provides protection from loss, damage, and unauthorized access.(U2720) 22.35 Assisted living residences shall comply with the Colorado Clean Indoor Air Act at Sections 25-14- 201 through 25-14-209, C.R.S.(U3030) 25.5 Before an individual moves in, the assisted living residence shall complete a pre-admission assessment to determine the appropriateness and need for secure environment residency. The pre-admission assessment shall include all the items required for the comprehensive assessment in Part 12.7(A) through (M), plus the following:(A) An evaluation by a licensed practitioner which has occurred within the previous ninety (90) calendar days and which describes the resident's medical condition and any cognitive deficits that contribute to wandering, compromised safety awareness, and other types of conduct; and(B) Detailed information from the resident's family and/or representative concerning the resident's recent relevant history and patterns of reduced safety awareness and wandering, along with any strategies used to prevent unsafe wandering or successful exiting, and any other known types of conduct.(U3050) 25.9 Each resident shall be re-assessed to determine his or her continued need for a secure environment every six (6) months and whenever the resident's condition changes from baseline status.(A) As part of the secure environment re-assessment, the assisted living residence shall consult with the resident's attending practitioner, family, and/or resident's representative and review service documentation dating back to the most recent comprehensive assessment.(U3120) 25.23 The assisted living residence shall ensure that residents in a secure environment have all the same resident rights as set forth in Part 13 of this chapter including, but not limited to, the right to privacy and confidentiality.

A licensure complaint, prompted by #CO34715, was completed on 8/28/2024. No deficiencies were cited.

A relicensure and complaint revisit was completed on 8/28/2024 for all previous deficiencies cited on 4/18/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24.

Based on interview and record review, the agency failed to ensure its quality management program (QMP) documented and implemented improvement strategies, affecting 45 current residents. This deficiency was previously cited during a re-licensure survey completed on 4/18/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Record Review a. On 8/28/24 at 7:30 a.m., QMP documentation was requested and not received during the onsite survey. 2. InterviewsOn 8/28/24 at 9:30 a.m., the director of wellness stated she was unaware of the residence implementing a QMP and the residence did not have meetings regarding a QMP.On 8/28/24 at 3:00 p.m., the administrator stated she did not know what a QMP was and acknowledged there was no QMP. She also stated she did not have a reason as to why the deficiency had not been corrected.

Based on observation, record review and interview, the residence failed to ensure the house rules addressed cooking, protecting valuables, pets, visitors, telephone use or use of common areas, affecting 45 current residents. This deficiency was cited previously during a state license survey on 4/18/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: Chapter VII regulations governing assisted living residences, part 13.3, requires that the assisted living residence establish written house rules and place them in a publicly visible location so that they are always available to residents and visitors. On 8/28/24 at 8:30 a.m., an environmental tour of the residence revealed the residence's posted house rules, dated 1/4/21. However, these posted house rules that were made available to residents and visitors did not include all required elements including: cooking, protecting valuables, pets, visitors, telephone use or use of common areas. On 8/28/24 at 9:34 a.m, the administrator stated the posted house rules were all the residence had developed, and they did not have anything else. The administrator later stated this deficiency that was previously cited was not corrected because it should have been done at the corporate level. She acknowledged the posted house rules were not comprehensive, and it was her responsibility to establish written house rules with all required elements and place them in a publicly visible location.

A revisit survey was completed on 12/15/23 for all previous deficiencies cited on 8/14/23. The facility is in compliance with all deficiencies that were cited.

A licensure complaint, prompted by #CO32990, was completed on 8/14/23. Deficiencies were cited.

Based on interview and record review, the residence failed to ensure any orders received from medical staff on behalf of an authorized practitioner were countersigned by said practitioner as soon as possible, affecting one of four sample residents (#2). Findings include:1. Resident #2 was admitted to the residence on 2/24/20 with diagnoses including dementia. A written practitioner order, dated 3/27/23, directed the residence to administer Seroquel 100 mg before bed. However, the residence received a verbal order on 6/13/23 for Seroquel 50 mg at bedtime daily. Another written practitioner order, dated 7/10/23, directed the residence to administer Seroquel 50 mg before bed daily. However, the residence received verbal orders on 7/19/23 for Seroquel 100 mg at bedtime. The July and August 2023 medication administration records read in part the residence administered Seroquel 50 mg from 7/1-7/18/23, then Seroquel 100 mg from 7/19-8/13/23. Further, the residence was unable to provide countersigned verbal orders for 6/13 and 7/19/23. A progress note, dated 6/13/23, read in part, the residence received a new order for Seroquel 50 mg at bedtime daily. However, the residence was not able to provide evidence of a countersigned order. A progress note, dated 7/21/23, read in part, the practitioner increased the dosage of Seroquel from 50 mg to 100 mg due to increased behaviors. However, the residence was not able to provide evidence of a countersigned order. On 8/14/23 at 12:53 p.m., the nurse stated the verbal orders were taken by her on 6/13 and 7/19/23; however, she was not aware the orders needed to be countersigned as soon as possible. She confirmed there were no written practitioner orders for the Seroquel dosage changes. On 8/14/23 at approximately 12:53 p.m., the consultant confirmed there were no countersigned orders. She stated she was aware that verbal orders were required to be countersigned by the practitioner. On 8/14/23 at 2:13 p.m., the administrator stated she was aware verbal orders were required to be countersigned by the practitioner. However, she stated she was unaware the nurse did not ensure the verbal order was countersigned. Additionally, she stated the orders should have been signed within a few days and they were not.

Based on interview and record review, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting three of four sample residents (#1, #3, #4). Findings include:1. Resident #4 was admitted to the residence on 6/3/22. A written practitioner order, dated 3/27/23, directed the residence to administer olanzapine 5 mg once daily. However, the August 2023 medication administration record (MAR) read the number nine on 8/7 and 8/8/23 with no progress note written. The back of the MAR read the number nine which indicated "see progress note". However, there was no progress note written. Therefore, the medication was not administered for a total of two doses. On 8/14/23 at approximately 2:13 p.m., the administrator stated the number nine on the MAR indicated staff should have written a progress note. However, she stated since there was no progress note written regarding the medication administration on 8/7 and 8/8/23, it meant the medication was not administered as required and the resident missed a dose. 2. Resident #3 was admitted to the residence on 9/1/21 with diagnoses including osteoarthritis. A written practitioner order, dated 9/9/22, directed the residence to administer vitamin D 50 mcg once daily. However, the July 2023 MAR read the number nine on 7/24/23. Therefore, the medication was not administered on 7/24/23 for a total of one missed dose. On 8/14/23 at 2:13 p.m., the administrator stated the medication was not administered as ordered. 3. Resident #1 was admitted to the residence on 6/16/23 with diagnoses including hypertension. A written practitioner order, dated 5/5/23, directed the residence to administer metoprolol tartrate 25 mg twice daily. However, the July 2023 MAR read the medication was out of stock in the morning on 7/27/23 for a total of one missed dose. On 8/14/23 at 2:13 p.m., the administrator confirmed the medication was out of stock and therefore not administered as required. She stated the expectation was for medications to always be in stock. On 8/14/23 at approximately 2:13 p.m., the consultant stated a documented nine without a progress note indicated the medications were not administered as required. She also confirmed the medication for Resident #1 was not administered.

A licensure revisit was completed on 4/18/23 for all previous deficiencies cited on 2/1/23. The residence is in compliance with all regulations surveyed.

A relicensure survey with complaint #CO31473 was completed on 4/18/23. Deficiencies were cited.

Based on record review and interview, the residence failed to show compliance with Colorado Adult Protective Services Data System (CAPS Check) requirements, affecting 36 current residents. Findings include:1. Referencesa. According to Colorado Revised Statutes (2017) 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."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. On 4/17/23 at 9:17 a.m., the personnel file for Staff #5 was requested. However, the residence was unable to provide evidence of a CAPS check request for Staff #5. The document provided, read in part, "Need CAPS authorization form to proceed."The personnel file for Staff #5 read she was hired on 2/10/22 as a qualified medication administration person (QMAP). The staff schedule revealed Staff #5 worked nine times in April 2023 on the following dates: 4/9-4/12, 4/14, 4/15-4/18/23.3. On 4/17/23 at 9:17 a.m., the personnel file for Staff #4 was requested. However, the residence was unable to provide evidence of a CAPS check request for Staff #4. The document that was provided, read in part, the CAPS check was completed 1/25/23 with no indication through CAPS of the results of the check. The personnel file for Staff #4 read she was hired as a caregiver. The staff schedule revealed Staff #4 worked eight times in April 2023 on the following dates: 4/9-4/11, 4/14-4/18/23.4. On 4/17/23 at 9:17 a.m., the personnel file for Staff #1 was requested. However, the residence was unable to provide evidence of a CAPS check request for Staff #1. The personnel file for Staff #1 read she was hired on 10/13/22 as a QMAP.The staff schedule revealed Staff #1 worked seven times in April 2023 on the following dates: 4/9-4/13, 4/17, and 4/18/23.5. On 4/17/23 at 9:17 a.m., the personnel file for Staff #3 was requested. However, the residence was unable to provide evidence of a CAPS check for Staff #3. The personnel file for Staff #3 read she was hired on 1/3/23 as a QMAP.The staff schedule revealed Staff #3 worked seven times in April 2023 on the following dates: 4/9, 4/11-4/14, 4/16, and 4/18/23. On 4/18/23 at approximately 1:03 p.m., the regional director of operations confirmed there was no CAPS check results available for Staff #1-#5. She stated the business office manager was a new employee and had not been fully trained yet. However, she confirmed the staff should not have been hired until the CAPS checks were completed and results were provided. She confirmed the residents who resided at the residence were at-risk.

Based on observation, record review and interview, the residence failed to comply with conditions imposed by the department on the license, affecting 36 current residents. Findings include:1. RecordsDepartment records read the residence was currently required to retain a consultant for six months. Following the completion of Event S21011 on 5/18/21, a licensure survey and complaint investigation, the department imposed a consultant for 12 months to address the cited deficiencies and to also ensure compliance with all other pertinent regulations. The intermediate condition read the consultant was required to complete the following, during the 30 days of the contract period:- Review all citations in event S21011, dated May 18, 2021, and evaluate the residence's current compliance with regulations outlined in 6 CCR 1011-1 Chapter 2 and Chapter 7 where applicable. The consultant shall ensure the residence is in compliance with Chapter 7 rules governing assisted living, in sections 6.7 (A-J), 12.6, 13.11 (A-G), 21.2, 25.21(A)(B) and 25.25 (F)(1)(2)(3)(4)(5)(a). The consultant was required to complete the following, within 60 days of the contract period:- Evaluate other sections of the regulations and provide recommendations to the residence on additional areas of noncompliance. The consultant shall implement a monitoring program, to be completed at least monthly, to ensure the residence remains in compliance with previously cited deficiencies. The monitoring program shall be incorporated into the residence's ongoing quality management program in accordance with 6 CCR 1011-1, Chapter 2. The consultant was required to complete the following, during the contract period:- The consultant shall conduct onsite visits twice weekly for the first 30 days then weekly for the next 180 days of the consultant contract. For the remaining 150 days, the consultant shall conduct at least five visits and increase onsite visits as necessary to provide training, mentoring, monitoring and maintaining compliance with 6 CCR 1011-1, Chapter 7.- The consultant shall ensure the residence is in compliance with the Quality Management Program (QMP) regulations in Chapter 2, section 4. Specifically, the consultant shall ensure the QMP is designed to improve resident safety and well-being, and promotes continued quality improvement to enhance service delivery. The consultant shall ensure the deficiencies identified in the survey events listed above, as well as other areas of identified deficient practice, are implemented in the program as a quality management project. For the deficiencies identified above as well as other areas of identified deficient practice, the consultant shall ensure the administrator has a process to correct identified deficiency, which includes measures put into place to ensure the deficient practice does not reoccur. The consultant shall ensure the administrator will monitor the corrective action to ensure the deficiency is remedied. The consultant will ensure the monitoring identifies how and what will be reviewed as part of monitoring, how a sample is identified for monitoring purposes, the total length of time the monitoring will continue and how the monitoring will be documented. The consultant was required to complete the following, during the final 30 days of the contract period: - ensure the final 30 days of the contracted period are spent preparing the administrator to independently manage the residence to ensure compliance with all applicable regulations governing assisted living residences. The consultant shall ensure the administrator has tools and resources in place to maintain compliance. The consultant was required to submit a final report to the department, following the end of the contract period, that contained the prior information as well as the actions taken to ensure the administrator has tools and resources in place to maintain compliance. Department records read the following deadlines were required for this intermediate condition:- Letter to department to identify possible consultant, due by 8/19/21.- Submit executed consultant contract to the department, due by 8/27/21.- Submit final consultant report, due by 9/15/22. Department records read the residence had appealed the intermediate condition on 8/25/21. Department records read the residence had agreed to settlement terms on 8/31/22; however, had not signed the settlement terms agreement. Department records read the residence had identified a possible consultant on 10/21/22. Additionally, the contract for the consultant was received on 11/16/22, and included the above consultant requirement information. Department records read on 2/7/23 a settlement agreement was finalized that read the following:- The consultant shall conduct onsite visits at the following frequency:For the first 30 calendar days of the consultancy, the consultant must conduct onsite visits at least twice per week;For the next 90 calendar days (i.e., day 31 through day 120 of the consultancy), the consultant must conduct onsite visits at least once per week; andFor the final 60 calendar days (i.e., day 121 through day 180 of the consultancy), the consultant must conduct at least four onsite visits. If the consultant determines that additional visits are necessary to provide and/or or assist in training, mentoring, monitoring, and maintaining compliance with 6 CCR 1011-1, Chapters 2 and 7, the consultant will conduct additional onsite visits as necessary during this period.- The consultant shall submit a final report to the Department no later than the final day of the consultancy period detailing the overall progress made, the systems and processes implemented to ensure ongoing compliance, and any remaining areas of noncompliance. Therefore, on the dates of the completion of the relicensure survey and compliant investigation, (4/17-4/18/23), the consultant would have been in her final 60 days as consultant for the residence. 2. Current deficient practiceDuring the 4/17-4/18/23 relicensure survey and complaint, the investigation established there was current deficient practice. Seventeen deficiencies were cited, including tags 540, 610, 736, 910, 934, 1180, 1192, 1332, 1350, 1362, 1514, 2978, 172, 260, 290, 512 and 514. Tag 1180 was cited at a D level, pattern of actual harm. (Cross-reference Q540, Q610, Q736, Q910, Q934, Q1180, Q1192, Q1332, Q1350, Q1362, Q1514, Q2978, B172, B260, B290, B512 and B514) 3. InterviewsOn 4/18/23 at 10:03 a.m., the consultant confirmed she had been the consultant utilized by the residence to fulfill the requirements of the department-issued intermediate condition. In regards to tag 1180, the consultant stated she had not been made aware by the residence that any residents had fallen with known injuries. She stated the former director of wellness (FDOW) had a program in place for fall management that had previously worked well for the residence. She stated the director of wellness (DOW) currently in the residence was new and had not been trained on the residence's fall management processes. The consultant stated she had discussed the DOW's training with the regional director of operations (RDO). The consultant stated the FDOW resigned from the residence at the end of March 2023 and the DOW had worked in the residence for approximately one week prior to the onsite visit. She stated the DOW should have updated care plans after residents had fallen to include interventions to prevent falls but the DOW had not been trained fully on updating the care plans. The consultant stated she was unaware of falls that had occurred that involved Resident #2 and Former Residents #13 and #14. In regards to tag 1192, the consultant stated all staff should have been trained on lift assistance. She stated the residence policy was for a nurse to assess a resident to determine if the resident required medical attention. The consultant stated she would have expected a resident that hit their head would have been sent to the hospital or emergency medical services would have been contacted to complete a neurological evaluation because the residence nurses were unable to complete neurological evaluations. The consultant stated the residence's policy did not require a resident to have been sent for evaluation after a head injury. On 4/18/23 at 12:53 p.m., the consultant stated in regards to tags 610 and 172, the residence had recently hired a new business office manager (BOM). She stated she had identified the residence did not have a Colorado Adult Protective Services (CAPS) check or criminal history records checks completed through Colorado Bureau of Investigation (CBI) for all staff. The consultant stated the BOM had been made aware of the requirements and had started to work on requesting them for all current staff. She stated the failure had been identified one and one half to two months prior to the onsite visit. The consultant added the acting administrator had been aware of the missing records checks. In regards to tag 2978, the consultant stated she had previously requested the dementia training for all staff from the residence and had not been provided with the documentation. She stated the residence had a process in place to complete the dementia training and added the residence was not following the process. She stated the process included an online training platform with training to complete upon hire and within the first 60 days of employment for staff. The consultant stated the residence was aware they were required to completed staff training related to dementia. In regards to tag 910, the consultant stated she had discussed the resident roster and the emergency binder with residence staff prior to the onsite visit. She stated a former staff had worked with her in regards to the resident roster and added she had identified the residence did not have a proper resident roster. In regards to tags 512 and 514, the consultant stated the administrator of record had previously completed the quality management program (QMP) documentation. She stated the administrator of record had monthly meetings to discuss and documented the QMP on a corporate document. The consultant stated since the RDO and acting administrator had taken over administrator responsibilities after the administrator of record resigned on 2/1/23, the QMP has not been continued. She stated she had not addressed the QMP concern with the RDO or acting administrator. In regards to tag 1362, the consultant stated she was unsure if the residence had a policy that addressed investigation of injuries of unknown origin. In regards to tag 736, the consultant stated she had discussed having a posted list of cardiopulmonary resuscitation (CPR) and first aid certified staff. She stated the administrator of record had previously put a star on the posted staff schedule next to each staff member that was CPR and first aid certified for all staff to be aware. The consultant stated the FDOW and Staff #7 had started to maintain the schedule in January 2023 and had not continued to include the stars. She stated the residence did not have any other posted list of CPR and first aid certified staff that she was aware of. In regards to tag 540 and 260, the consultant stated the acting administrator was responsible for the day to day operations of the residence. The consultant stated the RDO assisted the acting administrator and came to the residence approximately three times weekly; however, the acting administrator had managed the day to day operations of the residence. The consultant stated the administrator of record had not been the administrator for the residence since approximately 2/1/23. She stated the residence should have notified the department that the administrator of record was no longer at the residence. She added she had not discussed this with the acting administrator. In regards to tag 290, the consultant stated the residence's resident records were in an electronic system and information should have been easily provided for resident records. She stated that all residence staff had access to all residence policies and procedures and that she would have expected requested documents to have been provided promptly. The consultant stated some documents could have been delayed and if they were the residence should have communicated the delay to the department. The consultant stated requested documents should have been provided to the department the same day as requested. In regards to tags 1332 and 1350, the consultant stated she had provided all of the required contact information for the grievance posting and the residence only was required to add it to their document and post the new grievance policy. She stated she had discussed the required elements for the house rules that needed to be posted as well. The consultant stated she had discussed both items with the residence starting in December 2022. The consultant stated she was unsure why the correct house rules and the correct grievances documents were not posted. In regards to tag 934, the consultant stated the residence completed a monthly audit on each first aid kit to ensure all of the supplies were in the kits. She stated she was not aware the first aid kits were missing any required items. In regards to tag 1514, the consultant stated the acting administrator and DOW should have completed quarterly medication audits. She added the audits were being completed. She stated the last medication audit had been completed in December 2022. The consultant confirmed a medication audit had not been completed by the DOW or acting administrator and the residence had not completed an audit in the most recent quarter. The consultant stated she was aware of the terms of the intermediate condition. The consultant stated she believed all management, including the acting administrator, were aware of the intermediate condition. The consultant stated she had been at the residence frequently and discussed areas that needed improvement. She stated the RDO and acting administrator were aware of the areas of noncompliance. The consultant stated based on the requirements of the intermediate condition and the deficiencies cited the residence had not complied with the terms of the intermediate condition. On 4/18/23 at 1:03 p.m., the RDO stated she was aware of the intermediate condition requirements. The RDO stated she was aware the residence was required to maintain compliance with all regulations while under the intermediate condition and added it was difficult to maintain compliance.

Based on observation, record review and interview, the residence failed to notify the department of a change in administrator, at least 30 calendar days in advance, affecting 36 current residents. (Cross-reference Q0540)Findings include: On 4/17/23, the department's database read the administrator of record was the current administrator of the residence. On 4/17/23 at 7:49 a.m., Staff #5 stated the acting administrator had begun at the residence approximately one to one and one half months prior to the onsite visit. She stated the acting administrator was responsible for all of the day to day decisions in the residence. On 4/17/23 at approximately 9:45 a.m., the acting administrator stated she had began at the residence as the interim administrator on 3/1/23, approximately 47 days prior to the onsite visit. She stated she was enrolled in the administrator course and had not notified the department because she was interim. On 4/18/23 at 7:00 a.m., upon entrance to the residence, a posted since in the residence lobby identified the acting administrator as the "administrator on duty."On 4/18/23 at 10:28 a.m., a representative from the department confirmed the residence had submitted a request to change the administrator of record on 4/17/23 during the onsite visit. The representative sent email correspondence that read the regional director of operations (RDO) had been the person named as the administrator of record. On 4/18/23 at approximately 12:53 p.m., the consultant confirmed the administrator of record had not worked at the residence since 2/1/23. On 4/18/23 at 1:04 p.m., the RDO stated she began the role as the administrator of record as soon as the administrator of record no longer worked at the residence. She stated the residence had hired the acting administrator to fulfill the administrator role. She added they could not identify her as the administrator of record to the department because the acting administrator was not qualified. The RDO stated she believed the residence had 90 days to notify the department of the change in administrator. The RDO confirmed, contrary to her previous statement, she was aware the residence should have notified the department within 30 days but an unidentified person had told her she had 90 days to submit the notification. The RDO confirmed she had submitted the change and the payment had not been completed as it was submitted to the corporate office.

Based on interview and record review, the residence documents, staff information and other records as requested by the department, affecting 36 current residents. Findings include:1. Referencea. Chapter VII regulations governing assisted living residences, part 6.8, requires that the administrator shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to:(I) Completing, maintaining, and submitting all reports and records required by the Department.b. Chapter VII regulations governing assisted living residences, part 7.12, each personnel file shall include, but not be limited to, written documentation regarding the following items:(C) Orientation and training, including first aid and CPR certification, if applicable.c. Chapter VII regulations governing assisted living residences, part 18.8, requires that Resident records shall contain, but not be limited to, the following items:(B) Practitioner order; (E) Medication Administration Record. 2. Record ReviewOn 4/17/23 at 7:27 a.m., the following was requested from the acting administrator:a. Proof of influenza vaccinationsb. Staff time cards from the previous two weeksc. Emergency response policiesd. Fall management policye. Cardiopulmonary resuscitation (CPR) certifications for all staffOn 4/17/23 at 9:17 a.m., personnel files were requested for Staff #1-#5. On 4/17/23 at 10:18 a.m., the emergency response policies, an outdated fall management policy, and the CPR certifications were provided, approximately three hours after requested. On 4/17/23 at 12:25 p.m., time cards were provided, approximately five hours after request. Additionally, staff training was provided, approximately three hours after personnel files were requested. On 4/17/23 at 3:54 p.m., the COVID-19 ongoing vaccination plan and the administrator certification were requested. On 4/18/23 at 7:30 a.m., proof of influenza vaccinations for all staff were provided, approximately nine business hours after requested. On 4/18/23 at 8:54 p.m., the administrator certification was provided, approximately three business hours after it was requested. On 4/18/23 at 12:26 p.m., the updated fall management policy was provided, approximately 14 and one half business hours after it was requested. On 4/18/23 at 2:09 p.m., the COVID-19 ongoing vaccination plan was provided, approximately seven business hours after it was requested. On 4/18/23 at approximately 1:03 p.m., the regional director of operations stated she was not aware the department was at the residence on 4/17/23 due to a miscommunication between herself and the acting administrator. She stated she was not able to enter the residence until later in the morning which caused a delay in getting documentation collected. She also stated her expectation was for records requested by the department to be provided in a timely manner.

Based upon record review and interview, the residence failed to ensure the quality management plan (QMP) contained the required elements, affecting 36 current residents. Findings include:On 4/17/23, the residence's QMP was provided by the acting administrator. The QMP did not contain the following required elements: - A process for staff to report service delivery error and potential for error within a prescribed period of time and a plan for how staff will be trained regarding such reporting. - The methods used to collect and analyze data in order to find patterns and trends. - The method(s) used to select quality management projectsOn 4/18/23 at 1:09 p.m., the regional director of operations stated she believed the residence had a QMP process which met all of the requirements. She stated the residence would be able to provide additional QMP documentation, more than what had been provided on 4/17/23. On 4/18/23 at 2:12 p.m., the acting administrator provided additional QMP documentation for the residence; however, the documentation did not include a process for staff to report service delivery error and potential for error within a prescribed period of time and a plan for how staff would be trained regarding such reporting, the methods used to collect and analyze data in order to find patterns and trends or the method(s) used to select quality management projects.

Based upon record review and interview, the residence failed to ensure the quality management plan (QMP) contained improvement strategies, affecting 36 current residents. Findings include: On 4/17/23, the residence's QMP was provided by the acting administrator. The QMP did not contain the following improvement strategies:- The plan shall include how improvement strategies will be developed. - A description of the intervention design. - How staff will be allocated and/or trained to implement the strategy. - How the strategy will be evaluated for effectiveness. - Timelines for implementation and evaluation of the strategy and how the facility or agency is tracking the meeting of these milestonesOn 4/18/23 at 1:09 p.m., the regional director of operations stated she believed the residence had a QMP process which contained all of the residence's improvement strategies. She stated the residence would be able to provide additional QMP documentation, more than what had been provided on 4/17/23. On 4/18/23 at 2:12 p.m., the acting administrator provided additional QMP documentation for the residence; however, the documentation did not include improvement strategies would be developed, a description of the intervention design, how staff would be allocated and/or trained to implement the strategy, how the strategy would be evaluated for effectiveness, or timelines for implementation and evaluation of the strategy and how the facility or agency was tracking the meeting of these milestones.

Based on observation, interview and record review, the residence failed to ensure the administrator complied with all applicable state laws to help prevent the possible development and transmission of coronavirus (COVID-19) and failed to ensure the administrator was responsible for the day-to-day operation of the residence, affecting 36 current residents. (Cross-reference B0260)Findings include: 1. COVID-19 Vaccination Policy The Assisted Living Residences and Group Homes Mitigation and Outbreak Guidance, updated 2/22/23, required residences to keep a current COVID-19 ongoing vaccination and treatment plan and for the plan to be presented for review upon request during health facility inspections. On 4/18/23, the residence's COVID-19 vaccination policy was provided by the residence. Page three of the residence's COVID-19 vaccination plan was blank. On 4/18/23 at 2:18 p.m., the regional director of operations (RDO) stated she had recently updated the residence's COVID-19 vaccination plan. She added she was aware the plan was not up-to-date and not complete. 2. Day-to-Day Operations Chapter VII regulations governing assisted living residences, part 2.2, defines "Administrator" as a person who is responsible for the overall operation, daily administration, management and maintenance of the assisted living residence. The term "administrator" is synonymous with "operator" as that term is used in Title 25, Article 27, Part 1. On 4/17/23 at approximately 7:00 a.m., upon entrance to the residence the administrative assistant was asked to notify the administrator of record the surveyors had arrived. The administrative assistant notified the acting administrator. On 4/17/23 at 7:49 a.m., Staff #5 stated the acting administrator had begun employment at the residence approximately one to one and one half months prior to the onsite visit as the administrator of record. She stated the acting administrator was responsible for all of the day-to-day decisions in the residence. Staff #5 confirmed the acting administrator was the residence's current administrator and the administrator of record was no longer employed at the residence. On 4/17/23 at 9:20 a.m., the acting administrator stated the regional director of operations (RDO) oversaw the residence's day-to-day operations. She added, the RDO came in three times a week since she had become the administrator on 2/1/23. On 4/18/23 at 7:00 a.m., upon entrance to the residence, a posted since in the residence lobby identified the acting administrator as the "administrator on duty."On 4/18/23 at approximately 12:53 p.m., the consultant confirmed the administrator of record had not worked at the residence since 2/1/23. The consultant stated the acting administrator was responsible for the day to day operations of the residence. She confirmed the acting administrator was the person that currently oversaw the day-to-day operations. On 4/18/23 at 2:18 p.m., the RDO stated she was technically named as the administrator of the residence. However, she stated the acting administrator was going to be the administrator of record and stated the acting administrator handled the residence's day-to-day operations.

Based on record review and interviews, the residence failed to request, prior to staff hire, a name-based criminal history record check for each prospective staff member for five of five sample staff (#1-#5), affecting 36 current residents. Findings include:1. ReferenceChapter VII regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff" does not include individuals providing external services, as defined herein. 2. On 4/17/23 at 9:17 a.m., the personnel file for Staff #5 was requested. However, the residence was unable to provide evidence of a criminal history record check for Staff #5. The personnel file for Staff #5 read she was hired on 2/10/22 as a qualified medication administration personnel (QMAP). The staff schedule revealed Staff #5 worked nine times in April 2023 on the following dates: 4/9-4/12, 4/14, 4/15-4/18/23.3. On 4/17/23 at 9:17 a.m., the personnel file for Staff #2 was requested. However, the residence was unable to provide evidence of a criminal history record check for Staff #2. The personnel file for Staff #2 read he was hired on 10/22/18 as a caregiver. The staff schedule revealed Staff #2 worked eight times in April 2023 on the following dates: 4/9, 4/11-4/14, 4/16 and 4/18/23.4. On 4/17/23 at 9:17 a.m., the personnel file for Staff #4 was requested. However, the residence was unable to provide evidence of a criminal history record check for Staff #4. The personnel file for Staff #4 read she was hired as a caregiver. The staff schedule revealed Staff #4 worked eight times in April 2023 on the following dates: 4/9-4/11, 4/14-4/18/23.5. On 4/17/23 at 9:17 a.m., the personnel file for Staff #1 was requested. However, the residence was unable to provide evidence of a criminal history records check prior to hire for Staff #1. On 4/17/23 at 12:55 p.m., the residence provided a criminal history record check for Staff #1, dated 4/17/23. The personnel file for Staff #1 read she was hired on 10/13/22 as a QMAP.The staff schedule revealed Staff #1 worked seven times in April 2023 on the following dates: 4/9-4/13, 4/17, and 4/18/23.6. On 4/17/23 at 9:17 a.m., the personnel file for Staff #3 was requested. However, the residence was unable to provide evidence of a criminal history records check prior to hire for Staff #3. On 4/17/23 at 12:55 p.m., the residence provided a criminal history record check for Staff #3, dated 4/17/23. The personnel file for Staff #3 read she was hired on 1/3/23 as a QMAP.The staff schedule revealed Staff #3 worked seven times in April 2023 on the following dates: 4/9, 4/11-4/14, 4/16, and 4/18/23. On 4/18/23 at approximately 1:03 p.m., the regional director of operations confirmed there were no criminal history record checks available for Staff #1-#5 prior to 4/17/23. She stated the business office manager was a new employee and had not been fully trained yet. However, she confirmed the staff should not have been hired until the criminal history record checks were completed.

Based on observation, record review and interview, the residence failed to place in a visible location a list of all staff who had current certification in first aid and/or cardiopulmonary resuscitation (CPR), so that the information was readily available to staff at all times, affecting 36 current residents. Findings include:On 4/17/23 at approximately 7:30 a.m., an environmental tour of the residence revealed there was no list of all staff who had current certification in first aid and/or CPR in a visible location so the information was readily available to staff at all times. The residence's staff files read 18 staff members had current certifications in first aid and/or CPR. On 4/18/23 at 11:08 a.m., Staff #5 stated the administrator of record used to include CPR and first aid certification information on the staff schedule by putting stars next to staff names. She added she believed all staff were certified but was not certain if that was accurate. On 4/18/23 at 1:13 p.m., the regional director of operations stated the residence had a list of staff who were certified in first aid and/or CPR posted back by the residence's kitchen where a staff schedule was posted. She confirmed the list was not in a visible location and was behind a closed door.

Based on record review and interview, the residence failed to have a readily available current resident roster that included a residence diagram, affecting 36 current residents. Findings include: On 4/17/23 at approximately 7:27 a.m., a current resident roster was requested from the acting administrator. On 4/17/23 at 8:29 a.m., the acting administrator provided a current resident roster. However, the resident roster did not include a residence diagram that showed room locations. Additionally, the provided resident roster only contained 24 current residents. On 4/17/23 at approximately 9:45 a.m., a current resident roster that contained all current residents was requested from the acting administrator. On 4/17/23 at 10:18 a.m., the acting administrator provided a second resident roster that contained 36 current residents. The second provided resident roster did not contain a residence diagram that showed room locations. On 4/18/23 at 1:18 p.m., the regional director of operations stated she believed the resident roster should have contained resident room number and code status of residents. She stated she did not believe the residence had ever included all of the required items on their resident roster. Additionally, she confirmed there were 36 current residents.

Based on record review, observation and interview, the residence failed to ensure each first aid kit contained, at a minimum, triangular bandages with safety pins, affecting 36 current residents. Findings include:According to Medlink Healthcare Group, "A triangular bandage, also known as a triangular sling, is usually made of cotton or muslin cloth. These bandages are very versatile and efficient. These can be folded into a sling or can be used to provide the necessary pressure to a wound that is bleeding. Triangular bandages are a first-aid essential and should always be present inside your first-aid kit in the prescribed amount and condition ... " Medlink Healthcare Group (2023) retrieved from: https://www.mhg.sg/triangular-bandage-guide/#:~:text=These%20bandages%20are%20very%20versatile,the%20prescribed%20amount%20and%20condition. On 4/18/23 at 8:11 a.m., the acting administrator was asked where the first aid kit was located. The acting administrator was unsure and asked the administrative assistant (AA) to assist. On 4/18/23 at approximately 8:15 a.m., the AA provided four first aid kits, one from each of the four sections of the residence. The first aid kits were reviewed and revealed all four first aid kits did not contain a triangular bandage with safety pins. On 4/18/23 at approximately 8:22 a.m., the AA stated the residence did not have triangular bandages available and that the residence would need to order the bandages. She stated she was unaware the first aid kits were required to have a triangular bandage with safety pins. The AA stated she audited the first aid kits monthly and restocked the supplies each month or sooner if needed. On 4/18/23 at 1:17 p.m., the regional director of operations (RDO) stated she was aware first aid kits were required to have bandages, gauze and eye wash. The RDO stated she was unaware the first aid kits were missing items. She stated the residence utilized an outside company to restock supplies in the first aid kits and she believed the kits were stocked correctly.

Based on observations, interviews and record review, the residence failed to implement and follow their policy pertaining to fall management, including detailing in the resident's care plan the individualized approaches necessary to address fall risks, affecting seven of 11 sample residents (#1, #2, #4-#6, #7, #11) and two former residents (#13, #14). Specifically, Resident #7 was admitted to the residence on 6/14/22 with diagnoses including dementia. Resident #7 had a fall on 4/2, 4/11, and 4/16/23. The fall on 4/11/23 resulted in a broken ankle, broken ribs, a skin tear and pain. The resident fell again on 4/16/23. However, the care plan, dated 3/7/23, did not address that the resident was at risk for falls or an individualized approach necessary to address fall risk. Specifically, Resident #2 was admitted to the residence on 9/5/21 with a diagnosis of dementia. Resident #2 had falls on 1/29/23, 3/3/23, 4/12/23, and 4/16/23. The fall on 3/3/23 resulted in a bruise on Resident #2's head and the fall 4/16/23 resulted in a laceration, bruising and swelling on Resident #2's face. Resident #2's care plan, dated 9/7/21, did not include individualized approaches to prevent falls. Specifically, Resident #11 was admitted to the residence on 11/29/22 with diagnoses including dementia and seizures. Resident #11 had falls on 1/29/23, 2/7/23 and 4/17/23. The fall on 4/17/23 resulted in Resident #11 being taken to the hospital to get stitches on his head. Resident #11's care plan, dated 2/17/23, did not include individualized approaches to prevent falls. Specifically, Former Resident #13 was admitted to the residence on 1/11/23 with diagnoses including dementia and a history of falls. Former Resident #13 fell on 2/9 which resulted in left side pain, 2/11 which resulted in three skin tears, and 2/15/23 which resulted in the reopening of skin tears. On 2/20/23 the resident was sent to the emergency room because of complaints of side pain where it was determined he had broken ribs. Further, the care plan, dated 1/20/23, did not reveal the resident was at risk for falls or the individualized approach necessary to address fall risk. Specifically, Former Resident #14 was admitted to the residence on 11/22/19 with diagnoses including dementia. The resident fell on 9/25/22 and twice on 1/28/23. The second fall on 1/28/23 resulted in three lacerations to the resident's face and the resident passed away on 1/31/23. Additionally, the care plan, dated 9/17/22, read in part the resident was at risk for falls, however, it did not include the individualized approach necessary to address fall risk after her fall on 9/25/22 or either falls on 1/28/23. Findings include:1. Residence policy The residence's Fall Management policy, dated 4/18/23, read in part, if the resident was at risk for falls, staff interventions would be included in the resident's care plan. 2. Resident #7 was admitted to the residence on 6/14/22 with diagnoses including dementia. A progress note, dated 2/9/23, read in part, the resident had a fall which resulted in a scratch to her left abdomen. A care plan, dated 3/7/23, read in part, the resident was independent with mobility and transfers. However, the care plan did not include the individualized approach necessary to address fall risk as required. A progress note, dated 4/2/23, read in part, the resident fell. She fell out of bed. An incident report, dated 4/11/23, read in part, the resident fell out of bed which resulted in a swollen left ankle, a skin tear and pain. A progress note, dated 4/12/23, read in part, the resident had a broken left ankle and ribs. An incident report, dated 4/16/23, read in part, the resident fell in her room. On 4/17/23 at 7:34 a.m., Staff #10 stated Resident #7 was at risk for falls due to her history of falls. She stated the resident sustained a fractured left ankle due to a fall. Additionally, she stated she was not sure of the individualized approach necessary to address fall risk. On 4/17/23 at approximately 2:05 p.m., Staff #1 stated she was not sure if Resident #7 was at risk for falls. On 4/17/23 at 2:14 p.m., Staff #8 stated Resident #7 fell the previous week but she was not sure if the resident was at risk for falls. On 4/18/23 at 11:05 am., the legal representative for Resident #7 stated the resident was at risk for falls due to a history of falls. However, he stated he was not sure of the individualized approach necessary to address fall risk. On 4/18/23 at 11:32 a.m., Staff #5 stated Resident #7 was at risk for falls. She stated the resident fell and broke her ankle. She also stated staff were required to remind the resident to use her call light and keep her bedroom door open so staff could supervise her. On 4/18/23 at 11:43 a.m. Staff #2 stated Resident #7 was at risk for falls. He stated the resident fell and broke her ankle. He also stated staff were required to make sure the resident used a wheelchair now to prevent falls. On 4/18/23 at 11:47 a.m., the director of wellness stated she was aware the resident was at risk for falls. She stated it was her responsibility to update her care plan to include the individualized approach necessary to address fall risk. However, she stated the care plan was not updated because her first day of employment was 4/3/23 and she was still in the process of being trained on updating care plans. She stated staff were required to provide the resident with frequent checks. 3. Resident #2 was admitted to the residence on 9/5/21 with a diagnosis of dementia. On 4/17/23 from approximately 7:00 a.m. to 4:00 p.m. and 4/18/23 from 7:00 a.m. to approximately 3:00 p.m., Resident #2 was observed with bruising and a scab on her right eye and cheek. The residence's progress notes and incident reports for Resident #2, dated 1/29/23-4/16/23, read: On 1/29/23, Resident #2 was found on the floor with her head leaning on the toilet. On 3/3/23, Resident #2 slipped in the shower and hit her head on the wall. Resident #2 had a bruise on the back of her head. On 4/12/23, Resident #2 lost her balance and fell backwards into a seated position. Resident #2 was not injured. On 4/16/23, Resident #2 was found the floor of her bedroom. Resident #2 had a laceration, swelling and bruising on her right cheek and eye. Resident #2 stated "it hurts when touched." The residence's assessment for Resident #2, dated 4/16/23, read Resident #2 had three or more falls in the past three months. The assessment read Resident #2 had balance problems while standing or walking, changes in gait pattern when walking and read she required the use of an assistive device. The residence's care plan for Resident #2, dated 9/7/21, read Resident #2 was independent with mobility and transfers. The care plan did not include a section on falls. The care plan for Resident #2 was not updated to include individualized approaches necessary to address fall risks after Resident #2's falls on 1/29/23, 3/2/23, 4/12/23, or 4/16/23. On 4/18/23 at 8:37 a.m., Resident #2's family member stated Resident #2 had quite a few falls due to spatial awareness and imbalance issues from her dementia. She stated she had been working with staff to get them to remind Resident #2 to use her walker. Resident #2's family member stated she was unaware what staff were doing to prevent her from having future falls. She added, Resident #2 has had two instances of significant bruising on her face due to falls. On 4/18/23 at 1:17 p.m., the regional director of operations (RDO) stated she was only aware of Resident #2's most recent fall, which resulted in her black eye. She added she believed Resident #2's care plan was not updated after her fall due to the former director of wellness leaving the residence. 4. Resident #11 was admitted to the residence on 11/29/22 with diagnoses including dementia and seizures. A notification banner on the residence's electronic record system, dated 4/17/23, read Resident #11 was sent to the hospital for stitches on his head. The residence's progress notes and incident reports for Resident #11, dated 1/29/23-2/7/23, read: On 1/29/23, read Resident #11 tried to grab something off of the floor and lost his balance and fell. Resident #11 was not injured. On 2/7/23, read Resident #11 jerked backwards, lost his balance and fell back, resulting in him bumping his head on the wall. Resident #11 was not injured. The residence's assessment for Resident #11, dated 2/17/23, read Resident #11 was not a fall risk and did not require fall management devices. The residence's care plan for Resident #11, dated 2/17/23, read Resident #11 needed minimum assistance for mobility and transfers. Resident #11's care plan did not include a section on falls. The care plan for Resident #11 was not updated to include individualized approaches necessary to address fall risks after Resident #11's fall 1/29/23 or 2/17/23. On 4/17/23 at 2:23 p.m., Staff #9 stated Resident #11 had fallen in the morning at approximately 4:00 a.m., but stated he was back from the hospital after he had received stitches on his head. She added Resident #11 had fallen before. Staff #9 was unable to answer what interventions were in place to prevent Resident #11 from having falls. On 4/18/23 at 8:23 a.m., Resident #11's family member stated Resident #11 was at the hospital on 4/17/23 for what the residence assumed was a fall. She stated Resident #11 had had a few falls at the residence and was not sure what staff were doing to prevent him from falling. On 4/18/23 at 1:17 p.m., the RDO stated Resident #11 stated Resident #11 had returned from the hospital on 4/17/23 after he had received stitches on his head. She added he was not aware of Resident #11's prior falls but stated she would expect his fall interventions to be in his care plan. 5. Former Resident #13 was admitted to the residence on 1/11/23 with diagnoses including dementia. A progress note, dated 1/11/23, read in part, the former resident was newly admitted from a different assisted living residence with a history of falls. A care plan, dated 1/20/23, read in part, the former resident was independent with mobility and transfers. However, the care plan did not include the individualized approach necessary to address fall risk. A progress note, dated 2/9/23, read in part, the resident fell out of bed. He complained of left side pain. A progress note, dated 2/10/23, read in part, the resident was sent to the emergency department due to left side pain. A progress note, dated 2/11/23, read in part, the resident was found on the floor near his bed. The fall resulted in a skin tear to his left elbow, right elbow and left knee. A progress note, dated 2/15/23, read in part, the resident fell in his room which resulted in the skin tears from his previous fall to reopen. A progress note, dated 2/20/23, read in part, the resident was sent to the emergency department where it was found the resident had fractured ribs. On 4/18/23 at 11:32 a.m., Staff #5 stated Former Resident #13 was at risk for falls due to a history of falls. She also stated the former resident experienced left side pain due to a fall. On 4/18/23 at 11:43 a.m., Staff #2 stated the former resident was at risk for falls, however, he was not aware of the individualized approach necessary to address fall risk. 6. Former Resident #14 was admitted to the residence on 11/22/19 with diagnoses including dementia. A care plan, dated 9/17/22, read in part, the resident was at risk for falls. Staff were to ensure the resident's bed was in the lowest position, provide evening safety checks, and ensure all staff were aware she was at risk for falls. However, the care plan did not include individualized approaches necessary to address fall risk after her fall on 9/25/22 or after her falls on 1/28/23. A progress note, dated 9/25/22, read in part, the former resident had a fall. A progress note, dated 1/28/23 at 4:15 p.m., read in part, the resident fell in the living room. A progress note, dated 1/28/23 at 6:30 p.m., read in part, the resident fell in another resident's room and broke a lamp. This resulted in lacerations on her right forehead and two lacerations on her nose. She was sent to the emergency department. A progress note, dated 1/30/23, read in part, the former resident had two falls on 1/28/23. The first fall resulted in no injuries, however the second fall resulted in three lacerations. A progress note, dated 1/31/23, read in part, the former resident passed away at 7:10 a.m. On 4/18/23 at 2:14 p.m., Staff #8 stated the resident was at risk for falls due to her history of falls and wandering. She stated she was not aware of the individualized approach necessary to address fall risk. 7. Resident #1 was admitted to the residence on 4/3/23 with a diagnosis of metabolic encephalopathy. A residence incident report for Resident #1, dated 4/13/23, read Resident #1 fell in her bathroom. The fall resulted in a skin tear on her right finger and a bruise on her right elbow. The residence's progress notes for Resident #1, dated 4/14/23, read Resident #1 had a fall on 4/13/23 which resulted in an injury to a finger on her right hand and elbow. The residence's assessment for Resident #1, dated 4/3/23, read she was a fall risk with frequent falls which required fall protocol. The residence's care plan for Resident #1, dated 4/3/23, read she was a fall risk. The care plan read staff were to provide adequate lighting and a night light, if needed. Additionally, the care plan read Resident #1 was to have fall assessments completed, as needed. The care plan for Resident #1 was not updated to include individualized preventative approaches necessary to address fall risks. On 4/17/23 at 2:10 p.m., Staff #7 stated Resident #1 had a recent fall. He stated he heard her calling for help and had found her on the floor. Staff #7 added Resident #1 had cut her finger when she fell. Further, Staff #7 stated Resident #1 stated staff were expected to conduct more checks on her after the fall had occurred. 8. Resident #5 was admitted to the residence on 4/14/21 with a diagnosis of dementia. The residence's progress notes and incident reports for for Resident #5, dated 2/1/23- 3/28/23, read: On 2/1/23 read, Resident #5 found sitting on the floor in the hallway. No injuries were noted. On 3/28/23 read, Resident #5 found on the floor in the activity room at 2:10 p.m. and found on the floor again at 3:45 p.m. in the hallway. No injuries were noted for either incident. The residence's assessment for Resident #5, dated 2/1/23, read Resident #5 had three or more falls in the past three months. The assessment read Resident #5 had balance problems while standing or walking, decreased muscular coordination or jerking movements, and required the use of assistive devices. The residence's care plan for Resident #5, dated 2/1/23, read staff were to ensure they assisted with incontinence care and transferred, as allowed by Resident #5. Further, the care plan read staff were to be aware Resident #5 was at a risk for falls and read Resident #5 liked to sit on the floor randomly. The care plan for Resident #5 was not updated to include individualized approaches necessary to address fall risks after Resident #5's fall on 3/28/23. On 4/17/23 at 2:14 p.m., Staff #8 stated Resident #5 slid out of his wheelchair often which caused him to be a fall risk. On 4/18/23 at 8:14 a.m., Resident #5's family member stated he was aware of Resident #5's falls and being found on the floor. 9. Resident #6 was admitted to the residence on 4/25/17 with diagnoses including Alzheimer's disease. A care plan, dated 1/17/23, read in part, the resident was at risk for falls and a staff intervention in place to mitigate falls included ensuring all staff were aware the resident was at risk for falls. A progress note, dated 3/4/23, read in part, the resident fell in her room. On 4/17/23 at 9:28 a.m., the legal representative for Resident #6 stated the resident was at risk for falls, however,she was not aware of the individualized approaches necessary to address fall risk. On 4/18/23 at 12:52 p.m., Staff #4 stated Resident #6 was not at risk for falls and had never had a fall that she was aware of. On 4/18/23 at 12:52 p.m., Staff #1 stated Resident #6 was not at risk for falls and had never had a fall that she was aware of. 10. Resident #4 was admitted to the residence on 9/20/21 with diagnoses including dementia. A care plan, dated 1/5/23, read in part, the resident was at risk for falls and a staff intervention in place to mitigate falls included ensuring all staff were aware the resident was at risk for falls. A progress note, dated 3/19/23, read in part, the resident fell. On 4/18/23 at 12:52 p.m., Staff #4 stated Resident #4 was not at risk for falls and had never had a fall that she was aware of. On 4/18/23 at 12:52 p.m., Staff #1 stated Resident #4 was not at risk for falls and had never had a fall that she was aware of. On 4/18/23 at approximately 1:03 p.m., the regional director of operations confirmed the aforementioned residents were all at risk and the care plans should have included the individualized approach necessary to address fall risk. She stated the director of wellness was currently being trained on how to update care plans as required, however, the former director of wellness should have updated care plans prior to 3/31/23.

Based on interview and record review, the residence failed to promptly notify the resident's family and/or legal representative of a fall that required lift assistance, affecting one former resident (#12). Findings include:1. Residence policyThe residence's Fall Management and Lift Assistance policy, dated 1/1/19 and 4/18/23, read in part, the resident would promptly notify the resident's legal representative of a fall that resulted in lift assistance. 2. Former Resident #12 was admitted to the residence on 3/22/22 with diagnoses including dementia. An incident report, dated 3/25/23, read in part the resident fell at 7:00 p.m. which resulted in a bump to her head. However, the notification section of the incident report was blank. On 4/17/23 at 8:57 a.m., the legal representative for Former Resident #12 stated she was not notified the former resident fell on 3/25/23. She stated she found out about the fall on the morning of 3/26/23 when she visited the resident and saw that the resident had a bump on her head. On 4/17/23 at 2:38 p.m., Staff #6 stated she was the staff member who lifted Former Resident #12 off the floor on the evening of 3/25/23. She confirmed she did not notify the legal representative of the fall because she thought a different staff member did. She confirmed the expectation was that the legal representative should have been promptly notified of the fall. On 4/18/23 at approximately 1:03 p.m., the regional director of operations stated the legal representatives should be notified promptly whenever a resident had a fall. She stated she was not sure why the legal representative for Former Resident #12 was not notified of the fall immediately.

Based on observation, record review and interview, the residence failed to ensure the house rules addressed the use of electronic cigarettes and vaporizers and the consumption of marijuana, affecting 36 current residents. Findings include: Chapter VII regulations governing assisted living residences, part 13.3, requires that the assisted living residence shall establish written house rules and place them in a publicly visible location so that they are always available to residents and visitors. On 4/17/23 at 7:29 a.m., an environmental tour of the residence revealed the residence's posted house rules, dated 1/1/13. However, these posted house rules that were made available to residents did not address the use of electronic cigarettes and vaporizers or the consumption of marijuana. On 4/17/23 at 11:59 a.m., the residence's house rules, dated 1/4/21, were provided. The house rules addressed the use of electronic cigarettes and vaporizers and the consumption of marijuana; however, the updated rules were not posted. On 4/18/23 at 1:34 p.m., the regional director of operations stated the residence had updated the house rules to include electronic cigarettes and vaporizers and marijuana. However, she stated the residence must have not posted the updated house rules.

Based on observation, record review and interview, the residence failed to ensure the process for raising and addressing grievances and complaints was placed in a visible on-site location along with the full contact information for the state and local long-term care ombudsman, the Adult Protection Services of the appropriate county Department of Social Services, the advocacy services of the area's agency on aging and the Colorado Department of Public Health and Environment, affecting 36 current residents. Findings include:The residence's Grievance Policy posting, dated 1/15/13, read in part, the residence had established a policy and procedure regarding the filing of grievances. However, it did not include the contact information for the state and local long-term care ombudsman, the Adult Protection Services of the appropriate county Department of Social Services, the advocacy services of the area's agency on aging and the Colorado Department of Public Health and Environment. On 4/17 from 7:00 a.m. to 4:00 p.m. and 4/18/23 from 7:00 to 2:30 p.m., the residence's process for raising and addressing grievances and complaints was placed in a visible on-site location; however, it did not include the contact information for the state and local long-term care ombudsman, the Adult Protection Services of the appropriate county Department of Social Services, the advocacy services of the area's agency on aging and the Colorado Department of Public Health and Environment,On 4/18/23 at approximately 1:03 p.m., the regional director of operations stated she was aware that the grievance posting located near the entrance of the residence was outdated and did not include all the required contact information. She stated the updated grievance policy with all the required contact information should have been posted publicly.

Based on record review and interview, the residence failed to have policies and procedures for the identification, reporting, and investigation of injuries of unknown origin, affecting 36 current residents. Findings include: On 4/17/23 at 7:27 a.m., the residence's policy on investigations of injuries of known or unknown source/origin was requested. On 4/17/23 at 3:54 p.m., the residence's policy on investigations of injuries of known or unknown source/origin was requested again. On 4/18/23 at 7:00 a.m., the residence had not provided the residence's on investigations of injuries of known or unknown source/origin. On 4/18/23 at 1:08 p.m., the regional director of operations stated the residence had the policy and the residence could provide the policy for investigations of injuries of known or unknown source/origin. On 4/18/23 at 2:45 p.m., the residence was unable to provide a policy for investigations of injuries of known or unknown source/origin.

Based on record review and interview, the residence failed to ensure the administrator and a qualified medication administration person (QMAP) conducted quarterly audits of medication administration records, controlled substance list, medication error reports, and medication disposal records, affecting 11 of 11 sample residents who were administered medication (#1-#11). Findings include: The residence's Medication Audit Policy, dated 2/1/28, read the director of wellness (DOW) completed an audit of medications quarterly or more frequently as needed. On 4/17/23, medication audits were provided by the residence. The medication audits, dated 12/20/22 and unsigned by the administrator and director of wellness, had not been completed by the residence and had been completed by the residence's external consultant agency. On 4/18/23 at 1:42 p.m., the regional director of operations (RDO) stated the acting administrator and the director of wellness were expected to complete the residence's medication audits. The RDO confirmed no medication audit had been completed by the residence in the past 90 days. She confirmed the only medication audit that had been completed was competed by the residence's consultant agency.

Based on record review and interview, the residence failed to provide staff with six hours of general training and education on providing care and services for residents with dementia/cognitive impairment, affecting 36 current residents. Findings include: The residence operated as a secure environment and provided care to those with cognitive impairments. 1. Reference Chapter VII regulations governing assisted living residences, part 7.12, requires that each personnel file shall include, but not be limited to, written documentation regarding the following items:(B) Date of hire or acceptance of volunteer service and date duties commenced;(C) Orientation and training, including first aid and CPR certification, if applicable. 2. Personnel FilesThe residence's offered online dementia training's were provided by the residence. The trainings read staff were required to take an online class titled "An overview of Quality Dementia Care." The trainings offered did not include six hours of general training and education on providing care and services for residents with dementia/cognitive impairment. Staff #1 was hired by the residence on 10/13/22. The personnel file for Staff #1 did not have documentation she had received six hours of training and education on providing care and services for residents with dementia/cognitive impairment. The staff schedule revealed Staff #1 worked seven times in April 2023 on the following dates: 4/9-4/13, 4/17, and 4/18/23. Staff #3 was hired by the residence on 1/3/23. The personnel file for Staff #3 did not have documentation she had received six hours of training and education on providing care and services for residents with dementia/cognitive impairment. The staff schedule revealed Staff #3 worked seven times in April 2023 on the following dates: 4/9, 4/11-4/14, 4/16, and 4/18/23. Staff #4 was hired by the residence on an unknown date. The personnel file for Staff #4 did not have documentation she had received six hours of training and education on providing care and services for residents with dementia/cognitive impairment. The staff schedule revealed Staff #4 worked eight times in April 2023 on the following dates: 4/9-4/11, 4/14-4/18/23.3. Interviews On 4/18/23 at 11:38 a.m., Staff #1 stated the residence completed monthly online training for dementia and stated the residence staff completed an initial orientation. She added she had not completed six hours of dementia training with the residence. Staff #1 stated when a resident had behaviors, she was trained to allow them to have their behaviors and to leave the residents alone. On 4/18/23 at 11:42 a.m., Staff #4 stated she had not had training on dementia in person or online. On 4/18/23 at 1:43 p.m., the regional director of operations (RDO) stated all staff were required to complete training and education on providing care and services for residents with dementia/cognitive impairment through the residence's online training system. The RDO added if staff did not have the training, it had to have been an audit issue because reports were run on staff to ensure they had completed their training. Further, she stated if staff had not completed the training, they were expected to be taken off of the schedule, and not permitted to return to providing care and services to residents until the training and education was completed.

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 ound at 6 CCR 1011-1, Chapter 7.7.5 The assisted living residence shall select direct care staff based on such factors as the ability to read, write, carry out directions, communicate, and demonstrate competency to safely and effectively provide care and services. 12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident's condition changes from baseline status. 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. 25.10 In addition to the information required for a resident care plan at Part 12.10, the care plan for each resident in a secure environment shall include the following: (A) A description of the resident's wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact. 25.16 The assisted living residence shall ensure that each staff member assigned to the secure environment is trained on the care plan for each new resident that is part of the individual's assigned duties and responsibilities.

A licensure revisit was completed on 4/19/23 for all previous deficiencies cited on 2/1/23. The residence is in compliance with all regulations surveyed.

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A licensure complaint, prompted by #CO29408 was completed on 2/1/23. Deficiencies were cited.

Based on observation, interview, and record review, the residence failed to make available personal services, affecting one of six sample residents (#18). Findings include:1. Resident AgreementThe residence's sample resident agreement, undated, read in part, "The residence provides distinct personal service plans ... Each plan contains different levels of personal assistance and care services depending on the individual needs of the resident."2. Resident #18 was admitted to the residence on 5/23/14. On 2/1/23 from 7:25 a.m. to 8:27 a.m., the portable oxygen tank was empty for on the back of Resident #18's wheelchair. On 2/1/23 at 1:29 p.m., Staff #15 stated Resident #18 was required to have 4 liters (L) of oxygen at all times. However, he confirmed the resident's portable oxygen tank was empty earlier that morning because staff forgot to fill it. On 2/1/23 at 2:14 p.m., the wellness director stated the resident required two 2L of oxygen at all times. She stated staff were required to ensure the resident's portable oxygen tank was filled as required. A written practitioner's order, dated 12/27/22, directed the residence to administer 2L of oxygen continuously.

Based on interviews and record review, the residence failed to hold regular family council meetings at least quarterly, affecting 40 current residents. Findings include:On 2/1/23 the RN consultant provided family council meeting notes dated 1/12, 4/20, and 7/13/22. On 2/1/23 at 9:25 a.m., the RN consultant stated the last family council meeting was canceled due to construction in the residence. On 2/1/23 at approximately 2:13 p.m., the director of wellness stated the last family council meeting was in July 2022. She added she was aware the residence was required to hold family council meetings quarterly.

A licensure revisit was completed on 2/1/23 for all previous deficiencies cited on 2/24/21. The residence is in compliance with all regulations surveyed.

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally