SOMEREN GLEN ASSISTED LIVING

DESCRIPTION OF OCCURRENCE: On 9/7/23, resident (A), in her 90s, reported missing a can of Ensure (supplemental drink) from her apartment after it was cleaned by the housekeeper (1). FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police. Housekeeper (1) was sent home. Other residents were asked if they were missing anything and they stated no. Staff member (2) had previously counted the number of Ensures prior to housekeeper (1) entering the apartment and recounted after they left. One ensure was missing. Housekeeper (1) denied taking the Ensure or any other item. The facility investigation concluded they could not prove housekeeper (1) took the Ensure. To help prevent a recurrence, housekeeper (1)’s employment was terminated. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Sent to facility 8/26/2024 · released to the public 9/2/2024.

DESCRIPTION OF OCCURRENCE: On 8/29/23, the facility submitted a report regarding a medication error. Management discovered nurse (1) omitted administering a seizure medication for resident (A). The resident had experienced a seizure episode and was transferred to the hospital for an evaluation. Reportedly, resident (A) missed four doses of the seizure medication after his admission. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, and physician. An audit was completed and it was discovered the medication order was not entered into the medical record for resident (A) by nurse (1). Nurse (1) thought they had entered the medication into the record and was apologetic. No other medication concerns were identified. Resident (A) returned to the facility and the medication was restarted. Per the facility, resident (A) has returned to their baseline of function. The facility investigation concluded nurse (1) failed to ensure the medication was entered into the medication record for resident (A) as ordered by the physician. The facility recognized this may have been an oversight, however, this was not caught until resident (A) had a seizure and needed to be sent to the hospital. To help prevent a recurrence, nurse (1) was counseled on the need to accurately enter admission orders prior to returning to work. Two staff members planned to review the admission orders to ensure accuracy of data entered into the medication system. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Sent to facility 7/22/2024 · released to the public 7/29/2024.

DESCRIPTION OF OCCURRENCE: On 4/4/23 a female resident (A) in 80s reported missing two purses and four pairs of earrings over the past few months. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families/guardians, and ombudsman. The family was notified and asked that no report be made until the apartment was searched as resident (A) was not a reliable source of information. The staff assisted with looking for the missing items. The items were not located. Other items in the apartment were documented and accounted for. Resident (A) stated she thought a purse went missing on the night she had egg rolls, which was 4/1/23 and believed it was a woman. Staff that worked around that time were interviewed and did not indicate they knew where these items were or of them. The facility investigation concluded no assailant was identified due to the lack of evidence. To help prevent a recurrence, resident (A) was advised to use her drawer with the lock on it and to ensure her door was locked when she left her apartment. Resident (A) encouraged to report if she felt unsafe or anything missing. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Sent to facility 9/22/2023 · released to the public 9/29/2023.

DESCRIPTION OF OCCURRENCE: On 4/8/23, an agency qualified medication administration person (QMAP 1) left their shift at 10:15 p.m. and did not return. There was an allegation of neglect due to the staff member abandoning the job. The facility reported some resident medications were administered late. One resident (A), in her 80s, was distraught about receiving her medications late and the delay in the QMAP (1) responding to her call light. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families/guardians, Adult Protective Services, and ombudsman. A second staff member working on a different floor stepped in to provide care assistance and finished administering the medications for all residents. There was no reported harm to the residents, who received their medications late. A family member showed up to provide emotional support to resident (A) during the night. Management learned about a sheriff finding QMAP (1) asleep in the parking lot and ended up arresting them. The circumstances of the arrest were unknown and no follow up interview occurred with QMAP (1). A manager contacted the staffing agency of the event. Management concluded QMAP (1) abandoned their shift. To help prevent a recurrence, management hired permanent staffing to fill the night shift positions. The leadership team developed a rotation on call schedule to help provide additional support to staff when needed. Education was provided to staff on utilizing key contacts during such events. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Sent to facility 1/8/2024 · released to the public 1/15/2024.

DESCRIPTION OF OCCURRENCE: On 4/20/23, a chart review occurred for a resident (A), in her 90s, related to her recent hospitalization and identification of an in-house acquired infection to her wound. A director discovered several concerns related to the management of the resident’s wound in the facility from 3/1 through 4/5. Facility records showed staff (1) did not ensure physician orders were in place for wound care treatments and did not properly communicate with the primary physician about the status of the wound. Per facility protocol expectations and nursing standards of practice, staff (1) should have communicated with the resident's primary care physician (PCP) and obtained orders for wound care treatment. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the physician, family, and ombudsman. The facility reported the resident had received treatment for the wound infection in the hospital and has since returned with wound care treatment orders. Currently, the facility indicated the resident was receiving the appropriate treatment for the wound, which was showing signs of healing. Management suspended staff (1) pending investigation. No other residents residing in the facility were in need of wound care. The following information was identified through staff interviews and a chart review of the events leading up to the wound infection/hospitalization. A new wound was identified on 3/1 for resident (A), and hospital discharge instructions directed staff to follow up with the PCP or wound office for care instructions. Staff (1) did not follow the hospital discharge instructions and did not notify the PCP or wound care office for wound care orders. Instead, staff (1) followed wound care instructions of a family member (identified as a physician assistant (PA) not related to the PCP’s office). For a span of approximately 35 days, staff (1) did not contact the PCP’s office about the resident’s wound, obtain orders, or notify their office when the status of the wound changed. Staff (1) notified the family member/PA and followed their provided wound care orders since the resident’s readmission on 3/1. The family member/PA managed the resident's wound care and dressing changes. On 3/31, staff (1) alerted a director about the management of the resident’s wound. Immediate education was provided to staff (1) regarding facility protocols and PCP oversight. Following this conversation, staff (1) took no action and no wound care occurred between 4/1 and 4/5. There was a noted adverse change in the status of the wound. Management indicated staff (1) should have called the PCP to provide an update on the wound and obtain any necessary treatment orders versus following the family member/PA recommendations. On 4/5, an outside agency became involved in the resident’s care and communication occurred with the PCP office at this time. The resident was sent to the hospital for an apparent infection to the wound. She was admitted and received intravenous antibiotic treatment for the wound infection. The PCP’s office verified no facility staff contacted them about the resident’s wound from 3/1 through 4/5. Staff (1) acknowledged they followed the family member’s instructions for wound care management and communicated with them about the wound needs. Staff (1) indicated the director was not a medical professional, and responded to that conversation by taking no action with the resident's wound. The family of resident (A) reported the family member/PA’s involvement most likely contributed to confusion surrounding wound care protocols. From the findings, the facility concluded staff (1) used the family member’s orders as official treatment orders, which did not comply with facility protocol or standards of nursing practice. However, staff (1) had been trained on the proper protocols to follow with obtaining physician orders and notification standards but chose not to follow the standards or protocol. The allegation of neglect by staff (1) was substantiated, but the facility was unable to prove or disprove if the lack of treatment from 4/1 through 4/5 caused a wound infection. Staff (1) tendered her resignation stating “no fault” in this incident. The facility notified staff (1)’s oversight licensing board regarding the incident findings. Once a new Wellness Director was hired, education would be provided regarding community expectations of following policies, resident care needs, and notifying the provider. In addition, the director spoke with the family member/PA and requested a third party agreement if they still wanted to make judgment calls as a Physician’s Assistant on the medical care of this resident. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Sent to facility 2/5/2024 · released to the public 2/6/2024.

DESCRIPTION OF OCCURRENCE: On 2/4/23 a Aspercreme Lidocaine 4% patch that was prescribed for a female resident (A) age 101 was provided and placed on a male resident (B) in his 70s. Three staff members were involved, Nurse (1), and qualified medication administration person (QMAP) (1) and (2). FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician, families/guardians and Board of Nursing. Resident (B) was not prescribed the same dosage of lidocaine patch and the one place on him included aspirin. QMAP (1) was notified that resident (B) was having pain and to administer the pain patch. No patches were found by QMAP (1) in the medication cart. The patches had been received according to nurse (1). Resident (B) had a patch in place and was asked how, because he did not have any delivered from the pharmacy to the facility. The patch was removed, the physician for resident (B) was notified and changed the prescription so the patches could be purchased from the store as the pharmacy could not deliver the patches that were previously prescribed. Resident (B) was provided with a new patch. No side effects seen for resident (B). QMAP (1) and QMAP (2) admitted to placing the medicated patch for resident (A) on resident (B) based on the directions given from nurse (1). Nurse (1) stated they may have told both QMAPs to use another resident's medications because resident (B) was in pain. The facility investigation concluded the diversion occurred. Nurse (1) resigned promptly. To help prevent a recurrence resident rights for medication administration was reviewed with QMAPs. Both QMAPs were given a final warning. Nurses were educated on proper pain assessments. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Sent to facility 9/5/2023 · released to the public 9/12/2023.