GARDENS AT VIEWPOINTE, THE

A complaint revisit was completed on 1/22/26 for all previous deficiencies the previous deficiencies cited on 6/11/25. The residence is in compliance with all regulations surveyed.

A revisit survey was completed on 12/1/25 for all previous deficiencies cited on 5/13/25. The facility is in compliance with all deficiencies that were cited.

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 revisit to the 06/18/2025survey was completed on 08/27/2025. The facility was in compliance with all regulations surveyed. No response is required.

A complaint, prompted by #CO40359, was completed on 6/18/2025. Three deficiencies were cited. The facility is a three floor of a Type V (111) structure and licensed for twenty three (162) beds. The facility is protected by a complete National Fire Protectin Association (NFPA) 13 automatic fire suppression system.

Based on observations, interviews and record reviews, the facility failed to evacuate to a safe location, one resident that resided in room #306A, during a fire event that occurred on 6/04/2025. The failure impacted one resident and had the potential to impact all other residents that required the same or higher level of assistance during a fire oremergency evacuation event. Findings include:Regulatory reference2012 NFPA 101 Life Safety Code, Section 4.6.1.2 Any requirements that are essential for the safety of building occupants and that are not specifically provided for by this Code shall be determined by the authority having jurisdiction. At a minimum, the smoke compartment of origin shall be evacuated. ObservationsRoom 307 was observed with the facility administrator on 6/05/2025 at 08:19 a.m. The oxygen concentrator, which was reported by the local fire authority to be the source of a fire on 6/04/2025 at 11:44 p.m, had visual evidence of having been on fire. Room 306A was observed to be next to and with the same smoke zone as room 307. Record ReviewFire safety evaluation system (FSES) forms for all residents were requested. The facility administrator acknowledged the FSES forms furnished by the facility were not on the correct/indicated form. The administrator said the facility would need to complete reviews using the correct form. The corrected FSES for the resident in room 306A, provided electronically on 6/16/2025, documented that the resident does not respond to fire drills(score of 12 in section VII of worksheet 6.8.2) and needs limited assistance from staff to evacuate. InterviewsThe facility administrator was interviewed on 6/11/2025 at 2:30 p.m. The administrator stated there were four staff on duty in the facility during the fire. The administrator acknowledged that the resident in room 306A was not moved to a different smoke zone and remained in room 306A during the fire event. An interview with staff on was 6/11/2025 at 2:40 p.m. by telephone. The onsite staff stated the member facility did not evacuate the resident in the room. The staff said that they have been trained to evacuate the compartment with the incident to the next smoke zone within the building during a fire.

Based on observations, interviews, and record review, the facility did not meet requirements for a defend-in-place procedure in the event of a fire. Specifically, staff of the facility, classified as an existing board and care occupancy, could not provide evidence that the facility can be used as a defend-in-place facility. This failure had the potential to to affect all residents and occupants of the facility. Findings include:Regulatory Reference2012 NFPA 101, Section 33.3.1.2.2* Impractical. Large facilities classified as impractical evacuation capability shall meet the requirements of Section 33.3 for impractical evacuation capability, or the requirements for limited care facilities in Chapter 19, unless the authority having jurisdiction has determined equivalent safety is provided in accordance with Section 1.4. The Life Safety Code Handbook, 12th edition in part states the following. Page 1039 states. The Existing large facilities in which residents are classified as impractical to evacuate must comply with the requirements of Chapter 19, Chapter 32, or Chapter 33, as applicable (see 33.1.1.4 and 33.3.1.2.2). Record ReviewReview of the facility licensing records documented the facility is licensed for 162 beds. At the start of the investigation, the facility reported a census of 137 residents. At the time of the fire incident, 4 staff were onsite for the entire facility. Fire safety evaluation system (FSES) forms from the 2013 NFPA 101A for all residents were requested. The facilityadministrator acknowledged the FSES forms furnished by the facility were not on the correct/indicated form. The administrator said the facility would need to complete reviews using the correct form. The corrected FSES for all residents, provided electronically on 6/16/2025, documented:-Four residents require total assistance from two staff to evacuate-Six residents require partial assistance from two staff to evacuate-Of the remaining 130 resident rating sheets provided from the facility, 69 residents required supervision or assistance from the staff to evacuate as evidenced by documented failure to initiate and complete evacuation during fire drills and/or documented mobility, cognitive impairmentAccording to the 2013 NFPA 101A, the Evacuation Capability Score was 15.21. The Scores are as follows:- Less than 1.5 facility is Prompt; - Between 1.5 and 5.0, the facility is Slow;- Over 5, the facility is impractical. The 2012 NFPA 101 defines Impractical Evacuation Capability as "The inability of a group to reliably move to a point of safety in a timely manner."

Based on observation, record reviews, and interviews, the facility failed to maintain a facility constructed in conformity with the applicable standards adopted by the Division of Fire Prevention and Control (DFPC) related to existing residential board and care occupancies. Specifically, the facility failed to comply with requirements for fireevacuation procedures during a fire event, and the facility did not meet requirements for utilizing defend-in-place procedures. The facility failures had the potential to affect all occupants of the building. Findings include:Cross-reference to A0001 for observation, interviews, and record review related to failures to evacuate to a safe area resident that was in the smoke compartment where a fire event was occurring. Cross-reference to A0002 for observation, interview, and record review related to failures to have a building constructed board and care occupancy that met the requirements for defend-in-place procedures for a building, occupants, and staffing that rated as "impractical" in the event of an emergency evacuation.

A licensure complaint, prompted by #CO40320 was completed on 6/11/25. Deficiencies were cited.

Based on record review and interview, the residence failed to have policies and procedures to ensure the continuation of care to all residents for 72 hours following an emergency, including, but not limited to, a long-term power failure, affecting 121 current residents. (Cross-reference T1110)On 6/11/25, during the onsite visit, the residence's 72-hour continuation of care policy and procedure was requested but was not provided. On 6/11/25 at 1:16 p.m., the maintenance director stated he was not aware that the residence was required to have a 72-hour policy or procedure. He added that it made sense, given the recent power outage and the number of residents who required oxygen. On 6/11/25 at 2:33 p.m., the administrator stated that, prior to the onsite visit, the residence did not have a 72-hour continuation of care policy or procedure; however, during the onsite visit, the residence began working on the policy and procedure to ensure residents had access to power when required. He affirmed the residence experienced a power outage on 5/24/25 and did not have a plan in place, and the residence was required to utilize emergency medical services (EMS) to support residents on oxygen.

Based on record review and interview, the residence failed to develop and implement emergency preparedness policies and procedures which included all required elements, affecting 121 current residents. (Cross-reference T1110)Findings include:The residence's June 2019 Emergency Manual failed to contain the required elements, including circumstances procedure for evacuating the premises; an established means of communicating with families, staff, and other providers; a plan that ensures the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids; a plan to store and preserve medications; assignment of specific tasks and responsibilities to current staff members on each shift including use of a triage system to assess the needs of the most vulnerable residents first; a procedure to protect and transfer of health information as needed to meet the care needs of residents; and written agreements with other health facilities in the event of an evacuation. On 6/11/25 at 1:16 p.m., the maintenance director confirmed that there were instances where the residence had to evacuate all residents outside, such as in the event of a building fire or a nearby wildfire. He added that he was aware the evacuation plan included evacuating to a nearby hotel but was unable to state what else was included in the current evacuation plan or if it had all the necessary elements. On 6/11/25 at 2:33 p.m., the administrator stated that the current evacuation plan failed to contain all the required elements. However, after the residence became aware of the missing elements, they began working on a new plan during the onsite visit.

Based on observation, record review, and interview, the residence failed to provide a physically safe environment, either directly or indirectly, per the resident agreement, affecting 51 current residents. (Cross-reference T0914, T0920)Specifically, the residence failed to have procedures in place for safe evacuation from floors two and three for non-ambulatory residents in the event that the residence required a complete evacuation. Further, the residence failed to have a plan to ensure residents had continuous access to oxygen in the event of a power outage for those who utilized oxygen. The residence experienced a power outage on 5/24/25 wherein the residence was unable to ensure residents' access to oxygen without emergency medical services (EMS). On 6/5/25, the residence experienced a fire in a room on the third floor. The residence failed to update their policies and procedures or educate staff regarding what to do in the event of a fire or power outage. This created an immediate jeopardy risk of harm or death due to the risk of smoke inhalation, fire, or lack of required oxygen to 51 current residents. On 6/11/25, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. Reference and Residence PoliciesThe residence's July 2024 Residency Agreement read in part that the residence provided regular observations of residents to ensure the residence met the residents' health, safety, and emergent needs. Residence leadership staff were responsible for coordinating emergency actions. The residence's June 2019 Emergency Procedures Manual read in part that complete evacuations of residents may be required; however, the manual did not detail how the residence staff was to fully evacuate non-ambulatory residents on the second and third floors when the residence required a complete evacuation, and the elevator was inoperable or unsafe to use. Further, the manual read the residence had an alternate power source; however, the plan did not specify the location or type of power source. The plan read that in the event the alternate power supply fails, the residence should prepare to evacuate all residents. 2. Observations On 6/11/25 at 8:03 a.m., the room of Residents #28 and #29 demonstrated water damage due to sprinklers engaged by the fire that occurred on 6/5/25. On 6/11/25, during the onsite visit, Residents #21, #23-#26 utilized wheelchairs or were bed-bound and resided on the second or third floors of the residence. On 6/11/25, during the onsite visit, Residents #21 and #25-#28 utilized oxygen. 3. Record ReviewA photograph, dated 6/5/25, showed smoke damage originating from an oxygen concentrator up a wall approximately six feet and covering approximately six feet by four feet of the ceiling. The state fire authority (SFA) inspection, dated 6/5/25, read in part there was a fire at the residence on 6/5/25 at 12:16 a.m. The residence's emergency plans did not contain all of the required elements. Furthermore, the fire door behind which staff evacuated residents had gaps and required further inspection to determine whether it supported the residence's plan to defend in place rather than undergo a complete evacuation. A residence list, dated 6/11/25, read in part that Residents #21 and #23-#26 were non-ambulatory residents residing on the second and third floors and were unable to traverse stairs in the event of a complete evacuation. On 6/11/25 at approximately 7:30 a.m. and again at 8:15 a.m., the residence list of residents utilizing oxygen was requested. On 6/11/25 at 10:14 a.m., the residence provided a list of residents who utilized oxygen. The list included 46 current residents, including Residents #21 and #25-#284. InterviewsOn 6/11/25, during the onsite visit, Staff #11-#16 stated they did not know the residence's plan to evacuate Residents #21 and #23-#26 from their second or third-floor rooms in the event the residence required evacuation, such as if the residence was engulfed in flames or there was a nearby wildfire. Staff #15 and #16 stated there had been nearby wildfires within the last two years on two occasions. Staff #11-#16 affirmed that Residents #21 and #23-#26 would be unable to traverse stairs in the event of an evacuation and added that they were unsure how to safely escort them out of the building, as the staff would have needed to carry them. Staff #11-#16 stated they did not know the residence's plan to ensure continuous access to oxygen for the residents. Furthermore, the staff were unable to specify exactly how many residents used oxygen. On 6/11/25 at 2:00 p.m., Resident #28 stated that the residence's power went out recently, and she almost ran out of oxygen. She added she felt anxious of any other power outage now because of the event. On 6/11/25 at 8:30 a.m., the administrator stated that the residence's failure to have a plan to evacuate residents who were non-ambulatory from the second and third floors, along with the residence's lack of ability to ensure residents requiring oxygen had access to oxygen during a power outage put the residents at serious risk of harm. He agreed the residence required immediate remediation of the risk. He added that this was especially true since there had been a fire on 6/5/25 and the residence's "defend in place" status was in question, and that the residence had a power outage on 5/24/25 and required outside support to ensure residents' access to oxygen. 5. Immediate Jeopardy Risk - Written Evidence, Immediate CorrectionThe investigation established that the findings above placed 51 current residents at risk of immediate jeopardy due to smoke inhalation and burn injuries in the event of a fire, as well as due to a lack of access to oxygen in the event of a power outage. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.13 of Chapter VII regulations requires residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 6/11/25 at 3:41 p.m., the administrator submitted written evidence that read in pertinent part that on the date of the onsite visit, the residence secured an evacuation stair chair and an evacuation stair sling to evacuate non-ambulatory residents from the second and third floor. The residence trained all staff by their next shift to use the evacuation tools and provided a comprehensive evacuation plan until the residence's "defend-in-place" status was established. During the onsite visit, the residence purchased two local fire authority (LFA) generators to ensure the recharging of all portable oxygen concentrators, as well as a tracking system for all battery life and a shift check of total battery life for those with battery-operated concentrators. Additionally, during the onsite visit, the residence began tracking the number of portable cylinders for residents who had no battery-operated concentrators and added this tracking to the shift tracking on the medication administration record to ensure that each resident had access to the required oxygen in the event of a power outage for up to 72 hours. During the onsite visit or prior to their next shift, the residence trained each qualified medication administration person (QMAP) about the tracking, generators, and new 72-hour plan to ensure each resident had access to oxygen.

A complaint revisit was completed on 5/13/25 for all previous deficiencies cited on 1/22/25. Deficiencies were cited.

Based on record review and interview, the residence failed to be responsible for complying with authorized practitioners' orders associated with medication administration, affecting two (#9, #17) of six sample residents. This deficiency was cited previously during a state licensure survey. Although the residence corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. Resident #9 was admitted to the residence on 3/30/24 with diagnoses including dementia. Gabapentin A written practitioner's order, dated 10/22/24, directed the residence to administer gabapentin 300 mg capsule twice a day orally. However, the April 2025 medication administration record for Resident #9 read the medication was not in stock and not administered on 4/13 through 4/15/25 twice a day, for a total of six missed doses. LidocaineA written practitioner's order, dated 9/25/24, directed the residence to apply topically a thin layer of lidocaine on the right knee and right ankle three times at 8:00 a.m., 12:00 p.m. and 5:00 p.m. However, the April 2025 medication administration record, staff documented the resident did not receive 35 doses of the medication from 4/14 through 4/31 due to the medication not being available. On 5/12/25 at 1:00 p.m., the resident care coordinator confirmed that the medications were out of stock for both gabapentin and lidocaine. On 5/12/25 at 1:00 p.m., the administrator said he expected the residence to have all medications in stock and administered as ordered. The administrator stated that this deficiency was previously cited and was not corrected due to job transitions and a newly hired wellness director and coordinator. 2. Evidence obtained during the onsite visit revealed the residence additionally failed to comply with authorized practitioners' orders associated with medication administration for Resident #17.

Based on record review and interview the residence failed to on a quarterly basis audit the accuracy and completeness of medication administration records affecting four of six sample residents (#4,#9,#17-#20). This deficiency was cited previously during a state licensure survey. Although the residence corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:On 5/12/25 at approximately 9:30 a.m., the last two quarterly medication audits were requested from the administrator and provided. However, the audit tools provided revealed no evidence of an audit completed to ensure the accuracy of the medication administration records (MAR), medication error reports, and medication disposal records. On 5/12/25 at approximately 11:30 a.m., the administrator provided an additional medication audit tool titled "Medication Exception Report," dated April 2025. However, the secured environment section of the report indicated that the holes in the MAR had not been resolved or addressed. 2. InterviewsOn 5/12/25 at approximately 10:40 a.m., the health and wellness director admitted that she had not conducted the medication cart audit because she was recently hired. On 5/12/25 at approximately 1:40 p.m., the administrator stated that the regional nurse ran the medication exception report and emailed him the report to address the holes in the MAR. The administrator acknowledged that the facility has not completed a medication cart audit, controlled substance or medication error audit. The administrator added that this deficiency was previously cited and was not corrected due to job transitions and a newly hired wellness director and coordinator.

A relicensure survey with complaints #CO36009, #CO34198, #CO34057, and #CO33058 was completed on 1/22/25. Deficiencies were cited.

Based on record review and interview, the residence failed to provide, upon request, residence documents as requested by the department, affecting 144 current residents. (Cross-reference S1530, S1604)Findings include: On 1/21/25 at 8:04 a.m., staff cardiopulmonary resuscitation (CPR) and first aid certifications were requested. The CPR and first aid certifications were requested again at 1:00 p.m. and 3:06 p.m. and were not provided until 5:00 p.m. On 1/21/25 at 12:17, the signed practitioner orders and medication administration records (MAR) for Residents #1-#5, #7-#9, and former Resident #13 were requested. The practitioner orders and MARs were requested again at 3:00 p.m. On 1/21/25 at 3:30 p.m., the practitioner orders and MARs for Residents #2, #5, and #7-#9 were provided. On 1/22/25 at 9:02 a.m., the practitioner orders and MARs for Residents #1, #3, #4, and former Resident #13 were requested again and were not provided until 11:00 a.m. On 1/22/25 at 4:30 p.m., the interim administrator (IA) stated she was aware of the requirement to provide documentation to the department upon request. She stated that she and the clinical consultant (CC) had just begun employment at the residence three days prior to the onsite visit and received access to their electronic records system on 1/21/25. The IA stated she and the CC had difficulties printing the requested documents which was why it had taken so long to provide the documents.

Based on observation, interview and record review, the residence failed to develop and implement a fall management program detailing in each resident care plan the individualized approach necessary to address fall risks related to deficits in strength and balance and provide staff with training related to fall prevention affecting three of five sample residents with falls (#3, #4, and #6). Findings include:1. Record ReviewResident #3 was admitted to the residence on 10/22/23 with a diagnosis of Parkinson's Disease. A progress note, dated 12/9/24, read that Resident #3 was found on the floor of the kitchen in her room. Resident #3 had attempted to serve herself pudding in order to take her medications and fell on the floor. A progress note, dated 12/14/24, read that Resident #3 fell in the kitchen of her apartment. Resident #3 had attempted to serve herself supper. A progress note, dated 12/17/24, read that Resident #3 appeared to need a two person assist when transferring. The most recent assessment, dated 12/17/24, had interventions as follows: "Encourage non-skid footwear; keep apartment free of obstacles, clutter, and throw rugs; observe for obstacles before and during transfers; use assistive devices as ordered when ambulating; lock wheelchair brakes before transferring; all time during transfer; keep pendant nearby; and call for assistance." Additionally, the care evaluation read that staff were to provide stand-by assistance with all transfers. This was unchanged from the previous evaluation dated 12/11/24. A progress note, dated 12/24/24, read that Resdient #3 fell when she attempted to let a visiting family member into her room. A progress note, dated 1/3/25, read that Resident #3 was found by her table on the floor in a seated position. Resident #3 had attempted to organize her dishes on the top of the table and lost balance trying to pick one up off of the floor. 2. InterviewsOn 1/21/25 at approximately 8:00 a.m., Staff #5 stated that she assisted Resident #3 with toileting, showering and did fall checks once a day. On 1/21/25 at approximately 2:00 p.m., Resident #3 stated that she did not have good balance and that she would not be able to get up without assistance from staff. She stated that because she had a gluten-free diet, she made a lot of food in her room and she understood that the risk for fall in her kitchen was much higher because it was very small and she was unable to maneuver her wheelchair in the kitchen. On 1/21/25 at approximately 4:00 p.m., Staff #9 stated that she was unsure of where the care plan for Resident #3 was. 3. ObservationDuring the onsite visit on 1/21/25 in Resident #3's room there was a fork and a packet of cheese on the floor by the dining table. 4. Similar deficient practice was found for Residents #4 and #6.

Based on record review and interview, the residence failed to ensure residents had the right to be treated with respect and dignity, affecting one of twelve sample residents (Confidential Resident #13). Specifically, Confidential Resident #13 reported staff intimidated them and did not treat them respectfully and with dignity. Staff told Confidential Resident #13 not "fake cry" when they requested assistance with care needs. Confidential Resident #13 was fearful of retaliation and did not report the treatment out of the fear of retaliation. This resulted int the resident crying and feeling bad. Additionally, Confidential Staff #10 reported that they witnessed Staff #9 being disrespectful to residents, specifically to Confidential Resident #13. Additionally, Resident #5 stated that Staff #9 did not speak to him/her in a dignified fashion. Findings include:1. Residence PolicyThe residence's Resident Rights policy, dated 9/12/24, read in pertinent part that all residents had the right to be treated with dignity and respect. 2. InterviewsOn 1/21/25 at 2:00 p.m., Confidential Resident #13 stated that a staff member accused him/her of fake crying when Confidential Resident #13 asked for assistance with their care needs. Confidential Resident #13 stated that the staff member said, "Just try crying all the time that will help. Your crying doesn't help." Confidential Resident #13 stated that they felt this was disrespectful and it made them feel bad. Confidential Resident #13 stated that they were fearful of retaliation and did not report the mistreatment; however, Confidential Staff #10 knew about the incident because it happened more than once. On 1/21/25 at approximately 3:00 p.m., Confidential Staff #10 stated that three staff members, including Staff #9, yelled at residents all the time. Confidential Staff #10 stated that these staff refused to assist residents with care needs and told the residents that the care they requested was not on their care plan so they did not need to do it. Confidential Staff #10 stated that the staff told residents that because they were qualified medication administration personnel (QMAPs), they did not help with care needs. Confidential Staff #10 stated that her supervision were aware of the mistreatment. On 1/21/25 at 3:40 p.m., Resident #5 stated that Staff #9 was not nice to her. On 1/21/25 at approximately 4:00 p.m., Staff #9 stated that Resident #4 yelled and pretended to cry when she was asked to repeat herself. Furthermore, Staff #9 stated that Resident #4 requested assistance with care needs such as the application of lotion on her back, and Staff #9 did not assist because it was not in her care plan. On 1/22/25 at approximately 8:00 a.m., the health services coordinator stated that before the onsite visit, he was notified by some residents that Staff #9 was not kind to them. He stated that he informed his previous administrator and that he would look in the records to see if an investigation was completed. On 1/22/25 at approximately 9:00 a.m., the health services coordinator stated that he was not able to find any coaching that was done for Staff #9. On 1/22/25 at 3:30 p.m., the interim administrator stated that she expected reports of staff being unkind to residents to be investigated. 3. Record ReviewOn 1/22/25 at approximately 8:00 a.m., an investigation regarding staff being unkind and/or disrespectful to residents was requested. The residence was unable to provide an investigation report.

Based on record review and interview, the residence failed to prepare or administer only medication that had been ordered by an authorized practitioner, affecting three of ten sample residents (#5, #10, and #11). (Cross-reference S1568)Findings include:1. Record ReviewResident #5 was admitted to the residence on 5/29/23 with diagnoses of chronic atrial fibrillation, hyperlipidemia, and type 2 diabetes mellitus. The January 2025 medication administration record for Resident #5 read as follows:Eliquis 5 mg was administered twice daily from 1/4-1/6/25 and once daily on 1/3/25, 1/18/25, and 1/20/25. Furosemide 20 mg was administered once daily from 1/4-1/19/25. Jardiance 10 mg was administered once daily from 1/4-1/18/25. Metoprolol Tartrate 75 mg was administered twice daily from 1/4-1/12/25 and 1/14/25 then once on 1/13/25. Pantoprazole sodium 40 mg was administered twice daily from 1/4-1/11/25 and once daily on 1/3/25, 1/12/25, 1/13/25, and 1/15/25. On 1/21/25 authorized practitioner's orders were requested for Resident #5's medications on several occasions. The residence was unable to provide them for the above administered medications. 2. InterviewsOn 1/22/25 at approximately 2:30 p.m., the health services coordinator stated that he was not able to find the authorized practitioner's orders for the above listed medications. He stated that he requested a signed order be sent from Resident #5's previous residence. On 1/22/25 at approximately 4:00 p.m., the interim administrator stated that she expected the residence to have all practitioner's orders on site and available. 3. Similar deficient practice was found for Residents #11 and #12.

Based on observations, record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration affecting six of 10 sample residents (#1, #5, #6, #9, #11 and #12). (Cross-reference S1530)Findings include:1. Resident #9 was admitted to the residence on 3/30/24 with diagnoses including dementia and hypertension.a. Levothyroxine SodiumA written practitioner's order, dated 3/30/24, directed the residence to administer levothyroxine 75 MCG daily. However, the January 2025 medication administration record (MAR) revealed the residence failed to administer the medication on 1/3 - 1/5/25 because the medication was unavailable.b. MirtazapineA written practitioner's order, dated 7/11/24, directed the residence to administer mirtazapine 30 mg daily. However, the January 2025 MAR revealed the residence failed to administer the medication on 1/3 - 1/5/25 because the medication was unavailable. 2. InterviewsOn 1/22/25 at 2:22 p.m., the health services coordinator acknowledged the residence had run out of Resident #9's levothyroxine and mirtazapine and failed to administer the medications as ordered. On 1/22/25 at 4:00 p.m., the interim administrator said she expected staff to ensure all medications were available and to comply with practitioner's orders. 3. Similar deficient practice was found for Residents #1, #5, #6, #11 and #12.

Based on observations and interviews, the residence failed to properly label over-the-counter medications for five of 10 sample residents (#2, #4, #9, #11, #12). Findings include:1. ObservationsOn 1/22/25 at 1:30 p.m., a medication cart audit in the non-secure environment revealed over-the-counter medications for Residents #2, #4, #11, and #12 in a drawer. On 1/22/25 at 2:53 p.m., a medication cart audit in the secure environment revealed over-the-counter medications for Resident #9 in a drawer. 2. InterviewsOn 1/22/25 at 1:30 p.m., Staff #5 stated she was unaware of the requirement to label all over-the-counter medications with the residents' full first and last names. On 1/22/25 at 2:55 p.m., Staff #7 said she was unable to confirm whether the over-the-counter medications belonged to Resident #9 because the bottles were not labeled with the resident's name, only a room number. Staff #7 said she was unaware the residence was required to label all over-the-counter medications with a residents' first and last names. On 1/22/25 at 4:00 p.m., the interim administrator stated she was aware of the labeling requirements for over-the-counter medications. She stated she had only been employed at the residence for three days and that they had not had a chance to do medication cart audits; therefore, she was unaware that the above residents' over-the-counter medications had not been labeled properly.

Based on interview and record review, the residence failed to on a quarterly basis audit the accuracy and completeness of the medication administration records, affecting six of 10 sample residents (#1, #5, #6, #9, #11 and #12). Findings include:On 1/21/25 at 8:04 a.m., quarterly medication audits were requested from the administrator. However, the documents provided were the medication cart audits completed by the pharmacy, not the residence. On 1/22/25 at 7:50 a.m., Staff #3 said medications audits had not been completed for six months. On 1/22/25 at 4:00 p.m., the interim administrator stated she was aware of the medication audit requirements; however, she was unaware that the previous administrator had not completed the audits as required.

Based on record review and interview, the residence failed to include the resident's attending practitioner during six month reassessments or when the resident's condition changed from baseline status to determine the continued need for a secure environment, affecting five of five sample residents (#1, #6-#9) in the secure environment. Findings include:1. Resident #9 was admitted to the residence on 3/30/24 with a diagnosis of dementia. The pre-admission for secure placement document, dated 3/21/24 and signed by a practitioner, read in part: Resident #9 was easily confused and not easily redirected, continuously paced at night and would benefit from a smaller environment with more staff assistance. A functional assessment, dated 8/14/24, read in part: Resident #9 was able to walk independently and was an elopement risk. Pertinent intervention was Resident #9 residing in a secure environment. The functional assessment failed to include a signature from Resident #9's practitioner. A functional assessment, dated 1/7/25, read in part: Resident #9 was able to walk independently, had no wandering patterns or behaviors and was not an elopement risk. The functional assessment failed to include a signature from Resident #9's practitioner. 2. InterviewsOn 1/21/25 at 2:00 p.m., the memory care director (MCD) said she was responsible for conducting annual, bi-annual and change of condition assessments for residents in the secure environment. The MCD said she was not aware the residence was required to include the resident's practitioner as part of the assessment process for determining appropriateness of continued secure placement. On 1/22/25 at 4:00 p.m., the interim administrator said the residence was required to include residents' practitioners as part of the assessment process for determining appropriateness of continued secure placement. 3. Similar deficient practice was found for Residents #1 and #6-#8.

Based on record review and interview, the residence failed to provide an enhanced care plan for five of five sample residents (#1, #6-#9) in the secure environment. Findings include:1. Resident #9 was admitted to the residence on 3/30/24 with a diagnosis including dementia. Progress notes from 10/8/24 to 11/29/24 read Resident #9 was speaking poorly about other residents, in front of them, to other residents, was laughing at other residents and telling other residents what to do. Progress notes from 12/15/24 to 1/19/25 read Resident #9 was nose picking at the dining room table while other residents were present. A functional assessment, dated 1/7/25, read in part that Resident #9 had no wandering patterns or known behaviors. Resident #9's bedroom door was always unlocked and staff had a key when it was locked. Resident #9 would alert staff to any unwanted visitors and they would be removed. Resident #9 was welcome to visit a family member who resided in the non-secure area of the residence and was very independent. Resident #9 had hygiene items locked up except for her toothbrush, toothpaste and hairbrush. Items Resident #9 desired access to at all times were kept in her personal room so others could not gain access to them. The care plan, dated 1/7/25, did not identify Resident 9's documented behavioral expressions and individualized approaches implemented by staff to protect the resident and others, how Resident #9 would have continuous access to their room and be protected from unwanted visitors, the level and type of staff oversight that were necessary to meet the care needs of Resident #9 and a description of personal grooming and hygiene items that were deemed safe for the resident to use independently and how those items would be stored, preventing unauthorized use by others. 2. InterviewsOn 1/22/25 at 1:20 p.m., Staff #6 said Resident #9 spoke poorly of other residents and staff in front of them, calling them "stupid" or laughing at them. Staff #6 said Resident #9 had recently begun picking her nose in front of other residents and needed to be reminded to use tissues often. Staff #9 said Resident #9's care plan did not reflect this information and staff knew of behavioral expression by reporting to each other during shift reports. On 1/22/25 at 1:30 p.m., Staff #7 said Resident #9 called other residents "stupid" to their faces or loudly corrected others when things were done incorrectly. Staff #7 said they had witnessed the behavior first hand or heard from other staff members during shift reports. Staff #7 said Resident #9 was often redirected by staff to be kind to others or asked to refrain from calling people "stupid." On 1/22/25 at 3:00 p.m., the memory care director (MCD) said she was responsible for updating care plans for residents in the secure environment. The MCD said she was unaware that the residence was required to include information from the assessments pertaining to behavioral expressions, wandering patterns, continuous access to rooms and protection from unwanted visitors, necessary staff oversight and a description of personal grooming and hygiene products and how they would be stored to prevent unauthorized use. 3. Similar deficient practice was found for Residents #1 and #6-#8.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.7.13 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. 12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents: (C) Personal services including, but not limited to, a system for identifying and reporting resident concerns that require either an immediate individualized approach or on-going monitoring and possible re-assessment. 12.11 The assisted living residence shall be responsible for the coordination of resident care services with known external service providers. 14.20 The assisted living residence shall contact the authorized practitioner for clarification of any orders which are incomplete or unclear and obtain new orders in writing.

A revisit survey was completed on 9/13/23 for all previous deficiencies cited on 1/12/23. The facility is in compliance with all deficiencies that were cited.

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 #CO29347 and #CO30503 was completed on 1/12/23. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure that each staff member and volunteer received orientation and training, affecting one of four sample staff (#1). Findings include:The residence's emergency procedures manual, dated 2/23/17, read in part that staff received training specific to the residence's procedures upon attending orientation. The personnel file for Staff #1 revealed no evidence that she received initial orientation, including orientation on the residence's emergency response policies and procedures prior to providing care and services to residents. On 1/12/23 from approximately 7:00 a.m. to 2:00 p.m., Staff #1 was provided care and services to residents throughout the onsite visit. On 1/12/23 at 1:42 p.m., Staff #1 stated she had provided care and services to the residents for approximately four months prior to the onsite visit. She stated she did not receive orientation prior to providing care and services. Staff #1 stated the residence did not train her on the policy and procedure for power outages, adding that other staff would tell her what to do if an emergency arose. On 1/12/23 at 5:05 p.m., the administrator stated Staff #1 was a contracted staff and they therefore did not have documented training in the file. Contrary to the interview with Staff #1, the administrator stated that management did an orientation with her but did not document it; she then stated she was unaware that Staff #1 did not receive orientation prior to providing care and services to residents.

Based on record review and interview, the residence failed to include written documentation regarding orientation and training in each personnel file, affecting one of four sample staff (#2). Findings include:On 1/12/23, Staff #2's personnel files were provided and revealed Staff #2's file did not contain documentation regarding orientation and training. On 1/12/23 at 1:38 p.m., the business office coordinator (BOC) stated Staff #2 received orientation but it was not in the personnel file and she was unable to locate the documentation. On 1/12/23 at 5:05 p.m., the administrator stated the BOC was responsible for ensuring personnel files contained all of the required elements, and was unable to say why Staff #2's file did not have documentation regarding orientation and training.

Based on record review and interview, the residence failed to have readily available a roster of current residents, their room assignments and emergency contact information, along with a residence diagram showing room locations, affecting 89 current residents. Findings include:On 1/12/23 at approximately 8:07 a.m., the residence's roster for emergency preparedness was requested. The roster provided by the administrator did not include each residents' emergency contact information nor a residence diagram showing room locations. On 1/12/23 at 5:05 p.m., the administrator stated that she was aware of the requirement for the resident roster to include emergency contacts. She stated she was not aware that the resident roster was required to include a diagram of the residence showing room locations.

Based on record review and interview, the residence failed to complete a risk assessment of all hazards and preparedness measures to address natural and human-caused crises including, but not limited to, fire, gas explosion, power outages, tornado, flooding and threatened or actual acts of violence, affecting 89 current residents. Findings include:On 1/12/23 at approximately 12:16 p.m., a risk assessment of all hazards and preparedness measures to address natural and human-caused crises was requested. However, no such risk assessment was provided. On 1/12/23 at 5:05 p.m., the administrator stated she was not able to locate a documented assessment of all hazards and preparedness measures to address natural and human-caused crises. The administrator stated she had not known the assessment was required, and had not been asked to provide a documented assessment previously.

Based on interview and record review, the residence failed to have policies and procedures to ensure the continuation of care to all residents for 72 hours following an emergency including, but not limited to, a long-term power failure, affecting 89 current residents. Findings include:On 1/12/23 at approximately 8:07 a.m., the residence's 72 hour continuation of care policy was requested but was not provided. On 1/12/23, the administrator stated she believed there were components of a continuation of care policy in the residence's disaster plan, but she was not aware that the residence did not have a 72 hour continuation of care policy.

Based on record review, observation, and interview, the residence failed to have a battery or generator-powered alternative lighting system available in the event of a power failure, affecting 89 current residents. Findings include:1. References and Residence Policya. The residence's disaster plan, dated 2/23/17, read in part that in the event of an electrical outage, staff were to activate the residence's alternate power supply.b. According to Timeanddate.com, the time of sunrise on 10/23/22 for the city within which the residence was located was 7:16 a.m. Timeanddate.com (1/17/23) Sunrise, Sunset, Day Length, retrieved from: https://www.timeanddate.com/sun/usa/colorado-springs?month=10&year=2022 2. ObservationOn 1/12/23, during the onsite visit, no resident rooms were observed to have an alternative lighting source available. 3. Record ReviewA progress note, dated 10/23/22, read in part that during safety checks around 6:00 a.m. after the power outage, Resident #3 was found lying in the shower. The resident informed staff that she was using the bathroom when she fell into the shower curtain. 4. InterviewsOn 1/12/23 at 10:07 a.m., a family member of Residents #4 and #5 stated she was with her parents when the electricity went out at the residence on 10/23/22 from 12:29 a.m. to 7:01 a.m.. She stated she assumed the residence had a backup power system, but staff informed her there was not one. The family member stated it was extremely dark throughout the residence during this time, adding that staff was only able to find one flashlight. On 1/12/23 at 12:56 p.m., Staff #4 stated that on 10/23/22., all of the residence's lights went out with the exception of the exit signs, which glowed green. He stated that throughout the power outage, from approximately 12:30 a.m. until approximately 6:00 a.m., there were no lights in the residence's hallways or the resident rooms. Staff #4 stated emergency responders were at the residence to provide oxygen assistance to residents who required it, adding that "they were more concerned about the residents who could fall because of the blackout."On 1/12/23 at 1:51 p.m., Staff #5 stated she arrived at 5:30 a.m. on the morning the power was out. She stated most of the staff used their personal cell phones as a flashlight, adding they went to every resident room to request they stay in their room because it was very dark. Staff #5 stated there was no light in the residence other than the exit signs when she arrived for her shift, so the staff opened the residents' blinds for light when the sun came up. She stated that at approximately 8:00 a.m., the electricity was restored, went out again for another 10 minutes, then was restored permanently. On 1/12/23 at 4:03 p.m., the maintenance director (MD) stated the residence had emergency lights in the halls and common areas, but there were none in any resident rooms. He stated when the residence experienced an electricity outage on 10/23/22, these lights should have come on but would have turned off after approximately 90 minutes. The MD stated all residents had night lights in their rooms, adding that they were not battery powered so they did not produce any light when the electricity went out. The MD stated the residence did not have a backup generator. He stated the sunrise on 10/23/22 was approximately 7:00 a.m., so residents would have had a source of light beginning at approximately 7:00 a.m. On 1/12/23 at approximately 5:05 p.m., the administrator stated she was not the administrator on 10/23/22, and she therefore was not aware of how the incident was handled. She stated the residence's emergency kits had flashlights but was not sure how many. The administrator stated she was aware that the residence was required to have an alternative lighting system available, adding that alternative lighting for the residence required batteries as its power source.

Based on record review and interview, the residence failed to be responsible for complying with authorized practitioner orders associated with medication administration, affecting five of five sample residents (#1-#5). Findings include:1. Residence Policiesa. The residence's medication policy, dated 1/1/22, read in part that medications ordered by a practitioner were ordered from the pharmacy. The appropriate pharmacy delivered the medications that were ordered. New medications were delivered as soon as possible to the residence. The residence's medication handling and dispensing procedure was to give the correct medication to the correct resident according to the amount, time, and route of administration, as ordered by the practitioner.b. The residence's resident agreement, dated December 2016, read in part that when the residence provided medication administration to a resident, the residence's current medication system and policies were followed. 2. Resident #4 was admitted to the residence on 3/10/20 with diagnoses including depression, dementia, kidney stones, benign prostatic hyperplasia, and overactive bladder.a. FinasterideA written practitioner's order, dated 1/19/22, directed the residence to administer finasteride 5 mg daily. However, the January 2023 medication administration record (MAR) revealed the residence failed to administer the medication on 1/1-1/4/23 and 1/7-1/10/23 because the medication was not available, for a total of nine missed doses.b. MemantineA written practitioner's order, dated 1/19/22, directed the residence to administer memantine 10 mg twice daily. However, the January 2023 MAR revealed the residence failed to administer the medication 1/1, 1/2, 1/4, 1/5, and 1/6/23 because the medication was not available, for a total of nine missed doses.c. Oxybutynin ChlorideA written practitioner's order, dated 1/19/22, directed the residence to administer oxybutynin chloride 5 mg twice daily. However, the January 2023 MAR revealed the residence failed to administer the medication 1/1, 1/2, 1/4, 1/5, and 1/6/23 because the medication was not available, for a total of nine missed doses.d. AllopurinolA written practitioner's order, dated 1/19/22, directed the residence to administer allopurinol 300 mg daily. However, the January 2023 MAR revealed the residence failed to administer the medication on 1/1/23 because the medication was not available, for one missed dose.e. Citalopram HydrobromideA written practitioner's order, dated 1/19/22, directed the residence to administer citalopram hydrobromide 40 mg daily. However, the January 2023 MAR revealed the residence failed to administer the medication on 1/1/23 because the medication was not available, for one missed dose. 3. Resident #2 was admitted to the residence on 12/16/22 with diagnoses including nerve pain, dry eyes, and insomnia.a. Calcium Carbonate-Vitamin D3A written practitioner's order, dated 12/8/22, directed the residence to administer calcium carbonate-vitamin D3 twice daily. However, the January 2023 MAR revealed the residence failed to administer the medication for one dose on 1/2/23, two doses on 1/3/23, and one dose on 1/4/23 because the medication was not available, for a total of four missed doses.b. Carboxymethylcellulose Sodium Ophthalmic Solution 0.5%A written practitioner's order, dated 12/8/22, directed the residence to administer carboxymethylcellulose sodium ophthalmic solution 0.5% one drop into both eyes four times daily. However, the January 2023 MAR revealed the residence failed to administer the medication for three doses on 1/5 and 1/6/23, four doses on 1/7-1/10/23, and two doses on 1/11/23 because the medication was not available, for a total of 24 missed doses.c. Gabapentin A written practitioner's order, dated 12/8/22, directed the residence to administer gabapentin 300 mg twice daily. However, the January 2023 MAR revealed the residence failed to administer the medication for one dose on 1/2/23, two doses on 1/3/23,and one dose on 1/4/23 because the medication was not available, for a total of four missed doses.d. MelatoninA written practitioner's order, dated 12/8/22, directed the residence to administer melatonin 3 mg two tablets at bedtime. However, the January 2023 MAR revealed the residence failed to administer the medication from 1/1-1/3/23 because the medication was not available, for a total of three missed doses. On 1/12/23 at 4:26 p.m., the administrator stated that an external service provider supplied Resident #2's medications, adding that another pharmacy was not able to supply them. She stated the residence often was out of stock and had to wait for medications. The administrator stated the residence could not get the medications if the doctor did not approve refills. 4. Resident #1 was admitted to the residence on 5/17/22 with diagnoses including dementia and hypothyroidism.a. QuetiapineA written practitioner's order, dated 11/16/22, directed the residence to administer quetiapine 25 mg at bedtime and one daily as needed. However, the January 2023 MAR directed the residence to administer quetiapine as needed only, resulting in 11 missed doses.b. LevothyroxineA written practitioner's order, dated 5/17/22, directed the residence to administer Levothyroxine 25 mcg one and one-half tablets daily. However, the January 2023 MAR revealed the residence failed to administer the medication on 1/1, 1/5, 1/7-1/10, and 1/12/23 because the medication was not available, for a total of seven missed doses. On 1/12/23 at approximately 4:35 p.m., the administrator stated the residence had not been administering quetiapine at bedtime because Resident #1's family member, who provided her care prior to her admission, told staff that he did not administer that dose as ordered by the practitioner. The administrator stated the residence did not have a written order from the practitioner to discontinue the administration of quetiapine at bedtime. She stated the residence was waiting for Resident #1's practitioner to send a refill order for levothyroxine. 5. Resident #5 was admitted to the residence on 3/10/20 with diagnoses including osteoporosis.a. Align ProbioticA written practitioner's order, dated 12/2/22, directed the residence to administer Align probiotic one tablet daily. However, the January 2023 MAR revealed the residence failed to administer the medication on 1/7/23 because the medication was on order, for one missed dose.b. Preservision AREDS 2A written practitioner's order, dated 4/22/20, directed the residence to administer Preservision AREDS- 2 one capsule twice daily. However, the January 2023 MAR revealed the residence failed to administer the medication on 1/4/23 because the medication was not available, for one missed dose.c. Viactiv + Vitamin DA written practitioner's order, dated 12/9/22, directed the residence to administer a Viactiv + vitamin D chew once daily. However, the January 2023 MAR revealed the residence failed to administer the medication on 1/7/23 because the medication was on order, for one missed dose. 6. Resident #3 was admitted to the residence on 10/8/19 with diagnoses including anxiety. A written practitioner's order, dated 12/8/22, directed the residence to administer lorazepam 0.5 mg every morning. However the January 2023 MAR revealed the residence failed to administer the medication on 1/10 and 1/11/23 because the medication was not available, for a total of two missed doses. On 1/12/23 at 8:11 a.m., Staff #3 stated that sometimes the qualified medication administration persons ordered refills for medications repeatedly, and the pharmacy still did not deliver them timely. On 1/12/23 at approximately 4:35 p.m., the administrator stated the pharmacy was waiting for approval to refill lorazepam, adding that because it was a controlled medication, it took longer for the approval process to be completed. She stated the residence was waiting for the above medications to be delivered from their respective pharmacies. The administrator stated that it was the health and wellness director's responsibility to follow up on the delivery of medications that were out of stock; however, the residence currently did not have someone in that position. She added that the health and wellness coordinator had just started in the position within one week of the onsite visit.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.14.27 No stock medications shall be stored or administered by qualified medication administration persons. A) All over-the-counter medication prescribed for administration shall be labeled or marked with the individual resident's full name. 18.9 The face sheet shall be updated at least annually and contain the following information:(A) Resident's full name, including maiden name, if applicable;(B) Resident's sex, date of birth, and marital status;(C) Resident's most recent former address;(D) Resident's medical insurance information and Medicaid number, if applicable;(E) Date of admission and readmission, if applicable;(F) Name, address and contact information for family members, legal representatives, and/or other persons to be notified in case of emergency;(G) Name, address, and contact information for resident's practitioner and case manager, if applicable;(H) Resident's primary spoken language and any issues with oral communication;(I) Indication of resident's religious preference, if any;(J) Resident's current diagnoses; and(K) Notation of resident's allergies, if any.