BROOKDALE BRIARGATE

A revisit survey was completed on 3/6/24 for all previous deficiencies cited on 9/6/23. 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 #CO34517, was completed on 12/21/23. No deficiencies were cited.

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 7.4.5 The licensee shall appoint an administrator who meets the minimum qualifications set forth in these regulations and delegate to that individual the executive authority and responsibility for the administration of the assisted living residence.(A) If the assisted living residence does not have an administrator, the licensee shall appoint an interim administrator and delegate to that individual the executive authority and responsibility for the administration of the assisted living residence, until such time that the facility has an administrator.(1)The licensee shall notify the department of the interim administrator appointment within 24 hours of the appointment in accordance with 6 CCR 1011-1, Chapter 2 – General Licensure, Part 2.9.6.

A complaint revisit was completed on 12/21/23 for all previous deficiencies cited on 6/27/23. 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 #CO33298 was completed on 9/6/23. Deficiences were cited.

Based on record review, and interview, the residence failed to be responsible for the coordination of resident care services with known external service providers, affecting one former resident (#9). (Cross-reference Q1180, Q2130, Q2960)Findings include:1. ReferenceChapter VII regulations governing assisted living residences, part 2.21, defines "External services" as personal services and protective oversight services provided to a resident by family members or healthcare professionals who are not employees, contractors, or volunteers of the facility. External service providers include, but are not limited to, home health, hospice, private pay caregivers and family members. 2. Former Resident #9 was admitted to the residence on 7/15/23 with diagnoses including Parkinson's Disease and dementia. A care plan, dated 7/8/23, read in part, the resident had Parkinson's Disease, had fallen in the last 12 months, had a physical and memory impairment that required escort assistance and had a private pay caregiver who provided one-on-one (1:1) companionship. However, the care plan did not include the hours the external private pay caregiver provided companionship. A staff schedule read in part Staff #6-#9 worked from 2:00 p.m. to 10:00 p.m. on 7/28/23. A staff schedule dated 7/28/23, read Staff #3 worked from 10:00 p.m. to 6:00 a.m. A late entry progress note, dated 7/29/23 and authored by the health and wellness director (HWD), read that Former Resident #9 had sustained a fall and was unable to get off the floor. Staff #3 and #4 were unable to get Former Resident #9 off the floor and covered him with a blanket and put a blanket under his head. On 9/5/23 at 10:15 a.m., the former health and wellness coordinator (HWC) stated residence staff were trained to notify management if an external service provider including a private pay caregiver was unable to provide services as agreed upon. However, the former HWC stated she was not notified by any residence staff on 7/28/23 that the private pay caregiver for Former Resident #9 had failed to arrive at the residence for her scheduled shift on 7/28/23 from 9:00 p.m. to 7/29/23 at 9:00 a.m. The former HWC stated she had been responsible at the time for creating residence staffing schedules. She stated had the residence staff immediately reported the private pay caregiver had not arrived at the residence for her scheduled shift on 7/28/23 at 9:00 p.m. that she would have contacted the private pay caregiver's employment agency to find replacement coverage. The former HWC stated she was responsible for creating residence staff schedules. She stated if a private pay caregiver replacement had not been available or a residence staff had not been available, she would have gone to the residence herself on 7/28/23 to monitor the former resident for the entire private pay caregiver shift. On 9/5/23 at 10:46 a.m., the HWD stated that the family member for Former Resident #9 hired an external private pay caregiver agency to monitor Former Resident #9 on a twenty-four hours a day, seven days a week basis due to poor safety awareness. The HWD stated that the external private pay caregiver had called out for her shift starting on 7/28/23 at 9:00 p.m. to the following day at 9:00 a.m. The HWD stated she had not found out that the private pay caregiver had called out for her shift and had been made aware by one of the staff members on 7/29/23 after the incident occurred. She stated Staff #3 and #4 should have notified the management staff when the private pay caregiver called out for her shift so the residence could find coverage; however, the staff on shift the evening of 7/28/23 had not notified management staff. On 9/6/23 at 9:46 a.m., a representative from the external private pay caregiver agency for Former Resident #9 stated that Former Resident #9 had a private pay caregiver at all times due to his poor safety awareness. The representative stated, according to his family member, the former resident would walkwithout a walker and close his eyes which made him more susceptible to injuries from falls. The representative stated that one of the caregivers for the former resident did not show up to their 9:00 p.m. to 9:00 a.m. shift on 7/28/23. The representative further stated they had communicated with Staff #6 on 7/28/23 at around 9:00 p.m. that there was no private pay caregiver coming to the residence for the scheduled shift. On 9/6/23 at approximately 1:45 p.m., the administrator stated that she was aware of the requirement to coordinate care with all external service providers. The administrator stated that when Former Resident #9's private pay caregiver did not show up to their shift on 7/28/23, the former HWC was on call that night. The administrator acknowledged the former HWC should have been notified by residence staff so the former HWC could find replacement coverage with residence staff; however stated she was unaware if the former HWC was notified by residence staff.

Based on observation, interview and record review, the residence failed to detail in each resident's care plan the individualized approach necessary to address fall risk, and staff were not consistent in their understanding of the interventions in place for the residents, affecting one of three sample residents (#8) and one former resident (#9). (Cross-reference Q1160, Q1192, Q1312, Q2130, Q2960)Specifically, Resident #8 was admitted to the residence on 5/12/23 with a diagnosis of Alzheimer's disease. The residence had identified on the preadmission assessment that the resident was a high fall risk with a fall history. The care plan, dated 5/17/23, reflected this, read the resident used a walker, and that the residence implemented universal fall precautions. The resident had a fall without injury on 6/5 and 6/20/23. On 6/24/23, the resident fell twice and sustained a closed head injury with bruising which required treatment at the emergency department (ED). Resident #8 continued to fall on 8/2, 8/3, 8/5 and 8/16/23 with no injuries. Despite an after-visit summary, dated 8/7/23, that read the resident was encouraged to keep her room free of clutter, use her walker for ambulation and a halo safety ring mobility device, the residence failed to reassess the resident and update the care plan with individualized approaches necessary to address fall risk. The resident had another fall on 8/18/23 with pain in her neck, shoulder, and back. The resident fell again on 8/28/23 and was transferred to the hospital for further evaluation. Specifically, Former Resident #9 was admitted to the residence on 7/15/23 with diagnoses including Parkinson's Disease and dementia. The residence had identified on the preadmission assessment that the former resident used a walker for mobility, had a fall history, and had difficulty communicating his needs. The care plan, dated 7/8/23, reflected this, that the former resident required escort assistance, and had a private pay caregiver who was hired by the former resident's family member, monitored Former Resident #9 due to his poor safety awareness. The care plan also read there were universal potential interventions that could be added. On 7/16/23, Former Resident #9 sustained two falls, one without injury and one with bruising of the left wrist. The residence failed to reassess the former resident and update the care plan with individualized approaches necessary to address fall risk. On 7/28/23 during the 9:00 p.m. to 9:00 a.m. shift, former Resident #9's personal caregiver did not show up to their shift. The residence's investigation revealed the former resident had an additional fall on 7/28/23 that resulted in a fracture of his right hip which required treatment at the ED. The former resident was found the morning of 7/29/23 and screamed out in pain, and was sent to the hospital. Findings include:1. Residence policyThe residence's Fall Management Policy, dated October 2013 and updated August 2023, read in part, for residents who sustained falls, the residence documented those falls in the resident record. The service plan (care plan) was reviewed for potential fall interventions and updated as necessary. 2. Resident #8 was admitted to the residence on 5/12/23 with a diagnosis of Alzheimer's Disease.a. Record ReviewThe residence's pre-admission assessment, dated 5/7/23, read Resident #8 had fallen in the last 12 months, had a walker, and was a high fall risk. A quarterly assessment, dated 9/5/23, read Resident #8 had slightly limited mobility. The residence's care plan, dated 5/17/23, read in part, Resident #8 had Alzheimer's Dementia, had fallen in the last 12 months and had universal fall precautions for fall risk and required staff verbal cues to and from the dining area and activities, escort assistance and used a walker as a mobility aid. The care plan further read she had a walker. However, the care plan did not include updated individualized interventions after each fall, which included a halo safety ring mobility device for support out of the bed, a wheelchair for increased weakness and two hour safety checks. The residence's assessment, dated 5/17/23, read in part, Resident #8 required staff supervision, required limited assistance with an assistive device and had slightly limited ambulation. A progress note, dated 6/5/23, read that Resident #8 had an unwitnessed fall by her bedside without injury. A progress note, dated 6/7/23, read the family member of Resident #8 had requested a halo safety ring mobility device to assist with transfers out of the bed. A progress note, dated 6/20/23, read Resident #8 sustained an unwitnessed fall in her room near bedside when trying to go to the bathroom. A progress note, dated 6/24/23 at 6:00 a.m., read Resident #8 had an unwitnessed fall in her room and an abrasion was noted on her forehead. The resident was transported to the emergency department. A hospital discharge summary, dated 6/24/23, read that Resident #8 was seen for a fall and a computerized tomography (CT) scan of the head revealed a closed head injury. A progress note, dated 6/24/23, at 10:21 a.m., read in part: "the resident had an unwitnessed fall."A progress note, dated 6/25/23, read the resident was complaining of general discomfort from two falls dated 6/24/23. The health and wellness director (HWD) observed a rug-burn like injury to her forehead near the left eyebrow, a small bump to the back of the head and a purple bruise line near the buttock. A progress note, dated 8/2/23, read Resident #8 had an unwitnessed fall near her chair with no signs of injury. A progress note, dated 8/3/23, read Resident #8 had an unwitnessed fall near her television stand with no signs of injury and complained of neck pain. The resident was transferred to the hospital for further observation. A hospital discharge summary, dated 8/4/23, read that there were no injuries found from the resident's fall that occurred on 8/3/23 at the residence. A post-fall follow up, dated 8/5/23, read that the care plan was reviewed but no new changes were made. A progress note, dated 8/5/23, read Resident #8 had an unwitnessed fall without injury. An after visit summary, dated 8/7/23, read Resident #8 had a computed tomography scan (CT) on 8/3/23 after a fall. The resident had two falls in the past week and was encouraged to keep her room free of clutter, use her walker for ambulation and a halo safety ring mobility device while in bed. A progress note, dated 8/16/23, read Resident #8 had a fall in the residence dining area and hit her head on the dining room chair. There were no signs of injury. A progress note, dated 8/18/23, read Resident #8 had a fall with pain in neck, shoulder and back. A progress note, dated 8/28/23, read Resident #8 had an unwitnessed fall and hit her head. Resident #8 was transferred to the hospital for further evaluation.b. Observation and InterviewsOn 9/5/23 at 7:11 a.m., Staff #5 stated Resident #8 frequently fell, including when she attempted to get out of bed independently overnight. Staff #5 stated Resident #8 had a walker and a wheelchair and that she was unaware of any additional interventions since most of the falls occurred overnight when Staff #5 was not on shift. On 9/5/23 at 9:54 a.m., Resident #8 stated the resident had a wheelchair and a gait belt as needed for when she felt weak, and used her walker for ambulation otherwise. Resident #8 stated she had fallen out of bed in the past and had a halo safety ring mobility device on the side of her bed to help her get out of bed. On 9/5/23 at 10:57 a.m., the HWD stated she was responsible for updating care plans every six months and more frequently when a resident required additional assistance or had frequent falls. The HWD further stated Resident #8 used with a walker and a wheelchair as needed for weakness. The HWD stated Resident #8 required one person transfer assistance with the gait belt as needed and had fallen in the last two months in her bedroom. The HWD did not list any other interventions the residence had implemented for the resident. On 9/5/23 at approximately 3:26 p.m., a wheelchair, walker, gait belt, and halo safety ring device were observed in Resident #8's room. On 9/5/23 at 3:28 p.m., the practitioner for Resident #8 stated that Resident #8 was transferred to the hospital after a fall on 8/3/23; however, her scans were normal and there were no signs of injury. The practitioner stated that Resident #8 had multiple falls, and her interventions included a walker, wheelchair, keeping her room free of clutter, a halo safety ring mobility device, and reminders to call staff for assistance. On 9/6/23 at 7:57 a.m., Staff #3 stated Resident #8 had interventions that included two hour rounding, a walker for mobility and a wheelchair with one person transfer assistance for occasional weakness. On 9/6/23 at 10:33 a.m., the family member of Resident #8 stated the resident had frequent falls at the residence and sustained a fall toward the end of June 2023 with bruises and a head injury. The family member further stated she was unaware what interventions the residence had put in place. She further stated she vaguely remembered being provided fall management education upon Resident #8's admission. She stated that Resident #8's practitioner put in place a halo safety ring mobility device and a wheelchair in August 2023. The family member for Resident #8 stated she was concerned about the frequency of Resident #8's falls and stated since most of her falls occurred while getting out of bed, the resident would benefit from a fall mat. On 9/6/23 at approximately 1:45 p.m., the administrator stated Resident #8 was a high fall risk and stated she was unaware why the care plan for Resident #8 had not been updated to include individualized interventions since 5/17/23. The administrator stated the care plan should have been updated by the HWD or former health and wellness coordinator (HWC) to include individualized interventions for Resident #8. The administrator further stated "it was a lot of work"for the HWD alone to update all residents' care plans after each fall since the HWC resigned early August 2023. On 9/6/23 at approximately 2:00 p.m., the HWD stated she had not received hospital discharge paperwork from Resident #8's fall on 8/28/23. The HWD stated she had thought care plans only needed to be updated when a change was made to care. The HWD stated she was unaware new individualized interventions needed to be put in place after each fall. The HWD acknowledged the care plan should have included the two hour rounding, wheelchair for weakness, gait belt, and halo safety ring mobility device and should have been updated after Resident #8's fall with injury on 6/24/23.3. Former Resident #9 was admitted to the residence on 7/15/23 with diagnoses including Parkinson's Disease and dementia. a. Record Review The residence's pre-admission assessment, dated 7/8/23, read that Former Resident #9 used a walker for mobility, had fallen in the last 12 months and had difficulty communicating needs. The residence's care plan, dated 7/8/23, read that Former Resident #9 had Parkinson's Disease, had fallen in the last 12 months, had a physical and cognitive impairment that required escort assistance and had a private pay caregiver to provide ongoing monitoring due to Former Resident #9 having poor safety awareness. The care plan further read that Former Resident #9 used a walker as a mobility aid and read there were universal potential interventions that could be added. However, the care plan did not include individualized interventions updated after Former Resident #9 first fell on 7/16/23 such as a wheelchair and two-hour safety checks. An assessment dated 7/16/23, read Former Resident #9 had limited mobility, needed limited assistance to evacuate and walked with staff assistance or an assistive device. The assessment further read, the resident required supervision, guidance and reassurance, and experienced a fall without injury in the previous 12 months. The assessment read that Parkinson's disease progression likely contributed to Former Resident #9's fall. A progress note, dated 7/16/23 at 2:20 a.m., read Former Resident #9 had an unwitnessed fall in the common dining area and was found crawling on the floor. No injuries were noted. A progress note, dated 7/16/23 at 10:10 a.m., read Former Resident #9 had an unwitnessed fall in the leadership office and was found lying on his stomach face down. Former Resident #9 was transferred to the emergency room for further evaluation. A discharge summary, dated 7/18/23, read that Former Resident #9 was found to have bruising of the left wrist following a fall. A progress note, dated 7/18/23, read Former Resident #9 was transferred back to the residence after his fall on 7/16/23. A late entry progress note, dated 7/29/23 at 6:00 a.m. and authored by the HWD, read Former Resident #9 had an unwitnessed fall at 4:00 a.m., reported pain and was transported to the hospital for further evaluation. A hospital discharge summary, dated 7/30/23, read that Former Resident #9 was admitted after a fall and diagnosed with a right femur fracture. An investigation, dated 8/5/23, read that it was initially reported to the administrator that Former Resident #9 had fallen on 7/29/23 at 4:00 a.m.; however, upon further investigation, it was discovered that Former Resident #9 had fallen on 7/28/23 at 10:30 p.m. When day shift staff came in around 6:00 a.m. on 7/29/23, the former resident expressed pain, so emergency services were called for further evaluation. An email of further investigation findings, sent by the HWD on 8/6/23, read that Former Resident #9 had fallen on 7/28/23 at 10:30 p.m., and Staff #3 and #4 were the staff on shift who left the former resident on the floor. b. InterviewsOn 9/5/23 at 7:11 a.m., Staff #5 stated the night of 7/28/23, Former Resident #9 had a fall and Staff #3 and #4 had left him on the floor since around 10:00 p.m. the previous night. Staff #5 stated at 6:10 a.m., staff went into his room and he was yelling out "call 911" and so they did. Staff #5 stated that she was trained that as soon as a resident fell, to assess for injuries and try to provide lift assistance and to call 911 immediately if staff were unable to do so, if a resident hit their head or had apparent injuries. On 9/5/23 at 12:22 p.m., Staff #10 stated she had found Former Resident #9 after his fall at 6:00 a.m on 7/29/23, and called 911 when the former resident requested she do so. Staff #10 stated Former Resident #9 had previously fallen, including an incident where he crawled on the floor. Staff #10 stated Former Resident #9 had a wheelchair and walker as fall interventions and the former resident's family had hired an external private pay caregiver to monitor Former Resident #9's poor safety awareness. Staff #10 stated she was unaware of any additional fall interventions in place for Former Resident #9. On 9/5/23 at 2:11 p.m., Staff #4 stated that Former Resident #9 had an external caregiver who monitored him due to his poor safety awareness, had a walker for standing up and ambulating short distances, and a wheelchair for longer distances. Staff #4 acknowledged that she had left Former Resident #9 on the floor for 8 hours. On 9/6/23 at 11:48 a.m., the family member for Former Resident #9 stated that Former Resident #9 had fallen three times since he was admitted on 7/15/23. The family member for Former Resident #9 stated with the second fall on 7/16/23 the ambulance was called because the former resident had a skin tear and may have hit his head. The family member for Former Resident #9 stated that when Former Resident #9 fell on 7/28/23 he was found to have sustained a hip fracture the next day and stated that Staff #3 and #4 should have called him when the fall occurred and got him the assistance he needed. The family member further stated that Former Resident #9 had a walker and a wheelchair for longer distances which he had since before admission to the residence and was unaware of any interventions put in place by the residence. On 9/6/23 at approximately 1:45 p.m., the administrator stated Former Resident #9 was a high fall risk and stated the HWD was on vacation when the former resident fell on 7/16/23 which was why the care plan was not updated. The administrator stated the care plan should have been updated by the HWD or former health and wellness coordinator (HWC) to include individualized interventions for Former Resident #9 after Former Resident #9's fall on 7/16/23. The administrator further stated it was "a lot of work" for the HWD alone to update all the care plans after each fall. On 9/6/23 at 2:00 p.m., the HWD stated she was on vacation in July 2023 when Former Resident #9 had fallen on 7/16 and 7/28/23. The HWD stated the former HWC was responsible for updating care plans when she was on vacation and stated she should have updated the care plan for the former resident on 7/16/23; however, she did not. The HWD stated she wrote the progress note of Former Resident #9's fall when she returned from vacation at the beginning of August 2023. She stated she documented an incorrect time of the progress note because she was not aware until 8/3/23 when she returned from vacation that Former Resident #9 had actually fallen on 7/28/23 and was left on the floor.

Based on record review and interviews, the residence failed to follow their lift assistance policy, affecting one former resident (#9). (Cross-reference Q1180 and Q1312)Findings Include:1. Residence PolicyThe residence's Lift Assistance Policy, dated February 2022, read in part: The assisted living residence shall ensure to have assisted a resident who fell by following the fall management policy and if a resident were free of pain, the associate would physically perform lift assistance and lift the resident to a standing position. The health and wellness director (HWD) would call 911 if the resident complained of pain, had difficulty moving, had a physical or mental decline from baseline, experienced a head injury, requested 911 to be called, or refused lift assist. The residence's Fall Management Policy, dated August 2023, read in part, when a fall were to occur, residence staff were to assist the resident and provide first aid or call 911 and notify the HWD.2. Record Review and InterviewsA staff schedule dated 7/28/23, read Staff #3 worked from 10:00 p.m. to 6:00 a.m. The HWD documented in a late entry progress note, dated 7/29/23 at 4:00 a.m., that Staff #10 reported an unwitnessed fall from shift change report from Staff #3 and #4. The investigation read overnight Staff #3 and #4 reported Former Resident #9 was not in pain and staff surrounded him with pillows and covered him with a blanket because they felt he wanted to be on the floor due to his history of crawling on the floor in addition to staff not being able to lift him and did not want to break their backs. Although Staff #3 and #4 reported the Former Resident #9 was not in pain when they discovered him on the floor, the staff failed to provide lift assistance. The progress note was updated by the HWD on 7/29/23 at 6:00 a.m. to read the morning shift Staff #10 observed Former Resident #9 on the floor after it was reported to her from Staff #3 and #4 of his fall. When Staff #10 went into Former Resident #9's room, she tried to lift him and he reported pain. 911 was notified and Former Resident #9 was transported to the ED.Former Resident #9 was admitted to the residence on 7/15/23, with diagnoses including Parkinson's Disease and dementia. The residence's care plan, dated 7/8/23, read that former Resident #9 had Parkinson's Disease, had fallen in the last 12 months, used a walker for mobility, and had a physical and cognitive impairment that required escort assistance. However, there was no evidence on the care plan the resident had a history of crawling on the floor. The residence's pre-admission assessment, dated 7/8/23, read that Former Resident #9 used a walker for mobility, had fallen in the last 12 months and had difficulty communicating needs. The HWD documented a late entry progress note, dated 7/29/23 at 6:00 a.m., which read Former Resident #9 had an unwitnessed fall at 4:00 a.m. and the morning shift staff found the former resident on his backside with a pillow under his head and around his body. The former resident reported he had no pain and when staff attempted to lift him from the floor they were unable to get him up. The morning shift staff said the former resident reported pain when they attempted the lift assistance, so staff called 911 and the former resident was transported to the hospital for further evaluation. A hospital discharge summary, dated 7/30/23, read that Former Resident #9 was admitted after a fall and was found to have a right femur fracture. An initial investigation, dated 7/30/23, read that Staff #3 and #4 found Former Resident #9 on the floor at 4:00 a.m., and surrounded him with pillows and covered him with a blanket since he was not in pain. The overnight staff did not report to the administrator, the health and wellness coordinator (HWC), or the health and wellness director (HWD) the former resident's fall or call 911. When the dayshift came at 6:00 a.m., the former resident was in pain and was transported to the hospital where he was diagnosed with a hip fracture. Although staff had previously been trained to call 911 when a resident reported pain, that had not occurred. An occurrence report submitted on the department database, dated 7/30/23, read Staff #3 and #4 left Former Resident #9 on the floor and did not perform lift assistance, report to management, or contact emergency medical services. A final investigation report, dated 8/5/23, read that it was initially reported to the administrator that Former Resident #9 had fallen at 4:00 a.m.; however, upon further investigation, it was discovered that Former Resident #9 had fallen on 7/28/23 at 10:30 p.m. and Staff #3 and #4 did not perform lift assistance when the resident had expressed he was not in pain. 3. InterviewsOn 9/5/23 at 12:22 p.m., Staff #10 stated it had been reported to her by Staff #3 and #4 at shift report that Former Resident #9 was on the floor. Staff #10 went into his room on 7/29/23 at 6:00 a.m when she got on shift, she called 911 since the former resident requested it, as he was screaming out in pain from his leg and she could not lift him due to his pain. On 9/5/23 at 2:11 p.m., Staff #4 stated that she was on shift when Former Resident #9 had fallen on 7/28/23 at 10:30 p.m. Staff #4 stated the former resident was over six foot tall and "dead weight." She stated since she and Staff #3 were unable to lift him and felt he was comfortable due to his history of crawling on the floor and wanting to be there, she made the decision to wait for the morning shift to provide the lift assistance. Staff #4 stated the former resident reported no pain throughout her shift which ended at 6:00 a.m. She stated she did not think 911 was needed since the former resident did not express pain. Staff #4 also stated she had not notified her on-call supervisor who was the health and wellness coordinator (HWC) since the HWD was on vacation. On 9/6/23 at 7:57 a.m., Staff #3 stated she worked 10:00 p.m. to 6:00 a.m. on 7/28/23 and said she was unable to lift Former Resident #9 off the floor since he was a heavy resident and both she and Staff #4 had "back problems." Staff #3 stated Former Resident #9 had not expressed pain after he fell and so she decided to leave Former Resident #9 on the floor until morning shift came so they could provide lift assistance. Staff #3 further stated she had thought she could not call 911 if the former resident had not expressed pain. She stated the residence had not provided to her any lift assistance training until after Former Resident #9's fall. Staff #3 stated she was hired in 2021, and did not recall the residence ever providing lift assistance training to her. On 9/6/23 at 11:48 a.m., the family member for Former Resident #9 stated that when Former Resident #9 fell on 7/28/23 he was diagnosed the following day with a hip fracture. The family member stated Staff #3 and #4 should have called 911 when the fall occurred and got him the assistance he needed. On 9/6/23 at approximately 1:45 p.m., contrary to Staff #3 and #4's interviews, the administrator stated Staff #3 and #4 were unaware themselves why they had not called 911. The administrator stated the staff members did not perform lift assistance due to the inability to lift the former resident off the floor. She further stated Staff #3 and #4 claimed to have been unaware the former resident was injured and stated lift assistance should have been performed if he was not injured or in pain.

Based on interview and record review, the residence failed to ensure the residents had the right to be free from caretaker neglect, affecting one former resident (#9). (Cross-reference Q1160, Q1180, Q1192 and Q2960) 1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.10, defines "Caretaker neglect" as that which occurs when adequate food, clothing, shelter, psychological care, physical care, medical care, habilitation, supervision or any other service necessary for the health or safety of an at-risk person is not secured for that person or is not provided by a caretaker in a timely manner and with the degree of care that a reasonable person in the same situation would exercise, or a caretaker knowingly uses harassment, undue influence or intimidation to create a hostile or fearful environment for an at-risk person.b. The residence's Resident Rights Policy, dated January 2020, read in part: "Residents shall have the following rights: the right to be free from neglect." 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: (E) Is a person with a mental health disorder as defined in Section 27-65-102(11.5), Colorado Revised Statutes (C.R.S.). 2. Former Resident #9 was admitted to the residence on 7/15/23 with diagnoses including Parkinson's Disease and dementia. The face sheet read the former resident was 81 years old. The residence's care plan, dated 7/8/23, read that Former Resident #9 had Parkinson's Disease, had fallen in the last 12 months, used a walker for mobility; had a physical and cognitive impairment that required escort assistance; and, had a private pay caregiver who provided one-on-one (1:1) companionship due to poor safety awareness. However, there was no evidence on the care plan the resident had a history of crawling on the floor or that it was his preferred method of mobility. The residence's pre-admission assessment, dated 7/8/23, read that Former Resident #9 used a walker for mobility, had fallen in the last 12 months and had difficulty communicating needs. A late entry progress note, dated 7/29/23 at 6:00 a.m. and authored by the HWD, read Former Resident #9 had an unwitnessed fall at 4:00 a.m. and was found on his backside on the floor with a pillow under his head and around his body. When the former resident was found by the day shift staff, the overnight staff (#3, #4) reported he had no pain. When Staff #3 and #4 had attempted to lift him from the floor; they were unable to complete the lift. When morning shift staff came in at around 6:00 a.m., the former resident reported hip pain to the day shift staff and the former resident was transported to the hospital for further evaluation. A hospital discharge summary, dated 7/30/23, read that Former Resident #9 was admitted after a fall and diagnosed with a right femur fracture. An initial investigation, dated 7/30/23, read that Staff #3 and #4 found Former Resident #9 on the floor at 4:00 a.m., and surrounded him with pillows and covered him with a blanket since he was not in pain. The overnight staff did not report to the administrator, the health and wellness coordinator (HWC), or the health and wellness director (HWD) the former resident's fall or call 911. When the dayshift came at 6:00 a.m., the former resident was in pain and was transported to the hospital where he was diagnosed with a right femur fracture. Although staff had previously been trained to call 911 when a resident reported pain, that had not occurred. An occurrence report submitted by the residence on the department database, dated 7/30/23, read caretaker neglect of Former Resident #9 had occurred. The report read Staff #3 and #4 had left Former Resident #9 on the floor during the entire overnight shift. Neither staff reported to management that the former resident was injured nor did they contact emergency medical services. A grievance, dated 7/31/23 and submitted by the family member for Former Resident #9, read that after an unwitnessed fall, Former Resident #9 was left on the floor for hours. A corrective action report, dated 8/4/23, read this was a first reminder that Staff #3 was found to have neglected the former resident who fell and did not notify their supervisor or contact emergency medical services. The report read this behavior was in violation of the residence's policies and would not be tolerated. A final investigation report, dated 8/5/23, read that it was initially reported to the administrator that Former Resident #9 had fallen at 4:00 a.m. on 7/30/23; however, upon further investigation, it was discovered that Former Resident #9 had fallen on 7/28/23 at 10:30 p.m. When day shift staff came in around 6:00 a.m. on 7/29/23, the former resident expressed hip pain, so the day shift staff called emergency services for further evaluation. The overnight staff members (#3, #4) on shift did not notify their on-call supervisor who was the health and wellness coordinator (HWC), and did not call 911. The staff members were given corrective action for neglect of a resident because they had placed the former resident at further harm by leaving him on the floor. A corrective action report, dated 8/7/23 for Staff #4 read, this was a first reminder that the staff member was found to have neglected the former resident who fell and did not notify their supervisor or contact emergency medical services. The report read this behavior was in violation of the residence's policies and would not be tolerated. An email of further investigation findings sent by the HWD on 8/6/23, read that Former Resident #9 had fallen on 7/28/23 at 10:30 p.m., and Staff #3 and #4 were the staff on shift who left the former resident on the floor. A private pay caregiver hired by the former resident's family had been scheduled to provide night time monitoring for fall risk; however, had not arrived for their scheduled shift on the night of 7/28/23. Staff #3 and #4 had attempted to lift Former Resident #9 off the floor and were unable to do so. The staff members evaluated the former resident and asked if he was in pain and he stated "no". Staff #3 and #4 covered Former Resident #9 with a blanket and pillows around him and reported the fall to the day shift staff at 6:00 a.m. The day shift staff then found the former resident complaining of hip pain and made the decision to call 911. The HWD spoke with Staff #3 and #4 after her return from vacation on 8/3/23. Staff #3 and #4 had not notified the on-call health and wellness coordinator (HWC) that they were unable to lift the former resident from the floor. The residence provided education to Staff #3 and #4 that when they were unable to lift Former Resident #9, they should have called 911. On 9/5/23 at 7:11 a.m., Staff #5 stated the night of 7/28/23 that Former Resident #9 had a fall and Staff #3 and #4 had left him on the floor. Staff #5 stated at 6:10 a.m., staff went into his room and he was yelling out "call 911" and so they did. Staff #5 stated that she was trained that as soon as a resident fell, to assess for injuries and try to provide lift assistance and to call 911 immediately if staff were unable to do so, if a resident hit their head or had apparent injuries. On 9/5/23 at 9:05 a.m., the administrator stated that Former Resident #9 had not returned to the residence since being hospitalized on 7/29/23. She stated Staff #3 and #4 had no intent to harm Former Resident #9. She stated they had assumed since he had previously crawled on the floor on 7/16/23 that he wanted to be there. The administrator stated the private pay caregiver hired by the former resident's family to provide 1:1 services had not arrived for their scheduled their shift which started at 9:00 p.m. on 7/28/23 and an hour and one-half later at 10:30 p.m., Former Resident #9 wasfound by residence staff on the floor. On 9/5/23 at 9:06 a.m., the administrator stated when Staff #3 and #4 attempted to lift Former Resident #9 off the floor when he fell on 7/28/23 at 10:30 p.m., they were unable to do so. The administrator further stated Staff #3 and #4 placed pillows and blankets around the former resident and provided incontinence care and rounding while he lay on the floor. She stated that Staff #3 and #4 had reported Former Resident #9 was not in pain throughout the night. The administrator stated the former resident was first found with hip pain by day shift Staff #10 at 6:00 a.m., transported to the hospital, and diagnosed with a right femur fracture. The administrator stated she reported neglect to the department due to the length of time the former resident was on the floor with injury, and stated Staff #3 and #4 should have performed lift assistance, and notified the former HWC. She further stated if the former resident had been in pain at any time during the overnight shift that the staff should have called 911. On 9/5/23 at 10:15 a.m., the former HWC stated residence staff were trained to notify management if an external service provider including a private pay caregiver was unable to provide services as agreed upon. However, the former HWC stated she was not notified by any residence staff on 7/28/23 that the private pay caregiver for Former Resident #9 had failed to arrive at the residence for her scheduled shift on 7/28/23 from 9:00 p.m. to 7/29/23 at 9:00 a.m. The former HWC stated she was responsible for creating residence staff schedules. She stated if a private pay caregiver replacement had not been available or a residence staff had not been available, she would have gone to the residence herself on 7/28/23 to monitor the former resident for the entire private pay caregiver shift. On 9/5/23 at 10:46 a.m., the HWD stated that the family member for Former Resident #9 hired an external private pay caregiver agency to monitor Former Resident #9 on a 24/7-basis due to poor safety awareness. The HWD stated that the external private pay caregiver had called out for her shift starting on 7/28/23 at 9:00 p.m. to the following day at 9:00 a.m. The HWD stated she had not found out that the private pay caregiver had called out for her shift and had been made aware by one of the staff members on 7/29/23 after the incident occurred. She stated Staff #3 and #4 should have notified the management staff when the private pay caregiver called out for her shift so the residence could find coverage; however, the staff on shift the evening of 7/28/23 had not notified management staff. On 9/5/23 at 12:22 p.m., Staff #10 stated she had found Former Resident #9 at 6:00 a.m on 7/29/23 and called 911 when the former resident requested it. Staff #10 stated Former Resident #9 had previously fallen including an incident where he crawled on the floor and Staff #3 and #4 were under the impression Former Resident #9 wanted to be there. On 9/5/23 at 2:11 p.m., Staff #4 stated that she was on shift when Former Resident #9 had fallen on 7/28/23 at 10:30 p.m. after the former resident's private pay caregiver did not arrive for their scheduled shift. Staff #4 stated the former resident was over six feet in height and "dead weight." She stated since she and Staff #3 were unable to lift him, she made the decision to wait for the morning shift to provide lift assistance. Staff #4 further stated she placed pillows around the former resident with a blanket and checked on him hourly. Staff #4 stated the former resident reported no pain throughout her shift which ended at 6:00 a.m. on 7/29/23. She stated she was under the impression the former resident wanted to be on the floor since on 7/16/23 he was found crawling on the floor. Staff #4 stated she was trained to provide lift assist and call 911 and did not think 911 was needed since the former resident did not express pain. Staff #4 also stated she had not notified her on-call supervisor when the fall occurred. On 9/6/23 at 7:57 a.m., Staff #3 stated she worked the overnight shift from 7/28/23 10:00 p.m. to 7/29/23 at 6:00 a.m. and that she was unable to lift Former Resident #9 off the floor since he was a heavy resident and both she and Staff #4 had "back problems." Staff #3 stated Former Resident #9 had not expressed pain after he fell and so she decided to leave Former Resident #9 on the floor until morning shift came so they could provide lift assistance. Staff #3 further stated she had thought she could not call 911 if the former resident had not expressed pain. Staff #3 stated Former Resident #9 had a history of crawling on the floor and felt it might have been a similar situation. On 9/6/23 at 12:05 p.m., the practitioner for Former Resident #9 stated the resident was in a rehabilitation facility from his fall and was discharged the day of the onsite investigation. On 9/6/23 at 12:31 p.m., the administrator stated she was made aware by an external case manager at the emergency department where Former Resident #9 had been transferred to that the external case manager had already notified adult protective services (APS). On 9/6/23 at 11:48 a.m., the family member for Former Resident #9 stated he was notified by an unknown staff member on 7/29/23 in the early morning, who informed him that Former Resident #9 was found on the floor in pain with pillows around him and was being sent to the hospital. The family member for Former Resident #9 stated he was unsure how long the former resident was in pain since the former resident did not remember the fall due to his cognitive impairment. The family member stated he wished emergency medical services had been called sooner by Staff #3 and #4, rather than having left him on the floor, since it was discovered the former resident had sustained a right femur fracture from the fall. On 9/6/23 at approximately 1:45 p.m., the administrator stated she was aware of the right for a resident to be free from neglect and felt Staff #3 and #4 had not responded appropriately to Former Resident #9's fall. She acknowledged the incident was neglectful due to the staff members leaving him on the floor all night; staffs' failure to notify management, failure to perform lift assistance, and failing to call emergency medical services. The administrator further stated she had opened an investigation when she was made aware on 7/30/23 and discovered the incident to be "poor judgment" by the staff involved who did not understand the "intensity of the situation." She stated for this reason that she had provided them both retraining and corrective action.

Based on record review and interview, the residence failed to ensure resident records contained documented progress notes, by staff before the end of their shift, of out of ordinary events or issues that affected a resident's physical, behavioral, cognitive, and/or functional condition, along with the action taken by staff to address that resident's changing needs documented, affecting one sample resident (#8) and one former resident (#9). (Cross-reference Q1180 and Q1312)Findings include:1. Residence PolicyThe residence's Change in Condition Policy, updated February 2021, read a change in condition should be evaluated and documented for residents following a change in behavior, medical condition, or cognitive ability and the resident record should be updated. 2. Resident #8 was admitted to the residence on 5/12/23 with a diagnosis of Alzheimer's Disease. A progress note, dated 8/3/23, read Resident #8 had an unwitnessed fall near her television stand with no signs of injury and complained of neck pain. The resident was transferred to the hospital for further observation. A hospital discharge summary, dated 8/4/23, read that there were no injuries found from the resident's fall that occurred on 8/3/23 at the residence. A post-fall follow up, dated 8/5/23, read that the care plan was reviewed but no new changes were made. A progress note, dated 8/5/23, read Resident #8 had an unwitnessed fall without injury. However, there were no progress notes of when Resident #8 had come back from the hospital after her fall on 8/3/23 with the resident's status or wellbeing. A progress note, dated 8/28/23, read Resident #8 had an unwitnessed fall and hit her head. Resident #8 was transferred to the hospital for further evaluation. However, there were no progress notes that documented when Resident #8 returned from the hospital after her fall on 8/28/23 with the resident's status or wellbeing. The complete resident record for Resident #8 was requested on 9/5/23 at 8:47 a.m. and was provided at 1:00 p.m. On 9/5/23 at 9:54 a.m., Resident #8 was observed sitting in her recliner in her bedroom. On 9/6/23 at approximately 1:45 p.m., the administrator stated both the health and wellness director (HWD) and qualified medication administration persons (QMAPs) were responsible for documenting progress notes. The administrator stated she was unsure why a progress note had not been written when Resident #8 returned from the hospital after falls on 8/3 and 8/28/23 and acknowledged a progress note should have been completed. On 9/6/23 at 2:00 p.m., the HWD stated she was responsible for updating progress notes after hospitalization and documented progress notes after receiving discharge paperwork. The HWD stated a progress note was not completed after Resident #8's fall on 8/3/23 because she was on vacation at the time. She said it had been the former health and wellness coordinator's (HWC) responsibility while she was on vacation. The HWD further stated the reason a progress note was not completed when Resident #8 returned from the hospital on 8/28/23 was that she never received the hospital discharge paperwork. 3. Former Resident #9 was admitted to the residence on 7/15/23, with diagnoses including Parkinson's Disease and dementia. The complete resident record for Former Resident #9 was requested on 9/5/23 at 8:47 a.m. and was provided at 11:16 a.m. A late entry progress note, written by the HWD and dated 7/29/23 at 6:00 a.m., read Former Resident #9 had an unwitnessed fall at 4:00 a.m. and was found on his backside on the floor with a pillow under his head and around his body. The former resident reported he had no pain and when staff attempted to lift him from the floor they were unable to get him up. The morning shift staff said the former resident reported pain when they attempted the lift assistance so staff called 911 and the former resident was transported to the hospital for further evaluation. However, there were no progress notes in the record for Former Resident #9 documented by care staff before the end of their shifts about the incident. On 9/5/23 at 2:11 p.m., Staff #4 stated she had not completed a progress note or an incident report before the end of her shift on 7/28/23. On 9/6/23 at 7:57 a.m., Staff #3 stated the private pay caregiver hired by the former resident's family who provided one-on-one (1:1) companion personal services to the former resident had failed to arrive for their scheduled 9:00 p.m. on 7/28/23. She stated she found Former Resident #9 on the floor at 10:30 p.m. that night and she and Staff #4 were unable to lift him off the floor. Staff #3 further stated she was trained to document a incident report or progress note of any out of the ordinary event; however, had not made any note of the incident before the end of her shift since she was flustered. On 9/6/23 at 1:45 p.m., the administrator stated she was unaware if a progress note was made before the end of Staff #3 and #4's shift when Former Resident #9 had fallen the night of 7/28/23. The administrator stated she was unsure why a progress note had not been documented until the HWD created a late-entry note, and stated it should have been done. On 9/6/23 at 2:00 p.m., the HWD stated she was on vacation in July 2023 when Former Resident #9 had fallen on 7/16 and 7/28/23. The HWD stated she wrote the progress note of Former Resident #9's fall when she returned from vacation at the beginning of August 2023. She stated it had the incorrect time since she was not aware Former Resident #9 had actually fallen on 7/28/23 until she returned on 8/3/23. The HWD stated staff were required to document incident reports or a progress note. However, she stated normally she or the former HWC documented progress notes. She confirmed no progress notes were documented by the HWC. The HWD stated she was unaware of the requirement for staff to document a progress note of any out of the ordinary event before the end of their shift and had expected there to have been an incident report.

Based on observation, interview and record review, the residence failed to reassess residents in the secure environment to determine his or her continued need for a secure environment every six months and whenever the resident's condition changes from baseline status including consulting with the resident's attending practitioner, family and/or representative, affecting two of three sample residents (#6, #7) who resided in the secure environment. 1. Residence PolicyThe residence's Secure Environment policy, dated August 2021, read in part, "Each resident shall be re-assessed to determine his or her continued need for a secure environment every six months and whenever the resident's condition changes from baseline status."2. Resident #6 was admitted to the residence on 2/24/22. An initial secure environment assessment, dated 2/21/22, read in part, the resident required a secure environment because she had a diagnosis of dementia and had previously resided in a personal residence, wandered outside and was unable to find her way back. It was determined she would benefit from a structured environment with daily activities. An updated secure environment assessment, dated 8/20/23, read in part, the resident required a secure environment because she had a diagnosis of dementia, had previously resided in a personal residence, wandered outside and was unable to find her way back. It was determined she would benefit from a secure structured environment with daily programming. However, there had not been a secure environment assessment completed every 6 months between 2/21/22 and 8/20/23. On 9/5/23 at 9:05 a.m., the administrator stated that secure environment reassessments were completed every six months. The administrator further stated that the residence had been unable to obtain an updated secure environment assessment for the resident until she had seen a neurologist at the end of August 2023. On 9/5/23 at approximately 9:32 a.m., Resident #6 was observed in the secure environment. On 9/5/23 at 9:34 a.m., Resident #6 stated she had seen a neurologist at the end of August 2023 and did not recall that a practitioner assessment had been completed prior to that. Resident #6 stated she was completely independent; did not wander, have exit-seeking behaviors, and did not have dementia. The resident stated the neurologist had told her this so she was unsure why she resided in a secure environment. On 9/6/23 at 2:00 p.m., the health and wellness director (HWD) stated she was responsible for conducting secure environment assessments and that it had been difficult to obtain consultation with resident practitioner's for a secure environment assessment every six months. She stated she was aware it had not been done every six months. 3. Resident #7 was admitted to the residence on 2/20/22 with a diagnosis of Alzheimer's Disease. An initial secure environment assessment, dated 2/15/22, read in part, the resident had a diagnosis of Azhiemer's and required a structured schedule with daily activities. The resident could wander outside and not find her way back in. A secure environment assessment, dated 9/5/23 (the day of the onsite investigation), read the resident had a diagnosis of dementia and required a structured schedule with daily activities. The resident could wander outside and not find her way back in. The resident required a secure environment residence to facilitate a safe environment. However, there had not been a secure environment assessment completed every six months between 2/21/22 and 8/20/23. On 9/5/23 at 8:47 a.m. complete resident records were requested for Resident #7. On 9/5/23 at 9:28 a.m., Resident #7 was observed in the secure environment. On 9/5/23 at 9:59 a.m., Resident #7 stated she did not recall the last time she had seen a practitioner to be assessed for the secure environment. On 9/5/23 at 11:40 a.m. resident records for Resident #7 were provided. On 9/5/23 at 3:28 a.m., the practitioner for Resident #7 stated theresidence had emailed her the secure environment assessment that morning around 9:00 a.m.; however, the resident was not assessed by the practitioner. The external provider stated the residence had not sent a secure environment assessment to be filled out prior to this morning. On 9/6/23 at approximately 1:45 p.m., the administrator stated the residence likely missed completing the secure environment assessment between February 2022 and August 2023. However, contrary to the external provider interview, the residence had it completed as of yesterday. On 9/6/23 at 2:00 p.m., the HWD stated Resident #7's secure environment assessment must have been overlooked and because the secure environment assessment for Resident #6 had been requested the day prior, the residence had requested it from the external provider yesterday morning. . The HWD stated a secure environment assessment had not been completed for Resident #7 since she was admitted in February 2022. The HWD acknowledged it should have been completed.

Based on record review and interview, the residence failed to ensure the care plan for each resident in the secure environment included a resident's known behavioral expressions along with individualized approaches to be implemented, affecting one former resident (#9). (Cross-reference Q1180, Q1312 and Q2130)Findings include:Chapter VII regulations governing assisted living residences, part 12.10, requires that each resident care plan shall:(C) Promote resident choice, mobility, independence and safety;(D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs;The residence's Secure Environment policy, dated August 2021, read in part: "the service plan (care plan) shall include a description of the resident's wandering patterns and known behavioral expressions."Former Resident #9 was admitted to the residence on 7/15/23 with diagnoses including Parkinson's Disease and dementia. The residence's care plan for Former Resident #9, dated 7/8/23, read the resident had Parkinson's Disease, had fallen in the last 12 months, had a physical and memory impairment that required escort assistance and had a private pay caregiver who provided one-on-one companion services due to the resident's poor safety awareness. However; the care plan did not specify the former resident's behavioral expression of crawling on the floor and individualized approaches. A progress note, dated 7/16/23 at 2:20 a.m. authored by the health and wellness director (HWD), read that Former Resident #9 was witnessed getting down on the floor and crawling. Former Resident #9 reported he was trying to get off the floor; however, staff reported he would get down on the floor himself and crawl. On 9/5/23 at 10:46 a.m., the HWD stated that when Former Resident #9 had first moved into the residence, he was found crawling around on the floor and did not want to get up off of the floor. The HWD stated Former Resident #9 was assisted into his wheelchair and found on the floor crawling around and had not wanted to go back into his wheelchair. On 9/5/23 at 2:11 p.m., Staff #4 stated that she was on shift and witnessed Former Resident #9 crawling around in the hallway. Staff #4 stated that Former Resident #9 was unable to verbalize why he was crawling and when he was done crawling and expressed he wanted assistance, she redirected him into his room and lifted him up into his wheelchair. She further stated she informed Former Resident #9 that he was able to move around the residence in his wheelchair. On 9/6/23 at 7:57 a.m., Staff #3 stated that she had heard that Former Resident #9 was found crawling around on the floor when he was first admitted to the residence and had wanted to be on the floor. On 9/6/23 at 11:48 a.m., the family member for Former Resident #9 stated that Former Resident #9 had expressed unusual behaviors at home which included crawling on the floor, which was prior to admission to the residence on 7/15/23. The family member for Former Resident #9 further stated that the former resident had poor safety awareness due to his dementia, and would put himself on the ground and verbalize he was fine one moment, and the next he would ask for help not knowing why he was on the floor. On 9/6/23 at approximately 1:45 p.m., the administrator stated she was aware of the requirement for secure environment enhanced care plans to include a description of known behaviors and interventions. The administrator stated it had been reported to her by the HWD that Former Resident #9 had crawled on the floor on 7/16/23. The administrator further stated that the HWD was responsible for updating care plans along with the former Health and Wellness Coordinator (HWC). The administrator acknowledged that Former Resident #9's care plan should have been updated to include the behavior of him crawling on the floor.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident's condition changes from baseline status. 13.1 The assisted living residence shall adopt, and place in a publically visible location, a statement regarding the rights and responsibilities of its residents. The assisted living residence and staff shall observe these rights in the care, treatment, and oversight of the residents. 13.11 The assisted living residence shall investigate all allegations of abuse, neglect, or exploitation of residents in accordance with Part 5.3 and its written policy which shall include, but not be limited to, the following: (A) Reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator.

A licensure complaint, prompted by #CO29696 and #CO31472, were completed on 6/27/23. Deficiencies were cited. A change of ownership occured on 1/13/21.

Based on observation, record review, and interview, the residence failed to comply with authorized practitioners orders associated with medication administration, affecting one former resident (#2) and one of three sample residents (#4). Findings include:1. Residence Policy The residence's Medication and Treatment General Guidelines for Medication Administration Assistance dated 4/2022, read in part,"Trained and/or licensed associates may administer or assist the resident with medication management or medication administration treatment per physician/healthcare provider (HCP) order and as per state regulation."2. Resident #4 was admitted to the residence on 6/20/2022 with a diagnosis including Severe Vascular Dementia with mood disturbance. a. Haloperidol A written practitioners order dated 5/21/23, directed the residence to administer Haloperidol lactate oral concentrate 2 mg/ml. Give 0.25 ml by mouth every six hours. However, the June 2023 Medication Administration Records revealed the medication was not available on 6/15 at 2:00 p.m., to 6/17/23 at 8:00 a.m., for a total of six missed doses. 3. Former resident #2 was admitted to the residence on 7/14/2023 with a diagnosis of late onset Alzhimer's dementia with behavioral disturbance. a. Quetiapine Fumarate A written practitioners order dated 6/24/22, directed the residence to administer Quetiapine Fumarate 25 mg in a.m. and 50 mg before bed. However, the July 2022 MAR read the medication was not administered on 7/22-7/26/23, for a total of five missed doses. 4. Interviews:On 6/27/23 at approximately 3:15 p.m., the health and wellness director stated she was notified about the low medication quantity for Resident #4. She was informed staff had attempted to contact hospice and the pharmacy before the medication was depleted. Further, she said she was aware Resident #4 had missed several doses of the medication Haloperidol. On 6/27/23 at approximately 3:38 p.m., Staff #2 stated when medications only had a few days supply, management was notified immediately.

Based on observations and interview, the residence failed to ensure the use of the fireplace in the common area of the residence did not present a resident burn risk, affecting 36 current residents. Specifically, the residence was licensed as a secure environment and served residents with cognitive deficits. The residence's common area, where residents gathered, had a gas burning fireplace. The fireplace emitted heat through the glass and the temperature on the glass measured 394 degrees Fahrenheit. This failure created an immediate jeopardy risk of harm to all 36 residents residing in the residence. On 6/27/23, the department directed the residence to provide written evidence that the risk had been removed..Findings include: 1. References a. According to Children's Hospital Colorado (2022), "Contact with the glass of gas fireplace doors can result in second or third degree burns. Burns of the hand can result in hand dysfunction causing long term impairment and disability." Retrieved from: https://www.childrenscolorado.org/conditions-and-advice/parenting/parenting-articles/glass-door-fireplace-safety/#:~:text=Contact%20with%20the%20glass%20of,term%20therapy%20of%20the%20hand 2. Observations on 6/27/23 revealed the following:The residence operated as a secure environment and served residents with cognitive deficits. The fireplace was in the common area of the residence, approximately eight feet away from a seating area for residence. However, there were no protective barriers in front of the fireplace that prevented residents from accessing the fireplace. An intense heat was observed coming from the glass of the fireplace. Residents were observed to ambulate independently or utilized a walker to the common area. The common area was located in the front portion of the residence near the dining area. Two hallways containing resident's rooms, connected to the common area. From the bedrooms in the hallways, the common area, including the fireplace, was not visible. When staff members assisted residents in their bedrooms, the common area and the residents in the common area were not visible by staff. Upon entrance to the residence at approximately 7:00 a.m. on 6/27/23, residents were observed sitting in the common area in chairs and on the sofa near the fireplace. Staff #1 administered medications from the med cart located in the common area. Residents were observed going to the med cart for their medications and Staff #1 was also observed leaving the common area to administer medications in the resident's rooms. Residents in the common area were left unattended and out of line of sight when Staff #1 administered medications in the resident's rooms. At 7:05 a.m., a thermometer read that the glass of the fireplace was 394 degrees Fahrenheit. At approximately 7:30 a.m., the health and wellness coordinator (HWC) arrived at the residence. She was informed at that time of the temperature of the glass. She then touched the glass and said it was "hot." The HWC subsequently turned off the fireplace and informed the former administrator/executive director of the findings. 3. Interviews On 6/27/23 at approximately 7:05 a.m., Staff #1 stated the fireplace was generally turned on in the morning. She further stated, "It depends on the day when we turn it on. If residents want it turned on, we would."On 6/27/23 at 7:23 a.m., Staff #1 stated that night shift and morning shift staff members used the fireplace frequently. She stated that residents enjoyed the area for extra warmth. However, she said she never realized how hot the temperature was. On 6/27/23 at 7:30 a.m., the HWC stated she didn't know why the fireplace was turned on. 4. Immediate Jeopardy Risk - Written Evidence, Immediate Correction The investigation established that the findings above placed the 36 residents at immediate jeopardy risk for burns or other injuries from the fireplace. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 6/27/23 at 3:54 p.m., the administrator in training submitted written evidence that read in pertinent part: "Common area fireplace was disconnected on June 27, 2023 by Maintenance Technician. (Residence) has requested (outside construction) to bid the work of installing an electronic fireplace insert that does not produce heat. Until the new electronic fireplace is installed, Executive Director or designee will check fireplace daily to monitor that it remains disconnected. A new electronic fireplace that does not produce heat will be installed to maintain compliance"

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 7.13.10 Each assisted living residence shall develop and implement an internal process to ensure the routine and prompt handling of grievances or complaints brought by residents, family members, or advocates. The process for raising and addressing grievances and complaints shall be placed in a visible on-site location along with full contact information for the following agencies: (A) The state and local long-term care ombudsman; (B) The Adult Protection Services of the appropriate county Department of Social Services; (C) The advocacy services of the area ' s agency on aging; (D) The Colorado Department of Public Health and Environment; and (E) The Colorado Department of Health Care Policy and Financing, in those cases where the assisted living residence is licensed to provide services specifically for persons with intellectual and developmental disabilities. 17.7 Weekly menus shall be readily available for residents and public viewing no less than 24 hours prior to serving. 25.22 The assisted living residence shall meet the requirements of Part 13.10 regarding the internal grievance and complaint resolution process. In addition, the assisted living residence shall hold regular meetings to allow residents, their family members, friends, and representatives to provide mutual support and share concerns and/or recommendations about the care and services within each separate secure environment. (A) Such meetings shall be held at least quarterly, at a place and time that reasonably accommodates participation; and (B) The assisted living residence shall provide adequate advance notice of the meeting and ensure that details regarding any meeting are readily available in a common area within the secure environment.