BROOKDALE BROADMOOR

A relicensure survey with complaints #CO39636, #CO41124, and #CO41252 was completed on 5/14/26. Deficiencies were cited.

Based on record review and interview, the residence failed to include the methods used to collect and analyze data in order to find patterns and trends; and timelines for implementation and evaluation of the strategy, and how the residence is tracking the meeting of these milestones, affecting 67 current residents. Findings Include: 1. Record ReviewOn 5/13/26, the residence quality management program (QMP) was reviewed. a. The residence QMP identified trends in falls dated 1/27/26 and urinary tract infection 4/28/26, but did not document the data collection and analysis method used to identify either trend. The entries read that a trend existed without showing the data reviewed, the time frame analyzed, or the method applied to detect the pattern. b. The residence failed to document implementation and evaluation timelines for the fall interventions and the perennial care training. The entries omit start dates, evaluation dates, and milestone tracking, leaving no mechanism to measure whether either strategy was effective. 2. InterviewOn 5/14/26 at approximately 2:30 p.m., the administrator stated that she was unaware of the required components of the QMP.

Based on record review, observation, and interview, the residence failed to make a sanitary environment available, either directly or indirectly, through a resident agreement, affecting 67 current residents. Findings include:Residence PolicyThe residence housekeeping policy dated October 2025 read in pertinent part: "every community is required to have a common area cleaning program that creates a fresh impression- an environment that looks clean, is odor-free, and feels comfortable."2. ObservationOn 5/13/26 from 7:50 a.m. to 3:45 p.m., an environmental tour of the residence revealed the following: Dried food of varying sizes littered the floor in the secured environment dining room. A substance that appeared to be vomit was observed in the secured environment activity room sink. On 5/14/26 from 7:30 a.m. to 2:30 p.m., an environmental tour of the residence revealed the following: Dried food of varying sizes littered the floor in the secured environment dining room. Resident #15's apartment contained a strong urine odor, a dirty incontinence product was left on the floor, and an old stain on the floor. Similar deficient practice was found with Resident #12 and three unnamed residents. 4. InterviewOn 5/14/26 at approximately 3:00 p.m., the administrator stated she expected that the secured environment dining room and resident rooms to be cleaned and sanitized. She acknowledged that the clinical staff should have helped the housekeeper in maintaining a safe and sanitary environment.

Based on observation, record review, and interviews, the residence failed to ensure the comprehensive assessment included all required elements, affecting six of nine sample residents (#9, #10, #12, #15-#18) whose assessments were reviewed. Findings Include:Resident #18 was admitted to the residence on 11/28/25 with diagnoses including vascular dementia with mood disturbance, paranoid schizophrenia, and anxiety disorder. A progress note dated 5/11/26 read, Resident #18 refused care despite multiple staff attempts. "She picked her walker up as if she was gonna throw it at me." On 5/14/26 at approximately 9:00 a.m., Resident #18 was observed to be agitated and ran towards the administrator, pushing her walker into the administrator. A review of Resident #18's comprehensive assessment dated 5/10/26 read, Resident #18 may become agitated, disruptive, and obsessive, and may express anger verbally and physically. "Generalized behavioral interventions" included: redirection, calm communication, a positive physical approach, validation of emotions, cueing, distraction, and avoiding arguments. However, the assessment did not include individualized interventions specific to escalating threatening behaviors toward staff, including care refusal; staff safety measures during threatening episodes; responses to physical aggression involving the use of objects as potential weapons and changes in supervision needs during escalation; or de-escalation approaches. On 5/14/26 at 12:35 p.m., the administrator stated she was aware of Resident #18's increased behaviors and refusals, and expected the nursing staff to update the comprehensive assessment with individualized interventions for staff to assist Resident #18. She further stated that changes in residents' behavior and increased falls would constitute an update to all residents' comprehensive assessments, which were not completed for the sample residents. Record review and interviews revealed similar deficient practice for Residents #9, #10, #12, #15-#17.

Based on record review and interview, the residence failed to promote resident choice, mobility, independence, and safety and failed to detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs in a resident care plan, affecting six of nine sample residents (#9, #10, #12, #15-#18) whose care plans were reviewed. Findings include:1. Record ReviewResident #16 was admitted to the residence on 3/5/26 with diagnoses including vascular dementia, anxiety disorder, repeated falls, and unsteadiness on the feet. The Personal Service (Care) Plan for Resident #16, dated 3/5/26, read in part that the resident was at risk for falls and interventions included general fall precautions such as use of a low bed, floor mats, cueing to ask for help, and monitoring for changes in condition. A progress note dated 3/23/26 read in part that Resident #16 was found on the floor in her room after sliding from the bed. A progress note dated 4/7/26 read in part that Resident #16 was found on the floor after attempting to transfer from the bed without assistance. A progress note dated 4/9/26 read in part that Resident #16 slid from a recliner to the floor. A progress note dated 4/18/26 read in part that Resident #16 experienced one fall after sliding from the bed to the floor and a second fall later the same day. A progress note dated 4/19/26 read in part that Resident #16 was again found on the floor in the resident ' s room near the bed. A progress note dated 4/20/26 read in part that Resident #16 experienced another fall in the resident ' s room. However, the care plan was not updated to include individualized approaches specific to Resident #16 ' s repeated unsafe transfers, continued falls in similar circumstances, supervision needs during high-risk times, or staff instructions following continued falls. 2. InterviewOn 5/14/26 at 12:35 p.m., the administrator stated she was unaware of the continuous falls Resident #16 sustained and expected the care plan to be updated with individualized interventions. The administrator stated the health and wellness director was responsible for ensuring care plans were updated accordingly. 3. Record review and interviews revealed similar deficient practice for Residents #9, #10, #12, #15, #17, and #18.

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 7.18.3 Each assisted living residence shall implement a policy and procedure for an effective information management system that is either paper-based or electronic. If the ALR maintains both paper-based and electronic records, there shall be a method for integration of those records that allows effective continuity of care. Processes shall include effective management for capturing reporting, processing, storing and retrieving care/service data and information.

A relicensure survey and complaint revisit was completed on 5/14/26 for all previous deficiencies cited on 2/26/25. A deficiency was cited. The deficiencies cited for Event TRBN11 were cited prior to the regulation revision that was implemented on 7/1/25.

Based on record review, observation, and interview, the residence failed to make a sanitary environment available, either directly or indirectly, through a resident agreement, affecting 67 current residents. This deficiency was cited previously during a state licensure survey 3/26/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:Residence PolicyThe residence housekeeping policy dated October 2025 read in pertinent part: "every community is required to have a common area cleaning program that creates a fresh impression- an environment that looks clean, is odor-free, and feels comfortable."2. ObservationOn 5/13/26 from 7:50 a.m. to 3:45 p.m., an environmental tour of the residence revealed the following:Dried food of varying sizes littered the floor in the secured environment dining room. A substance that appeared to be vomit was observed in the secured environment activity room sink. On 5/14/26 from 7:30 a.m. to 2:30 p.m., an environmental tour of the residence revealed the following:Dried food of varying sizes littered the floor in the secured environment dining room. Resident #15's apartment contained a strong urine odor, a dirty incontinence product was left on the floor, and an old stain on the floor. Similar deficient practice was found with Resident #12 and three unnamed residents. 4. InterviewOn 5/14/26 at approximately 3:00 p.m., the administrator stated she expected that the secured environment dining room and resident rooms to be cleaned and sanitized. She further stated that the facility has not corrected the deficiency because the clinical staff should have helped the housekeeper in maintaining a safe and sanitary environment.

A relicensure survey with complaint #CO37375 was completed on 2/26/25. Deficiencies were cited.

Based on record review and interview the residence failed to comply with all occurrence reporting required by state law and investigate an occurrence to determine the circumstances of the event and institute appropriate measures to prevent similar future situations and document the investigation, affecting one former resident (#8). (Cross-reference S1324)Findings include:A progress note dated 7/26/24 read that Former Resident #8 went to the hospital due to decreased mobility and weakness. A text message between the POA and Former HWD dated 7/26/24, read that Former Resident #8's POA informed the Former HWD that Former Resident #8 was in the hospital with a cracked sternum and pneumonia. Progress notes dated 7/27/24 through 7/29/24 read that Former Resident #8 was in the hospital. A outside service provider note dated 8/1/24 read that Former Resident #8 was admitted to hospice upon return from the hospital to the residence with severe sepsis, aspiration pneumonia, and cellulitis. Additionally, Former Resident #8 was unable to feed himself. The same document stated that Former Resident #8 had recurring falls and that the residence staff reported that the falls were as frequent as two to three falls daily for two weeks which resulted in wounds. A progress note dated 8/1/24 read that Former Resident #8 returned to the residence. A progress note dated 8/7/24 read that Former Resident #8 was in his room screaming for help. When the staff went into his room Former Resident #8 was laying in bed unable to find his phone or his call light. The same note read that Former Resident #8 refused to feed himself. A progress note dated 8/16/24 read that a care meeting between Former Resident #8's POA, external services, and the residence occurred. The note read that the residence stated that the current level of care that Former Resident #8 required was equivalent to skilled nursing facility services which could not be provided by residence staff. The note stated that Former Resident #8's POA would provide feeding support and that new external services would take over care of other needs. A picture dated 8/27/24 was provided that showed Former Resident #8 laying in bed on his right side, his lower back and anal cleft visible. Covering the lumbar and sacral region was a large stage three or higher bed sore and dried feces was visible in the anal cleft. On 2/25/25 at approximately 2:00 p.m., all documentation for Former Resident #8 was requested. The residence was unable to provide any investigations for Former Resident #8, to include any law enforcement documentation. On 2/26/25 at approximately 9:30 a.m., Staff #2 stated that Former Resident #8 should not have been readmitted to the residence following his hospitalization because the care that he required exceeded the care that the residence was able to provide. Staff #2 stated that she informed the former administrator of Former Resident #8 and his requirement for higher care and the difficulties staff had meeting his needs. Staff #2 was not aware she was required to report the findings to law enforcement, therefore the resident's wound got worse. On 2/26/25 at 9:40 a.m., Staff #8 stated that she informed the former administrator that a skilled nursing facility would have been a better fit for Former Resident #8 because the residence staff was unable to provide the care he required, therefore the resident's wound got worse. Staff #8 stated she was not aware she was required to report the findings to law enforcement and only reported it to the former administrator.

Based on observations and interviews the residence failed to provide a sanitary environment, affecting 64 current residents. Findings include:On 2/25/25 to 2/26/25 during an onsite environmental tour, the following was observed:The assisted living residence had a urine odor throughout the day. The secure environment had a urine odor throughout the day. The secure environment had carpeting that contained large black stains near the entry door, kitchen door, reception area and throughout the hallways. The carpet also contained lint and dust materials throughout. The door handles leading to the secure environment courtyard had food particles and other residue. The windows and doors of the secure environment contained multiple fingerprints. The decorative edging on the wall of the secure environment contained dust and dirt. The benches located in the secure environment courtyard failed to have a seat. The sink in the dining room near the kitchen of the secure environment failed to have hand-washing soap. On 2/26/25 at approximately 11:30 a.m., the administrator acknowledged that the urine odor was very strong in both areas, assisted living and secured environment. On 2/26/25 at 1:00 p.m., the operations specialist explained the carpeting in the secure environment was old and cleaned on a routine basis. She reported the carpeting needed to be replaced and was in the process of getting that started. She reported the housekeeper was responsible for maintaining a sanitary environment in the common areas on certain days as well as the residents' rooms on the other days. She reported the maintenance director was responsible for ensuring the tasks were completed. The operations specialist acknowledged that the observations listed were not sanitary and needed to be fixed. She further explained they were working with specific residents who were contributing to the urine smell throughout the assisted living and secure environment of the residence.

Based on record review and interview the residence failed to provide staff training related to fall prevention affecting two of eight sample residents (#1, #2). Specifically, Resident #1 had an unwitnessed fall on 12/28/24 that resulted in a bump on her head and bruising. On 1/1/25, Resident #1 had a fall that resulted in no injury. On 1/6/25, Resident #1 had a fall that resulted in a large hematoma on the back of her head. On 2/13/25, Resident #1 had a fall that resulted in a small laceration and hematoma on the back of her head. The residence failed to provide staff training regarding individualized approaches implemented to prevent falls after each fall. Subsequently, Resident #1 fell four times between 12/28/24 and 2/13/25 with three of the four falls resulting in injury. Findings include:1. Resident #1 was admitted to the residence on 11/16/23 with a diagnosis of Alzheimer's disease with late onset. A care plan for Resident #1, dated 11/13/24, stated the residence's universal fall precautions, which read in part: "Familiarized the resident with the environment and routine of the community as needed, familiarized the resident with the call system and had him/her demonstrate use, remained alert to placing the resident's personal items within reach, educated the resident on reducing environmental clutter, and arranged furniture for adequate walkways. The resident was familiarized with handrails in bathrooms, and the bed was kept in a locked position, if applicable. The bed was kept in its low position when the resident rested in the bed and was raised, if possible, to a comfortable height when assisting the resident with transfers. The resident's wheelchair was locked in position when stationary. Floors were kept clean and dry. The resident was educated on the use of comfortable, properly fitting, non-slip footwear, and on the use of supplemental lighting and nightlights. Safe handling practices were followed. The resident was encouraged to participate in B-fit programs, the proper use of assistive devices was encouraged, and the resident's medications, pain level, and practitioner involvement were considered, along with the possibility of orthostatic hypotension and annual eye exams, labs, and physical and occupational therapy. Program participation was encouraged as a means to increase observation. The use of furniture corners or removal of sharp-edged furniture in the apartment was considered if needed, along with contrasting wall color behind the toilet for a visual cue to aid in defining toilet boundaries. The use of hip protectors to reduce the risk of injury was encouraged, along with the use of the low bed and scoop mattress to promote the resident to call for help, define bed boundaries, and reduce the risk of sliding from the bed. A bedside fall cushion mat and high-rise toilet seat were also used."In addition, specific fall prevention measures were added by the residence, which read in part: "(Resident #1) will be escorted and mobility needs would be met during the routine course of care. The resident would receive staff attention and/or verbally prompted when going to and from the dining room and/or community activities. The resident would maintain the current level of mobility with no increased incidence of falls." Furthermore, the staff's caregiver communication book failed to list specific interventions to prevent falls for Resident #1. An incident report dated 12/28/24 read in part Resident #1 had an unwitnessed fall in the residence hallway that resulted in physical signs of a head injury and signs of bruising. A progress note dated 12/30/24 reported in part, "(Resident #1) had an unwitnessed fall on 12/28/24 in the hallway. There were physical signs of head injury, however, staff reported (Resident #1) had a bump on her head with signs of bruising as a result of the fall."An incident report dated 1/1/25 read in part "(Resident #1) had an unwitnessed fall in the hallway with no physical signs of head injury or skin injury as a result of the fall."A progress note dated 1/1/25 read in part, "(Resident #1) had an unwitnessed fall on 1/1/25 in the hallway. There were no physical signs of head or skin injury as a result of the fall."A progress note dated 1/6/25 read in part, "(Resident #1) had fallen in the hallway resulting in a large hematoma to the back of her head."A progress note dated 2/13/25 read in part, "(Resident #1) was in the television room and missed the chair when she attempted to sit down which caused her to hit the back of her head. Resident #1 sustained a laceration measuring 0.1x1.0x0.0 with hematoma and discoloration surrounding the laceration, and a small serosanguineous drainage."Record review revealed the staff communication book failed to include specific interventions to prevent falls for higher-risk residents. 2. InterviewsOn 2/25/25 at 3:01 p.m., Staff #4 reported interventions to prevent falls for Resident #1 included keeping her in her room and encouraging her not to get up alone. Staff #4 explained they had been trained on how to access residents' care plans to view fall prevention interventions and they were added to the caregiver communication book, however, there were frequent miscommunications about what changes occurred and specific fall prevention interventions put in place. Staff #4's fall prevention interventions for Resident #1 contradicted with what was listed in Resident #1's care plan. On 2/25/25 at 3:14 p.m., Staff #5 reported interventions to prevent falls for Resident #1 included having her in the residence's common areas to provide supervision. She explained that staff communicated about specific interventions to prevent falls for higher-risk residents in a communication book which was located in the staff break room, and verbally during shift changes. Staff #5 reported being trained on how to access the residents' care plans. Staff #5's fall prevention interventions for Resident #1 contradicted with what was listed in Resident #1's care plan. On 2/25/25 at 3:21 p.m., Staff #6 reported interventions to prevent falls for Resident #1 included providing check-ins every 30 minutes. She explained that staff communicated about specific interventions to prevent falls for higher-risk residents in a communication book which was located in the staff break room, in meetings, and verbally during shift changes. Staff #5 reported being trained on how to access the residents' care plans. Staff #6's fall prevention interventions for Resident #1 contradicted with what was listed in Resident #1's care plan. On 2/26/25 at 10:08 a.m., the operations specialist reported specific resident fall prevention interventions were located in the resident's service and care plans. She explained that staff in assisted living and the secure environment had a binder that contained service plans with interventions. The residence also used an electronic monitoring system to assist with detecting falls. She explained that staff were trained on fall management and specific resident fall prevention interventions via online trainings, staff meetings, and impromptu service trainings with external service providers. She was unable to recall previous dates staff were trained on specific resident fall prevention interventions. The operations specialist acknowledged that there was a disconnect between staff and them knowing the specific interventions put in place to prevent falls for each resident. The operations specialist reported she was unsure of Resident #1's specific falls, however, she admitted being concerned. She reported the residence had a universal fall precautions list, but it was not specific to each resident. The operations specialist reported she expected staff to follow the fall interventions put in place and saw a pattern of this not being implemented which caused harm. On 2/26/25 at 11:34 a.m., the health and wellness director reported interventions to prevent falls were located in the care plan for each resident and the resident's care profile in the online system showed their mobility aid along with specific interventions. She explained that staff were trained on fall prevention and specific resident interventions via in-service training, online training, daily verbal communication on residents who were at a high risk, and collaboration with external service providers to do training on fall management. She reported being unsure when the last training occurred for specific fall prevention interventions for each resident. The health and wellness director reported she started her position with the residence in mid-December 2024 and until recently all fall incident report notifications went to the previous health and wellness director. She acknowledged the staff turnover had caused miscommunication about the fall precautions for Resident #1, however, she was now responsible for staff training. She acknowledged being unaware if staff were trained on specific interventions to prevent falls and was unable to provide documentation. She reported she was aware of Resident #1's falls in January 2025 and February 2025. She explained that she was not aware of staff not following the fall interventions put in place and acknowledged that the information absorbed by staff varied. She explained the residence had attempted to implement a communication book located in the break room due to the staff's lack of understanding. The health and wellness director admitted the lack of documentation and communication between staff had caused harm to Resident #1 and their fall history. 2. Similar deficient practice was found for Resident #2.

Based on observation, record review, and interview, the residence failed to provide residents who resided in the secure environment with regular opportunities to participate in structured engagement and support the pursuit of each resident's interests, affecting 26 current residents. Findings include: 1. ObservationsThroughout the onsite visit from 2/25/25 to 2/26/25, an activities schedule was not posted in the secure environment and the residence failed to provide the residents with opportunities to participate in structured engagement. 2. Interviews On 2/26/25 at 1:30 p.m., the operations specialist (OS) stated the secure environment was not currently providing daily structured engagement activities for the residents, as they did not have an activities director. She stated that care staff occasionally helped with resident engagement activities if an itinerary was provided to them; however, due to the onsite visit, that did not happen. The OS acknowledged that there should have been daily scheduled engagement activities provided for the residents. On 2/26/25 at 1:30 p.m., the administrator confirmed the OS's statement. On 2/25/25 at 3:01 p.m., Staff #4 reported the residence had not provided activities in the secure environment due to not having an activities director.

Based on interview and record review, the residence failed to ensure residents had the right to be free from neglect, affecting one former resident (#8). (Cross-reference S430)Specifically, Former Resident #8 was readmitted to the residence following a hospital visit where his diagnosis included severe sepsis, cellulitis, a foley bag, and the inability to feed himself. The residence staff upon Former Resident #8's return to the residence informed their former administrator that Former Resident #8's care needs were too great for the level of care that they were able to provide. Furthermore, the residence relied on Former Resident #8's power of attorney (POA) to provide care that they were unable to provide which left the resident without care for the time between the POA's visits to the residence. This resulted in the rapid deterioration of Former Resident #8's condition, which included a diagnosis of cellulitis which turned into a stage three wound or higher. Findings include:1. Residence PolicyA document titled Resident Agreement, dated December 2023, part D. Health Assessment, read: "You agree that we may periodically assess your health to create and update a Personal Service Plan and/or to determine whether you are appropriate to remain at the Community (residence)."A document titled Resident Rights, dated January 2020, read that the residents had the right to be free from neglect. 2. Record ReviewA progress note dated 7/18/24 read that Former Resident #8 had a hospital note stating that he had a urinary tract infection. A text message between the POA and Former HWD dated 7/18/24 read that Former Resident #8's POA informed residence staff of low blood pressure reading of 68/45. A progress note dated 7/26/24 read that Former Resident #8 went to the hospital due to decreased mobility and weakness. A message between the POA and Former HWD dated 7/26/24, read that Former Resident #8's POA informed the Former HWD that Former Resident #8 was in the hospital with a cracked sternum and pneumonia. Progress notes dated 7/27/24 through 7/29/24 read that Former Resident #8 was in the hospital. A outside service provider note dated 8/1/24 read that Former Resident #8 was admitted to hospice upon return from the hospital to the residence with severe sepsis, aspiration pneumonia, and cellulitis. Additionally, Former Resident #8 was unable to feed himself. The same document stated that Former Resident #8 had recurring falls and that the residence staff reported that the falls were as frequent as two to three falls daily for two weeks which resulted in wounds. A progress note dated 8/1/24 read that Former Resident #8 returned to the residence. A progress note dated 8/7/24 read that Former Resident #8 was in his room screaming for help. When the staff went into his room Former Resident #8 was laying in bed unable to find his phone or his call light. The same note read that Former Resident #8 refused to feed himself. A progress note dated 8/16/24 read that a care meeting between Former Resident #8's POA, external services, and the residence occurred. The note read that the residence stated that the current level of care that Former Resident #8 required was equivalent to skilled nursing facility services which could not be provided by residence staff. The note stated that Former Resident #8's POA would provide feeding support and that new external services would take over care of other needs. A picture dated 8/27/24 was provided that showed Former Resident #8 laying in bed on his right side, his lower back and anal cleft visible. Covering the lumbar and sacral region was a large stage three or higher bed sore and dried feces was visible in the anal cleft. An outside service provider note dated 9/10/24, read that Former Resident #8 was pronounced deceased at the residence at 10:43 p.m. 3. InterviewsOn 2/24/25 at approximately 4:00 p.m., Former Resident #8's POA stated that before returning to the residence the former HWD came to the hospital and did an assessment. She stated the information that she was provided by the former HWD and former administrator was that Former Resident #8's care was manageable with external care providers assistance and that this was the only reason she agreed to Former Resident #8 returning to the residence. On 2/25/25 at approximately 7:30 a.m. Staff #2 stated that Former Resident #8 was not able to care for himself when he returned to the residence on 8/1/24 and that the care he did need exceeded the care that was provided. On 2/26/25 at approximately 11:30 a.m. the administrator stated that Former Resident #8 should have been reassessed for placement and that it was neglectful not to. On 2/26/25 at approximately 11:30 a.m. the HWD agreed that the wound on Former Resident #8's lumbar and sacral from 8/27/24 resembled a stage three or higher wound depending on the depth.

Based on record review and interview the residence failed to ensure that only medications ordered by an authorized practitioner were prepared for and administered to residents, affecting three of three sample residents (#1-#3). Findings include:1. Resident #2 was admitted to the residence on 3/19/21 with a diagnosis of dementia in other diseases classified elsewhere with behavioral disturbances, chronic pain, essential hypertension, and major depressive disorder. The February 2025 medication administration records (MAR) revealed the residence administered the following medication to Resident #2 without the practitioner's orders as follows:Tramadol 50 mg was administered on 2/1-2/2/25 and 2/4-2/17/25. Olanzapine 5 mg was administered 2/1-2/14/25. Acetaminophen 325 mg was administered 2/1-2/24/25. Bupropion HCI 150 mg was administered 2/1-2/24/25. Olmesartan medoxomil 40 mg was administered 2/1-2/24/25. Polyvinyl alcohol povidone 1.4-.6% was administered on 2/1-2/2/25 and 2/4-2/17/25. Quetiapine fumarate 25 mg was administered 2/1-2/24/25. Lidoderm patch 5% was administered 2/1-2/24/25. Senna 8.6 mg was administered 2/1-2/24/25. Calmoseptine external ointment (methol- oxide) 0.44-20.6% was administered 2/1-2/24/25. Voltaren arthritis pain external gel 1% (diclofenac sodium) was administered 2/1-2/24/25. Similar deficient practice was found for Resident #1 and Resident #3.2. InterviewOn 2/25/25 at 1:15 pm., the health and wellness director explained she was responsible for obtaining practitioner's orders and had implemented the process of obtaining signed practitioner's orders on a monthly basis about two weeks ago. She acknowledged not having all signed practitioner's orders for Resident #1-#3 medications and explained she expected to have them.

Based on observation and interview the residence failed to ensure that qualified medication administration persons (QMAP) are trained in and apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications, affecting 64 current residents. Findings include:1. ObservationDuring medication administration on 2/25/25 from 7:37 a.m. to 8:26 a.m., the QMAP in the secure environment failed to wash their hands after administering medications to residents, escorting residents to breakfast by holding their hands, and touching her face, hair, and door knobs. During this time the QMAP failed to use basic infection control and prevention after each encounter. During medication administration on 2/25/25 at approximately 7:30 a.m., the QMAP in the assisted living environment failed to use hand sanitizer or wash their hands before and after administering medications to residents, administering salves to residents, and handing and taking objects from residents. 2. InterviewOn 2/25/25 at 8:26 a.m., Staff #3 reported they had been trained on basic infection control and prevention when preparing and administering medications, however, she acknowledged that she did not follow the protocols and needed to. On 2/26/25 at 1:20 p.m., the health and wellness director confirmed that qualified medication administration persons (QMAP) are trained monthly to apply nationally recognized protocols for basic infection control and prevention when preparing and administering medications. She explained she would expect the QMAPs to wash their hands before and after administering medications. The health and wellness director reported she expected hand sanitizer to be at the medication cart, and acknowledged that it was not. She reported she expected hand sanitizer to be in the medication carts and for staff to follow basic infection control protocols.

Based on record review and interview, the residence failed to ensure two individuals who are qualified medication administration persons, nurses, or practitioners jointly counted all controlled substances at the end of each shift and signed documentation regarding the results of the count at the time it occurred, affecting three of the eight sample residents prescribed controlled substances (#1-#3) who resided in the secure environment. Findings include:1. Record ReviewA review of the controlled substance count sheets revealed the following:2/2/25- no signature for off-duty at 6:00 a.m. 2/2/25- no signature for on-duty at 2:00 p.m. 2/2/25- no signature for off-duty at 10:00 p.m. 2/3/25- no signature for on-duty at 10:00 p.m. 2/4/25- no signature for off-duty at 6:00 a.m. 2/4/25- no signature for on-duty at 2:00 p.m. 2/4/25- no signature for off-duty at 7:00 p.m. 2/7/25- no signature for on-duty at 8:30 p.m. 2/8/25- no signatures for on and off duty at 6:00 a.m. 2/8/25- no signature for on-duty at 8:00 p.m. 2/9/25- no signature for off-duty at 6:00 a.m. 2/13/25- no signature for on-duty at 2:00 p.m. 2/13/25- no signature for on and off duty at 10:00 p.m. 2/14-2/15/25- no signatures for on and off duty for all shifts. 2/16/25- no signature for off-duty at 6:00 a.m. 2/16/25- no signature for on-duty at 2:00 p.m. 2/16/25- no signature for on and off duty at 10:00 p.m. 2/17/25- no signature for off-duty at 1:54 p.m. 2/17/25- no signature for on-duty at 10:00 p.m. 2/18/25- no signature for off-duty at 6:00 a.m. 2/18/25- no signature for on-duty at 10:00 p.m. 2/19/25- no signatures for on and off-duty shifts. 2/20/25- no signature and time for off duty and no signature or time for on-duty shift. 2/20/25- no signature for off-duty at 10:00 p.m. 2/21/25- no signature for on-duty at 6:00 a.m. 2/22/25- no signatures for on and off duty for all shifts. 2/23/25- no signatures for on and off duty shift at 6:00 a.m2/23/25- no signature for off-duty at 10:00 p.m. 2/24/25- no signature for on-duty shift at 2:00 p.m. 2/24/25- no signatures for on and off duty at 10:00 p.m. 2/25/25- no signature for off-duty shift at 6:00 a.m. 2/25/25- no signature for on-duty shift at 10:00 p.m. 2. InterviewOn 2/26/25 at 1:18 p.m., the health and wellness director explained that two qualified medication administration personnel (QMAP) were expected to sign off at the beginning and end of their shift to confirm the controlled substance count. She acknowledged that two QMAPs did not sign off at the beginning and end of their shifts.

Based on observations and interviews the residence failed to provide residents with the opportunity to choose where and with whom they were able to sit during dining times, affecting 26 current residents in the secured environment. Findings include:On 2/25/25 at approximately 12:00 p.m., Staff #7 was observed directing multiple residents in the secured environment dining room to different seats than the ones they had chosen to sit at. Staff #7 stated that residents had assigned seating because some liked to talk more than others and that they always had assigned seating. On 2/26/25 at approximately 11:30 a.m., the administrator stated that the residence did not have assigned seating. She stated that she was aware of the regulation that provided residents with the right to sit where and with whom they chose. The administrator stated she was not sure why staff were assigning seats.

Based on observation and interview, the residence failed to ensure the residence grounds were maintained to protect residents from slopes and hazards, affecting six of six residents who used the designated smoking area. Findings include: 1. Non-secure Environment On 2/25/25 at approximately 8:17 a.m, an environmental tour revealed the residence had a walkway and a designated smoking area that separated the non-secure and secure environment. The concrete walkway between the houses had drop-offs that measured approximately eight inches onto a rocky area. The designated smoking area off to the side of the non-secure environment consisted of a large concrete patio with drop-offs that measured between five to six inches. On 2/25/25 at 8:20 a.m., the operations specialist (OS) stated as far as she knew, the walkway and patio had always been like that and had not been pointed out to them during previous inspections. The OS acknowledged that the five to eight inch drop offs posed a potential fall hazard. 2. Secure Environment On 2/26/25 at 9:36 a.m., an environmental tour of the outdoor courtyard revealed two metal bench frames that were missing the back and seat, along with four to five inch drops from the concrete walkway to the mulch ground throughout the courtyard. On 2/26/25 at 1:05 p.m., the OS stated she was aware the benches were missing the backs and seats because they had not been finished being put together yet. She acknowledged if a resident attempted to sit down on one of the benches, it could cause a potential fall resulting in injuries. Additionally, she acknowledged the four to five inch drop offs along the walkway posed a potential fall hazard.

Based on observation and interview, the residence failed to provide toilet paper in a dispenser, liquid soap, and paper towels or hand drying devices in the secure environment common bathroom, affecting 26 current residents in the secure environment. Findings include:On 2/25/25 to 2/26/25 during an onsite environmental tour the residence revealed the common bathroom in the secure environment failed to have toilet paper in a dispenser, liquid soap, and paper towels or hand drying devices available. On 2/26/25 at 12:26 p.m., the operations specialist reported she was unaware of the missing items in the common bathroom of the secure environment and was aware of what items were required to be in the common bathroom at all times. She reported housekeeping was responsible for ensuring the common bathroom was stocked with supplies and clean at all times. She reported she expected the required items to be in the common bathroom.

Based on observation and interview, the residence failed to have a secure outdoor area that was independently accessible without staff assistance, affecting 26 residents in the secure environment. Findings include: 1. Observations On 2/25/25 at 7:45 a.m., a tour of the secure environment revealed there were four sets of doors throughout the residence that led to the secure outdoor area, and all of the doors were locked. On 2/25/25 from 7:45 a.m. to 5:00 p.m., all of the doors that led to the secure outdoor area remained locked; therefore, prohibiting independent access for the residents who attempted to go outside. On 2/25/25 at approximately 2:47 p.m., residents of the secure environment attempted to access the secure courtyard; however, the door was locked. 2. Interviews On 2/25/25 at 9:00 a.m., Staff #3 stated the doors to the secure outdoor area should have been unlocked; however, was unsure why the doors were still locked. She stated the doors were locked overnight for safety, but that the doors were usually unlocked after breakfast was over. Staff #3 stated she was unable to unlock the doors, as she did not have a key. On 2/25/25 at 1:30 p.m., the operational specialist (OS) stated the doors to the secure outdoor area had been locked because it had been very cold out there. She stated since the weather was starting to get warmer, the residence was in the process of preparing the courtyards and getting the courtyard cleaned up. The OS stated that weather permitting, the doors should have been unlocked.

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 7.14.10 Unless otherwise allowed by statute, the assisted living residence shall not permit a qualified medication administration person to perform any of the following tasks: (H) Pre-pouring of medication17.3 The assisted living residence shall offer drinks, including water and other liquids, to residents with every meal and between meals throughout the day. The assisted living residence shall also ensure that residents have independent access to drinks at all times.

A revisit survey was completed on 2/12/24 for all previous deficiencies cited on 5/11/23. The facility is in compliance with all deficiencies that were cited.

A revisit survey was completed on 2/12/24 for all previous deficiencies cited on 5/11/23. The facility is in compliance with all deficiencies that were cited.

A licensure complaint, prompted by #CO31893 was completed on 5/11/23. Deficiencies were cited.

Based on interview and record review, the residence failed to provide, upon request, residence documents, staff information and other records as requested by the department, affecting five of five sample residents (#14, #24, #27, #29, #30). Findings include:1. Referencea. Chapter VII regulations governing assisted living residences, part 6.8, requires that the administrator shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to: (I) Completing, maintaining, and submitting all reports and records required by the Department. 2. Record reviewOn 5/11/23 at 7:00 a.m., a current resident roster and staff list with phone numbers was requested. On 5/11/23 at 7:10 a.m., a resident roster was provided, however, it was not up-to-date with all current residents and did not contain the required elements. On 5/11/23 at 8:00 a.m., original documented requests were re-requested to the health and wellness director (HWD) and business office coordinator (BOC). On 5/11/23 at 8:15 a.m., the residence's medication policies, resident agreement, last 90 days of investigations and last three medication audits were requested. The staff list with phone numbers and current resident roster were re-requested. On 5/11/23 at 8:15 a.m., the BOC stated that she would attempt to fulfill requests and get surveyors electronic access. However, the electronic access was unable to be fulfilled on the department issued computers rendering it un-retrievable by the department. On 5/11/23 at 9:34 a.m., the complete resident records for Residents #14, #24, #27, #29 and #30, all April and May 2023 medication administration records (MARS) practitioner orders and infection prevention training was requested. A resident roster with all required elements, and a staff list with phone numbers were requested a third time. On 5/11/23 at 9:55 a.m., almost three hours after the original request, an up-to-date resident roster and a staff list with phone numbers was provided. On 5/11/23 at 10:34 a.m., the administrator provided care plans dated the day of the onsite investigation, progress notes, MARS and practitioner orders in a physical record for sample residents #14, #24, #27, #29, #30 and provided the requested policies except for the medication administration policies, medication audits, all resident care plans, and resident assessments. On 5/11/23 at 11:47 a.m., over three hours after first requested, investigations in the past 90 days were provided, and infection prevention training was provided. The administrator requested elaboration from the surveyors on what medication policies were required. On 5/11/23 at 11:57 a.m., almost three hours after first requested, assessments were provided for all sample residents except Resident #24, medication audits were provided and additional care plans were provided except for Resident #24. On 5/11/23 at 12:22 p.m., four hours after first requested, medication policies were provided. On 5/11/23 at 2:50 p.m., the care plan and assessments were re-requested for Resident #24 since the ones provided were of a different resident with the same last name. On 5/11/23 at 4:13 p.m., over an hour after requested again since provided for the wrong resident although request was specifically for Resident #24 at 8:15 a.m., the assessments and care plans for Resident #24 was provided. On 5/11/23 at 5:23 p.m., the administrator stated he was aware of the regulation to provide information timely and stated that since he had come into the residence after 8:00 a.m., he had staff printing off documentation. The administrator stated that everyone made mistakes and thought that he had provided all documentation timely.

Based on record review and interview, the residence failed to comply with occurrence reporting required by state law, affecting one sample resident (#30). Findings include:1. References a. According to the Occurrence Reporting Manual, dated May 2018, "Any time that a resident or patient of the facility cannot be located following a search of the facility, the facility grounds, and the area surrounding the facility and there are circumstances that place the resident's health, safety or welfare at risk or, regardless of whether such circumstances exist, the patient or resident has been missing for eight hours." Section 25-1-124 (2)(c), C.R.S.b. Chapter VII regulations governing assisted living residences, defines an at risk adult as any person who was 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), C.R.S.;(F) Is mentally impaired as defined in Section 24-34-501(1.3)(b)(II), C.R.S.;2. Resident #30 was admitted to the residence and secure environment on 4/16/23, with a diagnosis of Alzheimer's Disease. A progress note, dated 4/16/23, read that Resident (#30) had arrived to the residence with his family member who stayed in his room, and Resident #30 came out and asked a new staff member to let him out and they did. Resident #30 walked to his family member's house which was 20 minutes from the residence, stopped at a restaurant to eat lunch and went to his family member's house. The health and wellness coordinator (HWC) telephoned the family member for Resident #30 and explained that a staff member did not know Resident #30 was a new resident and let him out of the secure environment. The family member telephoned the HWC back to inform him that Resident #30 was in their yard. The family member for Resident #30 subsequently took him back to the residence. A one on one staff member was assigned to the resident and photo was posted of Resident #30 to introduce to each staff member. Resident #30 was oriented to people and place but not time. Staff member that let Resident #30 out had been educated. On 5/11/23 at approximately 2:20 p.m., a review of the department's database revealed the residence failed to report a missing person to the department as an occurrence. An email from the occurrence reporting staff at the department, dated 5/11/23, read the residence was required to submit an occurrence report as the missing person incident involved an at risk adult. 3. InterviewsOn 5/11/23 at 5:05 p.m., the administrator stated that he was not aware that Resident #30 was a resident and the family member brought him back. The administrator acknowledged the potential for adverse outcomes from Resident #30 getting out of the secured environment and agree it warranted an occurrence report. On 5/11/23 at 7:20 p.m., Resident #30's family member stated that Resident #30 when Resident #30 was first admitted to the residence a staff member who did not know Resident #30 accidentally let him out of the the secure environment since they thought he was a visitor and not a resident. Resident #30's family member stated that Resident #30 was out for about an hour and stopped at a restaurant for lunch and then wandered back to Resident #30's house where she then ended up finding him.

Based on record review and interview, the residence failed to ensure the administrator complied with all applicable state and local laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 66 current residents. Findings include:The COVID-19 Mitigation and Outbreak Guidance for Assisted Living Residences and Group Homes for Residents with Intellectual and Developmental Disabilities, dated 2/22/23, required residences to: -Ensure timely and accurate reporting of all EMResource reporting requirements. Reporting should occur once during each bi-monthly reporting period (period one, defined as days 1-14 of each month) and (period two, defined as days 15-31 of each month). Multiple reports within the same reporting period will overwrite previous reporting and does not meet requirements for future reporting periods. The residence's resident roster read the residence had 66 current residents. On 5/11/23 at 2:00 p.m., a review of the residence's EMResource details revealed the last date the residence reported updated information was 4/17/23, the last update to the number of residents being on 12/5/22, which read that there were 60 current residents. Therefore, EMResource was not updated bi-monthly, or to reflect the residence's 66 current residents. On 5/11/23 at 5:05 p.m., the administrator acknowledged that he was aware he had to update EMResource bi-monthly and to reflect any changes in census and stated that he updated today after it was brought to his attention that it was not up to date to reflect there were now 66 residents.

Based on record review and interview, the residence failed to ensure a comprehensive assessment was updated for residents whenever residents' condition changed from baseline status, affecting two of five sample residents (#24 and #27). (Cross-reference Q1150, and Q2130). Findings include:1. Residence Policy The residence's Fall Management Policy, dated 2. Resident #24 was admitted to the residence on 3/24/20, with diagnoses including muscle weakness, repeated falls, and unspecified displaced fracture. A progress note dated 4/27/23 read that Resident #24 was sent out to the hospital for a fall and had a headache and laceration. An emergency department discharge summary dated 4/28/23 read that Resident #24 was discharged with a contusion and hematoma over the right frontal scalp from a fall. An assessment dated 12/28/22, read in part that Resident #24 had a history of falls with injury and required the use of a walker and a wheelchair. However, the assessment was not updated after Resident #24 was discharged from the hospital with injury on 4/28/23, from a fall that occurred on 4/27/23. On 5/11/23 at 5:05 p.m., the District Director of Clinical Services stated that Resident #24 was assessed after her fall on 4/27/23 and the residence did not document it as required. 3. Resident #27 was admitted to the residence on 12/17/19, with diagnoses including primary hypertension, hyperlipidemia and hyperglycemia. On 1/10/23 a hospital discharge note read that Resident #27 was admitted with acute chest pain. A hospital discharge summary, dated 2/17/23, read that Resident #27 was admitted with "slurred speech, dysarthria and ataxia was noted- was admitted to the hospital with a diagnosis of cerebrovascular accident unspecified- likely chronic right thalamic stroke."An assessment dated 12/18/22 and updated 5/11/23 (the day of the onsite investigation) revealed no evidence it was updated to reflect the change of condition Resident #27 experienced after his hospitalization on 2/17/23. On 5/11/23 at 1:27 p.m., the administrator stated that Resident #27 has had a decline over several months with the first where Resident #27 had increased anxiety and on 1/10/23 when he was admitted for acute chest pain. The administrator stated that the largest decline in the last week where Resident #27 was admitted into hospice with a diagnosis of kidney failure. The administrator stated that he would consider Resident #27 to have experienced a change in condition and stated he should have been reassessed after his hospitalization on 2/17/23. In a second interview on 5/11/23 at approximately 2:00 p.m., the administrator stated that comprehensive assessments were completed by the health and wellness coordinator. On 5/11/23 at 5:05 p.m., the administrator stated assessments should have been updated after a change in condition.

Based on observation, record review and interview, the residence failed to ensure each residents' care plan identified all external service providers and care coordination, promoted residence choice, mobility, independence and safety, and detailed specific personal service needs and preferences along with staff tasks necessary to meet those needs, affecting three of five sample residents (#24, #27, and #29). (Cross-reference Q1160, Q1468 and Q2130) 1. Residence PolicyThe residence's Change in Condition Policy, updated February 2021, read in part: "any change in condition should be evaluated and documented for residents who exhibit deviation in physician or mental status ... and update the resident record and service plan as needed."2. Resident #27 was admitted to the residence on 12/17/19, with diagnoses including Alzheimer's Disease, cerebral vascular disease primary hypertension, hyperlipidemia and hyperglycemia. On 5/11/23 at approximately 12:50 p.m., the administrator stated that Resident #27 was admitted to hospice due to kidney failure. In a second interview on 5/11/23 at 1:27 p.m., the administrator stated that Resident #27 has had a decline over several months with the first where Resident #27 had increased anxiety and on 1/10/23 when he was admitted for acute chest pain. He stated Resident #27 recently had become very confused. The administrator stated that the largest decline was when the resident was admitted to external hospice with a diagnosis of kidney failure. The administrator stated that he would consider Resident #27 to have experienced a change in condition and stated he should have had his care plan updated to reflect his hospitalization on 2/17/23. The record for Resident #27 revealed the following:A hospital discharge summary, dated 2/17/23, read Resident #27 was admitted with "slurred speech, dysarthria and ataxia was noted- was admitted to the hospital with a diagnosis of cerebrovascular accident unspecified- likely chronic right thalamic stroke."A progress note, dated 5/8/23, read in part: Resident #27 was in bed, unshaven and incontinent of urine. The resident's dog had not been taken out and had defecated an urinated on the floor. Staff assisted the resident with setting up a shower, very confused today, clothes stung all over the room and the dog blankets were soaked in urine. A care plan dated 12/18/22 and updated 5/11/23 (the day of the onsite investigation) read in part: Resident had occasional incontinence that was self managed, used a cane to ambulate, was oriented to person, place and time, required reminders to let his dog out to the bathroom, had a history of refusing showers. However, the care plan was not updated after the resident experienced a change of condition after his hospitalization on 2/17/23 until the day of the onsite investigation 5/11/23 to include external hospice and staff taking the resident's dog to the bathroom. Additionally, after the update the care plan failed to address the hospitalization in February 2023 and include staff tasks necessary to meet the residents needs when he was resistant to bathing, had anxiety, when he became confused or tasks related to his new diagnosis of kidney failure. 3. Resident #24 was admitted to the residence on 3/24/20, with diagnoses including muscle weakness, repeated falls, and unspecified displaced fracture. A progress note dated 4/27/23 read that Resident #24 was sent out to the hospital for a fall and had a headache and laceration. An emergency department discharge summary dated 4/28/23 read that Resident #24 was discharged with a contusion and hematoma over the right frontal scalp from a fall. An care plan dated 12/28/22, read in part that Resident #24 had a history of falls with injury and required the use of a walker and a wheelchair, however, it was not updated after Resident #24's fall with injury on 4/27/23 to include staff tasks necessary to meet his needs. 4. Resident #29 was admitted to the residence on 3/27/23 with diagnoses including anemia, hypothyroidism, nausea, constipation and vitamin d deficiency. On 5/11/23 at 8:30 a.m., breakfast was brought to the room for Resident #29. A progress note dated 3/27/23 read Resident #29 arrived at the residence in a bus wearing a bledsoe brace on the left foot, unable to bend knee due to pain. A care plan for Resident #29, dated 4/24/23, read that Resident #29 required assistance to and from dining rooms for meals, and required transfer assistance. However the care plan did not include Resident #29's preferences to receive meals in her room requiring staff to bring her meals and did not mention that she required three person assistance with transfers out of the bed. On 5/11/23 at 7:14 a.m., Staff #20 stated that Resident #29 required two staff members on each side and one staff member by her leg that she had broken before admission to the residence to get out of bed, for a total of three person transfer assistance. Staff #20 stated that Resident #29 did not like to get out of her bed and preferred meals to be brought to her room. On 5/11/23 at 8:30 a.m., Staff #10 stated that Resident #29 required at least two person assistance with transfers, however, preferred to receive her meals in her room and refused to get out of bed most days. On 5/11/23 at 5:03 p.m., the administrator acknowledged that Resident #29's preferences to eat meals in her bed and for staff to provide that service to her as well as details on her transfer status should be included the care plan for Resident #29. On 5/11/23 at 2:30 p.m., the health and wellness director stated that she would consider hospitalizations a change in condition that require an update to the care plan. On 5/11/23 at 5:05 p.m., the administrator stated that care plans should have been updated after a change in condition.

Based on record review and interview the residence failed to coordinate care with known external service providers affecting two of two sample residents (#27 and #29). (Cross-reference Q1468, Q1430, Q1146, and Q1150). Findings include:1. References and Residence Policya. Chapter VII regulations governing assisted living residence defines, in part 2.21, "External services" means 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.b. The residence's Resident Agreement dated September 2018, read in part: "... (the residence) will assist in evaluating each resident's needs and planning and implementing an appropriate plan for care."c. The residence's Evaluation Process Policy, updated January 2019 read in part: "residents should be evaluated to determine the level of care and services needed or requested utilizing various systems and processes (e.g. personal services system, software programs, etc.) including resident specific physician/healthcare provider orders. The evaluation will be used to determine the price for needed care and services or other requests by the resident and family/responsible party."2. Resident #29 was admitted to the residence on 3/27/23 with diagnoses including anemia, hypothyroidism, nausea, constipation and vitamin d deficiency. The residence's face sheet for Resident #29 read that Resident #29's former provider and the residence's pharmacy provided medications. On 5/11/23 at 7:14 a.m., Staff #20 stated that Resident #29 had no practitioner that had come to evaluate Resident #29 since she was admitted and her medications had not been filled. On 5/11/23 at 8:30 a.m., Staff #10 stated that the Health and Wellness Coordinator assessed Resident #29 to move into the residence without her medication. On 5/11/23 at 12:27 p.m., Resident #29's listed practitioner on her face sheet stated that she was discharged from her care on 3/27/23, and had not provided medication orders since Resident #29 resided at the previous residence in March 2023. The listed practitioner stated that the residence had never reached out to get new medication orders. On 5/11/23 at 12:41 p.m., a representative from residence's pharmacy listed on Resident #29's face sheet, stated that they did not fill Resident #29's medication and never have. On 5/11/23 at 12:45 p.m., contrary to what the pharmacy representative and former practitioner for Resident #29 stated, the administrator stated that Resident #29 was still under her former practitioner's care company and had reached out a number of times to get Resident #29's medication. The administrator stated that Resident #29's former practitioner had not let the residence know that they discharged Resident #29 from their care, and had assumed her provider would transfer from the previous residence. On 5/11/23 at 1:22 p.m., Contrary to what the administrator stated, Resident #29's former practitioner stated that the residence reached out to her office for the first time the day of the onsite investigation on 5/11/23 about the medication orders. Resident #29's former practitioner stated that Resident #29 would have been able to start care with another one of the practitioner's at the practitioner's office; however, no one from the residence had ever reached out to have her seen until the day of the onsite investigation. Resident #29's former practitioner further stated that her not getting the above medications was not life-threatening, however, would expect the residence to provide the resident with her medications. On 5/11/23 at 5:05 p.m., the administrator stated that the residence had attempted to fill Resident #29's medications and reached out to her former practitioner the day of the onsite visit and recommended to them that they follow their patient when admitted to a new residence. The administrator stated he had reached out to Resident #29's former practitioner's office prior to the day of the onsite investigation. 3. Resident #27 was admitted to the residence on 12/17/19, with diagnoses including primary hypertension, hyperlipidemia and hyperglycemia. A hospital discharge summary, dated 2/17/23, read that Resident #27 was admitted with "slurred speech, dysarthria and ataxia was noted and was admitted to the hospital with a diagnosis of cerebrovascular accident unspecified and likely chronic right thalamic stroke." The discharge summary recommended facility based rehab of one to two hours of therapy daily. However, there was no evidence of external service therapy provider in Resident #27's record. On 5/11/23 at 2:30 p.m., the health and wellness director stated Resident #27 did not receive in house rehabilitation after his hospitalization on 2/17/23, and stated that she should have gone through his hospitalization notes better. On 5/11/23 at 5:05 p.m., the administrator acknowledged he was aware of the regulation to coordinate care and acknowledged he should have done more for Resident #27 and Resident #29 to ensure they did not go without services.

Based on observation, record review and interview, the residence failed to ensure that only medication ordered by an authorized practitioner was prepared for or administered to residents, affecting three of four sample residents (#24, #27, and #30). (Cross-reference Q1468 and Q1160)Findings include: 1. Residence Policya. The residence's Medication Administration policy, updated March 2023, read in part: "medications and treatments should be administered within the parameters of the physician (practitioner) orders."2. Resident #27 was admitted to the residence on 12/17/19, with diagnoses including primary hypertension, hyperlipidemia and hyperglycemia. The residence's April and May 2023 medication administration records (MARs) for Resident #27, read the following medication had been administered in which there was no evidence of a written practitioner's order:Mirtazapine 7.5 mg once daily: administered on 4/1-4/25/23. Sertraline 100 mg once daily: administered on 4/1-4/25/23. Levothyroxine 75 mcg once daily: administered on 4/1-4/3 and 4/9/23. Amlodapine besylate 10 mg once daily: administered on 4/1/23. Aspirin 81 mg once daily: administered on 4/1/23. On 5/11/23 at 2:30 p.m., the health and wellness director (HWD) stated that all Resident #27's medications were ordered by qualified medication administration personnel (QMAPS) through his external provider. The HWD stated that whenever new orders came in they would add and remove the old orders, which she thought had occurred for Resident #27's medications. 3. Resident #30 was admitted to the residence on 4/16/23, with a diagnosis of Alzheimer's Disease. The residence's April and May 2023 MARs for Resident #30, read the following medication had been administered in which there was no evidence of written practitioner's orders:Triamcinolone acetonide 0.1% twice daily: administered on 5/1/23 both doses, 5/2-5/10/23 in the evening. 4. Resident #24 was admitted to the residence on 3/24/20, with a diagnosis of muscle weakness. On 5/11/23 at 3:00 p.m., calmoseptine ointment 0.44-20.6% was observed in the medication cart for Resident #24. On 5/11/23 at 4:10 p.m., Resident #24's calmoseptine order was requested and never provided. The residence's April and May 2023 MARs for Resident #24, read the following medication had been administered in there was no evidence of written practitioner's orders:Calmoseptine ointment 0.44-20.6% twice daily: administered on 4/1-4/7/23 in the evening, 4/9-4/10/23 both morning and evening doses, 4/11-4/13 in the evening, 4/16-4/17/23 both doses, 4/18/23 in the evening and 5/6-5/10/23 in the evening. On 5/11/23 at 5:10 p.m., the HWD stated that she had reached out to the external provider for Resident #24's calmoseptine ointment order since she was unable to find it. The HWD acknowledged that calmoseptine should not have been administered without a practitioner's order. On 5/11/23 at approximately 5:10 p.m., the administrator acknowledged that he was aware there needed to be a practitioner's order for all medications prior to administration. On 5/11/23 at 5:10 p.m., the HWD stated that there should have been an order for all medications prior to administration.

Based on observation, interview, and record review, the residence failed to comply with authorized practitioner orders associated with medication administration affecting four of four sample residents (#24, #27, #29, #30). (Cross-reference Q1160, and Q1430). 1. Residence PolicyThe residence's medication administration policy, updated March 2023, read in part: "medications and treatments should be administered within the parameters of the physician (practitioner) orders."The residence's Medication and Treatment Policy, updated August 2022, read in part: "explanations of medications not given should be documented, otherwise medications on the electronic medication administration record (eMAR) should be marked as administered."2. Resident #27 was admitted to the residence on 12/17/19, with diagnoses including primary hypertension, hyperlipidemia and hyperglycemia. On 5/11/23 at 3:09 p.m., a medication cart audit was conducted and revealed that amlodipine, aspirin, debrox solution, docusate sodium, magnesium and levothyroxine were not in stock.a. Docusate Sodium A written practitioner's order, dated 4/26/23, directed the residence to administer docusate sodium 100 mg once daily. However, the April and May 2023 eMARs read that the residence failed to administer docusate sodium on 4/27-5/11/23, and read to see progress notes and there was no explanation, for a total of fifteen missed doses. b. Amlodipine A written practitioner's order, dated 4/26/23, directed the residence to administer amlodipine besylate 10 mg once daily. However, the April and May 2023 eMARs read that the residence failed to administer amlodipine on 4/27-5/11/23, and read to see progress notes and there was no explanation, for a total of fifteen missed doses. c. Aspirin A written practitioner's order, dated 4/26/23, directed the residence to administer aspirin 81 mg once daily. However, the April and May 2023 eMARs read that the residence failed to administer amlodipine on 4/27-5/11/23, and read to see progress notes and there was no explanation, for a total of fifteen missed doses. d. LorazepamA written practitioner's order, dated 4/26/23, directed the residence to administer lorazepam 0.5 mg every eight hours. However, the April and May 2023 eMARs read the medication had not been administered due to not being transcribed on the eMARs from 4/27-5/11/23, for a total of fifteen missed doses. e. Potassium Chloride 20 mgA written practitioner's order, dated 4/26/23, directed the residence to administer potassium chloride 20 meq once daily. However, the April and May 2023 eMARs read the medication had not been administered 4/27-5/11/23 and read see progress notes and there was no explanation, for a total of fifteen missed doses. f. SertralineWritten practitioner's orders, dated 4/26/23, and 5/3/23, directed the residence to administer sertraline 100 mg once daily. However, the April and May 2023 eMARs read the residence failed to administer sertraline due to it being taken off the eMAR without a discontinue order on 4/27-5/11/23, for a total of fourteen missed doses. g. LevothyroxineA written practitioner's order, dated 4/26/23, directed the residence to administer levothyroxine 75 mcg once daily. However, the April and May 2023 eMARs read that the residence failed to administer levothyroxine on 4/27-5/7/23 and 5/9-5/11/23 and read pharmacy action required, for a total of fourteen missed doses. h. Potassium Chloride 40 mgA written practitioner's order, dated 5/3/23, directed the residence to administer potassium chloride 40 meq twice daily. However, the May 2023 eMAR read 20 meq instead of 40 meq twice daily was administered from 5/4/23 in the evening through 5/11/23 in the morning, for a total of fourteen missed doses.i. Magnesium A written practitioner's order, dated 5/3/23, directed the residence to administer magnesium 30 mg once daily. However, the May 2023 eMAR read the medication had not been administered from 5/3-5/10 and on 5/9/23 read see progress notes andthere was no explanation, for a total of eight missed doses. On 5/11/23 at 2:30 p.m., the HWD stated that she had an order to stop Resident #27's sertraline and was not sure where it was. The HWD stated that she would have expected the residence to administer all of Resident #27's medications in compliance with practitioner's orders. On 5/11/23 at 3:07 p.m., the resident care coordinator stated that she followed the eMAR and even though Resident #27's sertraline was in the medication cart, since it was not on the eMAR she had not been administering it. On 5/11/23 at 3:47 p.m., the practitioner for Resident #27 stated that she was not aware that Resident #27 had missed the above medications and would have expected to have been notified by the residence of the missed medications. On 5/11/23 at 5:05 p.m., the administrator stated the health and wellness coordinator (HWC) was responsible for transcribing medications on the eMAR. The administrator stated that Resident #27 should have been administered his potassium chloride as ordered which was 40 meq twice daily. The administrator further acknowledged that he should have been getting two doses of 20 mg if the medication was sent by the pharmacy in 20 mg doses and acknowledged there was an error when it was transcribed onto the eMAR.3. Resident #29 was admitted to the residence on 3/27/23 with diagnoses including anemia, hypothyroidism, nausea, constipation and vitamin d deficiency. On 5/11/23 at 7:40 a.m., Staff #20 only administered Resident #29's Tylenol.a. Ascorbic acidA written practitioner's order, dated 3/17/23 directed the residence to administer ascorbic acid 500 mg twice daily. However, the April and May 2023 eMARs read that the residence failed to administer ascorbic acid 4/1-5/10/23 both doses, on 4/7, 4/8 and 5/11/23 in the morning the eMARs read to see progress notes and there was no explanation, for a total of eighty-one missed doses.b. Pantoprozole sodium A written practitioner's order, dated 3/17/23 directed the residence to administer pantoprazole sodium 20 mg once daily. However, the April and May 2023 eMARs read that the residence failed to administer pantoprazole sodium 4/1-5/11/23, and on 4/7 and 4/8/23 the eMAR read to see progress notes and there was no explanation, for a total of forty-one missed doses. c. BoronA written practitioner's order, dated 3/17/23 directed the residence to administer two tablets of boron 3 mg once daily. However, the April and May 2023 eMARs read that the residence failed to administer boron 4/8-5/11/23, and on 4/8/23 the eMAR read to see progress notes and there was no explanation, for a total of thirty-four missed doses. d. TylenolA written practitioner's order, dated 3/17/23 directed the residence to administer two tablets of Tylenol 500 mg three times daily. However, the April and May 2023 eMARs read that the residence failed to administer Tylenol for the night time dose on 4/7/23, and 4/24-4/25/23 for a total of 3 missed doses. On 5/11/23 at 7:20 a.m., Staff #20 stated that Resident #29 was admitted to the residence with only her Tylenol and boron in stock. However, the residence ran out of boron and the pharmacy would not send refills of any of Resident #29's other medications. On 5/11/23 at 12:27 p.m., Resident #29's listed provider on her face sheet stated she had not provided medication orders since Resident #29 resided at the previous residence in March 2023. The listed provider stated that the residence had never reached out to refill prescriptions. On 5/11/23 at 12:41 p.m., a representative from residence's pharmacy listed on Resident #29's face sheet, stated that they did not fill Resident #29's medication and never have. On 5/11/23 at 12:45 p.m., the administrator stated that he had assumed Resident #29's provider would transfer from the previous residence. The administrator stated they were working on getting discontinue orders for all of Resident #29's medications except her Tylenol, which was the only medication she was administered and did not refuse. On 5/11/23 at 1:22 p.m., Resident #29's former practitioner stated that he would expect the residence to be providing Resident #29 with her prescribed medications. 4. Resident #24 was admitted to the residence on 3/24/20, with a diagnosis of muscle weakness. On 5/11/23 at 3:08 p.m., a medication cart audit was conducted and revealed that Resident #24's escitalopram was not in the cart. a. EscitalopramA written practitioner's order, dated 7/19/22 directed the residence to administer escitalopram oxalate 10 mg once daily. However, the April and May 2023 eMARs read the medication was not administered and to see progress notes with no explanation provided on 4/1-4/8, 4/10-4/16, 4/18-5/7, and 5/9-5/11/23, for a total of thirty-eight missed doses. b. Aspercreme LidocaineA written practitioner's order, dated 7/19/22 directed the residence to administer aspercreme lidocaine 4% once daily. However, the April 2023 eMAR read the medication was not administered and to see progress notes with no explanation provided on 4/4/23 in the evening, and 4/17-4/18/23 in the evening, for a total of three missed doses. On 5/11/23 at 5:10 p.m., the health and wellness director (HWD) stated although there were times Resident #24 refused her medication, the residence should have ensured all her medications were in stock and complied with practitioner's orders. There will be times they refuse but yes should have complied with orders. 5. Resident #30 was admitted to the residence on 4/16/23, with a diagnosis of Alzheimer's Disease. On 5/11/23 at 3:09 p.m., a medication audit of Resident #30's medication revealed that aripiprazole and multivitamin were not in stock.a. Multivitamin A written practitioner's order, dated 3/9/23 directed the residence to administer multivitamin once daily. However, the April and May 2023 eMARs read the medication was not administered from 4/17-5/11/23, for a total of twenty-six missed doses.b. AripiprazoleA written practitioner's order, dated 3/9/23 directed the residence to administer aripiprazole 4 mg once at bedtime. However, the May 2023 eMAR read see progress notes on 5/8- 5/10/23 without an explanation, for a total of three missed doses. On 5/11/23 at 4:12 p.m., the practitioner for Resident #30 stated they had not been notified of his missed medications and expected to have been. 6. InterviewsOn 5/11/23 at 8:30 a.m., Staff #10 stated that she was responsible for ordering medications before they ran out of stock. On 5/11/23 at 2:29 p.m., the administrator said if there were no progress notes, a medication was not administered. The administrator stated that he would expect staff to put an exception code for pharmacy action required which meant medications were not administered, for all out of stock medications. On 5/11/23 at 2:30 p.m., the HWD stated that she would expect there to be corresponding progress notes for the medications that had a code to see progress notes and did not have an explanation, and if there was no progress note the medication was not administered. The HWD stated she also needed to educate the HWC on not taking medications off the eMARs without discontinue orders and on transcribing medications onto the eMAR. The HWD stated that all medications that were not in stock were not administered. On 5/11/23 at 3:07 p.m., the residential care coordinator stated that when it said to see progress notes on the eMAR meant that a medication was out of stock. On 5/11/23 at 5:10 p.m., the administrator acknowledged that he would expect the residence to comply with practitioner's orders, and stated that the RCCs and qualified medication administration persons were responsible for ordering medication, and the HWC was responsible for transcribing medications onto the eMAR.

Based on record review and interview, the residence failed to ensure the administrator and the qualified medication administration supervisor (QMAP) conducted quarterly audits of medication administration records, controlled substance lists, medication error reports, and medication disposal records for completeness and accuracy, affecting five of five sample residents (#14, #24, #27, #29-#30). Findings include:1. Residence PolicyThe residence's Medication Audit Policy, dated April 2022, read that "medication administration records (MARs) change of shift audits should be completed for each shift or during the change of each shift. The MAR audit is defined as verifying that all medications are administered or signed-off during the current shift as per physician/healthcare provider order. A 'yes' or 'no' is recorded in the MAR audit column of the Controlled Substance/MAR change of shift audit form." However, the policy did not reflect the regulation that quarterly audits must be completed with the administrator and QMAP supervisor and did not address medication error reports and disposal records, and did not mention that all irregularities must be investigated and resolved. 2. Record ReviewOn 5/11/23 at 8:15 a.m. the residence's quarterly medication audits which included audits of medication administration records', controlled substance lists, medication error reports, and medication disposal records were requested. On 5/11/23 at 12:07 p.m., medication audits were provided dated 5/2/23 to present revealed the form focused on four areas of the medication program-Medication administration records (MARS), controlled substances, medication disposal and cart audit. Specifically, the section of the audit related to MARs read the following areas were audited to ensure the accurateness and completeness of the MARs:Med carts locked when unattended;Med binder is secured when unattended;Associates administering medications have signed off on eMAR;Medication disposal policy is available;Individual resident medications are labeled by the pharmacy. However, the audit tool provided revealed no evidence of an audit completed to ensure the accuracy of the MARs in regards to the written practitioner's orders in relation to what was transcribed on the MARs and when the medications were administered, and revealed they were only conducted by the Residential Care Coordinator (RCC) and not by the administrator. On 5/11/23 at 12:07 p.m., the Health and Wellness Director (HWD) stated that the administrator did not participate in medication audits, and they were only done by clinical staff. The HWD stated that she had lost previous audits and only had two audits from May 2023. On 5/11/23 at 5:05 p.m., the administrator stated that he did not do medication audits so he was not sure how to ensure that MARs were accurate with the orders. The administrator acknowledged that he was not aware he had to participate in medication audits.

Based on record review and interview, the residence failed to ensure resident records contained progress notes regarding any out-of-the-ordinary event or issue 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, affecting three of five sample residents (#24, #27, and #29). (Cross-reference Q1146 and Q1150). Findings include:1. Residence PolicyThe residence's Change in Condition Policy, updated February 2021, read in part: "any change in condition should be evaluated and documented for residents who exhibit deviation in physician or mental status ... and update the resident record as needed."2. Resident #27 was admitted to the residence on 12/17/19, with diagnoses including primary hypertension, hyperlipidemia and hyperglycemia. On 1/10/23 a hospital discharge note read that Resident #27 was admitted with acute chest pain. A hospital discharge summary, dated 2/17/23, read Resident #27 was admitted with "slurred speech, dysarthria and ataxia was noted- was admitted to the hospital with a diagnosis of cerebrovascular accident unspecified- likely chronic right thalamic stroke." On 5/11/23 at approximately 12:50 p.m., the administrator stated that Resident #27 was admitted to hospice and had experienced a decline the week prior to the onsite investigation due to kidney failure. However, there were no progress notes in Resident #27's record that documented a change in his condition and admission to hospice. On 5/11/23 at 2:30 p.m., the HWD stated that she would consider Resident #27's hospitalization on 2/17/23 a change and there should have been a progress note about this as well as his admission to hospice. 3. Resident #24 was admitted to the residence on 3/24/20, with diagnoses including muscle weakness, repeated falls, and unspecified displaced fracture. A progress note dated 4/27/23 read Resident #24 was sent out to the hospital for a fall and had a headache and laceration. A progress note dated 4/28/23 read Resident #24 was due to return the evening of 4/28/23 and a discharge planner was spoken to. An emergency department discharge summary dated 4/28/23 read Resident #24 was discharged with a contusion and hematoma over the right frontal scalp from a fall. However, there were no progress notes of when Resident #24 had come back from the hospital, or progress notes that detailed action taken by staff to address Resident #24's changing needs. On 5/11/23 at 5:23 p.m., the administrator stated that actions taken by staff should have been documented in Resident #24's progress notes. 4. Resident #29 was admitted to the residence on 3/27/23 with diagnoses including anemia, hypothyroidism, nausea, constipation and vitamin d deficiency. A review of Resident #29's record revealed there were no advance directives. On 5/11/23 at 10:20 a.m., Resident #29 stated that she did not wish to receive life saving treatment in the event of an emergency. On 5/11/23 at 5:23 p.m., the administrator stated that he had been unable to get Resident #29 to sign any paperwork, and stated he was not aware if Resident #29 wanted to refuse life saving treatment. On 5/11/23 at 5:23 p.m., the administrator stated there should have been follow-up actions taken by staff in progress notes and stated that he was not aware that out-of-the-ordinary events had to be documented before the end of each shift. The administrator stated that the health and wellness director and health and wellness coordinator were responsible for entering progress notes.

PLEASE NOTE: The Public Health Order 20-20 (PHO) Requirements for Colorado Skilled Nursing Facilities, Assisted Living Residences, Intermediate Care Facilities and Group Homes for COVID-19 Prevention and Response has been discontinued. A revisit to determine compliance with the cited deficiency can no longer be completed.

PLEASE NOTE: The Public Health Order 20-20 (PHO) Requirements for Colorado Skilled Nursing Facilities, Assisted Living Residences, Intermediate Care Facilities and Group Homes for COVID-19 Prevention and Response has been discontinued. A revisit to determine compliance with the cited deficiency can no longer be completed.

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 revisit was completed on 5/11/23 for all previous deficiencies cited on 12/19/22. Deficiences were cited.

Based on record review and interview, the residence failed to ensure the administrator complied with all applicable state and local laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 66 current residents. Findings include:The COVID-19 Mitigation and Outbreak Guidance for Assisted Living Residences and Group Homes for Residents with Intellectual and Developmental Disabilities, dated 2/22/23, required residences to: -Ensure timely and accurate reporting of all EMResource reporting requirements. Reporting should occur once during each bi-monthly reporting period (period one, defined as days 1-14 of each month) and (period two, defined as days 15-31 of each month). Multiple reports within the same reporting period will overwrite previous reporting and does not meet requirements for future reporting periods. The residence's resident roster read the residence had 66 current residents. On 5/11/23 at 2:00 p.m., a review of the residence's EMResource details revealed the last date the residence reported updated information was 4/17/23, the last update to the number of residents being on 12/5/22, which read that there were 60 current residents. Therefore, EMResource was not updated bi-monthly, or to reflect the residence's 66 current residents. On 5/11/23 at 5:05 p.m., the administrator acknowledged that he was aware he had to update EMResource bi-monthly and to reflect any changes in census and stated that he updated today after it was brought to his attention that it was not up to date to reflect there were now 66 residents.

Based on record review and interview, the residence failed to ensure resident records contained progress notes regarding any out-of-the-ordinary event or issue 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, affecting three of five sample residents (#24, #27, and #29). (Cross-reference Q1146 and Q1150). Findings include:1. Residence PolicyThe residence's Change in Condition Policy, updated February 2021, read in part: "any change in condition should be evaluated and documented for residents who exhibit deviation in physician or mental status ... and update the resident record as needed."2. Resident #27 was admitted to the residence on 12/17/19, with diagnoses including primary hypertension, hyperlipidemia and hyperglycemia. On 1/10/23 a hospital discharge note read that Resident #27 was admitted with acute chest pain. A hospital discharge summary, dated 2/17/23, read Resident #27 was admitted with "slurred speech, dysarthria and ataxia was noted- was admitted to the hospital with a diagnosis of cerebrovascular accident unspecified- likely chronic right thalamic stroke." On 5/11/23 at approximately 12:50 p.m., the administrator stated that Resident #27 was admitted to hospice and had experienced a decline the week prior to the onsite investigation due to kidney failure. However, there were no progress notes in Resident #27's record that documented a change in his condition and admission to hospice. On 5/11/23 at 2:30 p.m., the HWD stated that she would consider Resident #27's hospitalization on 2/17/23 a change and there should have been a progress note about this as well as his admission to hospice. 3. Resident #24 was admitted to the residence on 3/24/20, with diagnoses including muscle weakness, repeated falls, and unspecified displaced fracture. A progress note dated 4/27/23 read Resident #24 was sent out to the hospital for a fall and had a headache and laceration. A progress note dated 4/28/23 read Resident #24 was due to return the evening of 4/28/23 and a discharge planner was spoken to. An emergency department discharge summary dated 4/28/23 read Resident #24 was discharged with a contusion and hematoma over the right frontal scalp from a fall. However, there were no progress notes of when Resident #24 had come back from the hospital, or progress notes that detailed action taken by staff to address Resident #24's changing needs. On 5/11/23 at 5:23 p.m., the administrator stated that actions taken by staff should have been documented in Resident #24's progress notes. 4. Resident #29 was admitted to the residence on 3/27/23 with diagnoses including anemia, hypothyroidism, nausea, constipation and vitamin d deficiency. A review of Resident #29's record revealed there were no advance directives. On 5/11/23 at 10:20 a.m., Resident #29 stated that she did not wish to receive life saving treatment in the event of an emergency. On 5/11/23 at 5:23 p.m., the administrator stated that he had been unable to get Resident #29 to sign any paperwork, and stated he was not aware if Resident #29 wanted to refuse life saving treatment. On 5/11/23 at 5:23 p.m., the administrator stated there should have been follow-up actions taken by staff in progress notes and stated that he was not aware that out-of-the-ordinary events had to be documented before the end of each shift. The administrator stated that the health and wellness director and health and wellness coordinator were responsible for entering progress notes.