FLORENCE CARE HOME

A relicensure survey with complaint #CO40497 and #CO40842 was completed on 9/10/25. Deficiencies were cited.

Based on interview and record review, the residence failed to ensure the administrator completed the 40 hours of administrator training before assuming an administrator position within 30 days of appointment as required, affecting 10 current residents. Findings include: On 9/9/25 at 9:15 a.m., the 40-hour administrator training certification was requested. However, the administrator training certification provided her nursing home administrator (NHA) license and a 10-hour bridge course. On 9/9/25 at 9:26 a.m., the administrator stated she had her NHA so she did not take the 40 hour certification training. On 9/10/25 at approximately 4:30 p.m., the administrator confirmed that she only had her NHA and a 10-hour bridge certification course. She continued to say that she believed that since her NHA was a more extensive training, she only needed to take the 10-hour bridge course since she had learned so many regulations for the NHA licensure. She also mentioned being upset since she was not informed that all administrators were required to take the 40-hour administration certification courses.

Based on record review and interview, the residence failed to update resident's comprehensive assessment whenever the resident's baseline status changed, affecting one of three sample residents (#2). Findings include:1. Record ReviewResident #2 was admitted to the residence on 8/3/23 with a diagnosis of generalized muscle weakness. An incident report dated 8/13/25 read that Resident #2 fell during a transfer to his wheelchair and 'claimed' to hit his head. An external service unit was dispatched, and he was not taken to the hospital. An initial assessment, dated 3/28/25, and a bowel assessment, dated 5/6/25, were provided; no other assessments were provided for Resident #2 when requested. 2. InterviewsOn 9/10/25 at 1:02 p.m., the administrator stated that Resident #2 did not have any previous falls and confirmed the fall was new for him. She stated she had not completed an updated assessment for him after his fall. The administrator mentioned that the fall was new to him several times during the interview and agreed the residence should have done a reassessment for him since falls were new and that was a change in baseline for him. On 9/10/25 at 1:47 p.m., the registered nurse (RN) stated that it was rare for Resident #2 to fall and acknowledged it to be new but was unaware if a reassessment was done or not for him.

Based on record review and interview, the residence failed to comply with authorized practitioner's ordersassociated with medication administration except for those medications which a resident self-administers, affecting one (#1) of three sample residents. Resident #1 admitted to the residence on 31/11/23 with a diagnosis including hemoplagia, hypertension, myocardial infarction and cardiomegaly. A written practitioner's order, initially dated 8/6/25, directed the residence to discontinue lisinopril 40mg. Updated orders sent on 8/6/25, directed the residence to start administering lisinopril 5mg once daily for Resident #1's hypertension. However, the August 2025 medication administration records (MAR) showed the medication was no longer on the electronic medication record (MAR), therefore, the medication was not given from 8/8/25 to 8/12/25. An external pharmacy medication delivery form read Resident #1's 5 mg lisinopril was delivered to the residence on 8/8/25. On 9/10/25 at 3:09 p.m., the administrator stated she was unaware why the medication was no longer on the electronic MAR and stated that the residence had switched pharmacies and thought that may have been the reason the medication was not on the MAR.On 9/10/25 at approximately 3:45 p.m., the registered nurse (RN) said an external pharmacy delivered the medication on 8/8/25 and depending on when the medication was "checked in" the medication should have been administered. On 9/10/25 at approximately 3:50 p.m., the administrator called the electronic database provider and found that the pharmacy failed to follow the residence's agreed-upon procedure when medication was delivered. The administrator stated that when the pharmacy dropped off the medication, the pharmacy was supposed to send a "check-in" note to the electronic database so that the residence could click it and the orders, medication, and any other pertinent information could be transcribed and automatically added to the electronic MAR. However, she revealed that the pharmacy did not do this. This meant that though the medication was still scheduled to be given daily, the MAR did not add the medication back to the 'pass list' since the residences' "check-in" process was not done. She also said even though the residence had the medication and the practitioner's order, staff would not administer the medication because it would not show up on the electronic MAR.

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 7.9.2. The assisted living residence shall have written policies and procedures regarding the visitation rights detailed in Section 25-3-125(3)(a), C.R.S. Such policies and procedures shall: (A) Set forth the visitation rights of the resident, consistent with 42 CFR 482.13(h); 42 U.S.C. 1396r(c)(3)(C); 42 U.S.C. 1395i(c)(3)(C); 42 CFR483.10(a), (b), and (f); and Section 2527-104, C.R.S., as applicable to the facility type; (B) Describe any restriction or limitation necessary to ensure the health and safety of residents, staff, or visitors and the reasons for such restriction or limitation; (C) Be available for inspection at the request of the Department; (D) Be provided to residents and/or family members upon request; and (E) Include the right of each resident of an assisted living residence to have at least one visitor of the resident ' s choosing during their stay at the residence, unless restrictions or limitations under federal law or regulation, other state statute, or state or local public health order apply. This visitation right shall be exercised in accordance with the following: (1) A visitor to provide a compassionate care visit to alleviate the resident's physical or mental distress. (2) For a resident with a disability: (a) A visitor or support person, designated by the resident, orally or in writing, to support the resident during the course of their residency. The support person may visit the resident and may exercise the resident ' s visitation rights even when the resident is incapacitated or otherwise unable to communicate.(b) When the resident has not otherwise designated a support person and the resident is incapacitated or otherwise unable to communicate their wishes, an individual may provide an advance medical directive designating the individual as the resident ' s support person or another term indicating that the individual is authorized to exercise visitation rights on behalf of the resident. Pursuant to Section 15-18.7-102(2), C.R.S., "(2) ' Advance medical directive ' means a written instruction concerning medical treatment decisions to be made on behalf of the adult who provided the instruction in the event that he or she becomes incapacitated. An advance medical directive includes, but need not be limited to: (a) A medical durable power of attorney executed pursuant to Section 15-14-506; (b) A declaration executed pursuant to the "Colorado Medical Treatment Decision Act", article 18 of this title; (c) A power of attorney granting medical treatment authority executed prior to July 1, 1992, pursuant to Section 15-14-501, as it existed prior to that date; or (d) A CPR directive or declaration executed pursuant to article 18.6 of this title." (3) For a resident who is under eighteen years of age, the parent, legal guardian, or person standing in loco parentis to the resident is allowed to exercise these visitation rights pursuant to any limitations described in Parts 9.2(F) and (G). (F) The policies and procedures may impose limitations on visitation rights. During a period when the risk of transmission of a communicable disease is heightened, an assisted living residence may: (1) Require visitors to enter the residence through a single, designated entrance; (2) Deny entrance to a visitor who has known symptoms of the communicable disease; (3) Require visitors to use medical masks, face-coverings, or other personal protective equipment while on the assisted living residence premises or in specific areas of the residence; (4) Require visitors to sign a document acknowledging: (a) The risks of entering the residence while the risk of transmission of a communicable disease is heightened; and (b) That menacing and physical assaults on health-care workers and other employees of the residence will not be tolerated; (5) Require all visitors, before entering the residence, to be screened for symptoms of the communicable disease and deny entrance to any visitor who has symptoms of the communicable disease; (6) Require all visitors to the residence to be tested for the communicable disease and deny entry for those who have a positive test result; and (7) Restrict the movement of visitors within the residence, including restricting access to where immunocompromised or otherwise vulnerable populations are at greater risk of being harmed by a communicable disease. (8) If an assisted living residence requires that a visitor use a medical mask, face covering, or other personal protective equipment or to take a test for a communicable disease in order to visit a resident at the assisted living residence, nothing in these regulations: (a) Requires the residence allow a visitor to enter, if the required equipment or test is not available due to lack of supply; (b) Requires the residence to supply the required equipment or test to the visitor, or bear the cost of the equipment for the visitor; or (c) Precludes the health-care residence from supplying the required equipment or test to the visitor. (G) The policies and procedures may impose additional limitations for the visitors of a resident with a communicable disease who is isolated. In this case, the residence may impose additional restrictions including: (1) Limiting visitation to essential caregivers who are helping to provide care to the resident; (2) Limiting visitation to one caregiver at a time per resident with a communicable disease; (3) Scheduling visitors to allow for adequate time for screening, education, and training of visitors and to comply with any limits on the number of visitors permitted in the isolated area at the time; and (4) Prohibiting the presence of visitors during aerosol-generating procedures or during collection of respiratory specimens. (H) Any limitations imposed shall be consistent with applicable federal law and regulation and other state statute. 9.3 The assisted living residence shall have an involuntary discharge grievance policy that complies with Section 25-27-104.3, C.R.S., and includes, at a minimum: (A) The individual designated by the assisted living residence to receive involuntary discharge grievances. (B) The ability for any of the persons the assisted living residence is required to notify in accordance with Part 11.16 to file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (A), above, within 14 calendar days after written notice of the involuntary discharge is provided by the assisted living residence. (C) The ability for the resident, or other person allowed to file a grievance to receive assistance in preparing and filing a grievance without interference from the assisted living residence. (D) A requirement that grievances related to involuntary discharge be submitted to the individual designated by the facility in accordance with subpart (A) as follows: (1) In writing, or (2) Orally submitted to the individual designated in accordance with subpart (A), above. In the case of an oral submission, the assisted living residence shall ensure the individual submitting the grievance retains proof of the oral submission through a witness or other evidence. (a) If the grievance is orally submitted and witnessed, the assisted living residence shall ensure that the resident or other person filing the grievance has the witness ' s name and contact information, and shall keep that information as part of the grievance documentation. (E) A requirement that no later than 5 business days after the submission of a grievance in accordance with subpart (D), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall provide a response to the grievance as follows: (1) A written response shall be provided to the individuals required to receive notice in Part 11.16, the state long-term care ombudsman, and the designated local ombudsman. (2) An oral explanation of the written response shall be provided to the resident and/or person filing the grievance, as appropriate. (3) The written response shall include the following statement regarding the filing of an appeal: "If the resident, or other person that submitted this grievance is dissatisfied with this response, they may file an appeal to the executive director of the Colorado Department of Public Health and Environment within 5 business days after receiving this written response. The appeal must include the original grievance, the original notice of involuntary discharge and supporting documentation given to the resident as part of that notification, and any additional information or documentation." (F) Acknowledgement that if the resident, the individual filing the grievance, or the assisted living residence is dissatisfied with the findings and recommendations of the Department related to an appeal, they may request a hearing conducted by the Department pursuant to Section 24-4-105, C.R.S. (G) A requirement that the assisted living residence not take any punitive or retaliatory action against a resident due to the resident filing a grievance or appeal pursuant to this Part. (H) A requirement that the assisted living residence continue to assist with planning a discharge or transfer of the resident while the grievance or appeal to the Department is pending. (I) A requirement that the resident be allowed to return to the assisted living residence if all of the following apply: (1) The stated reason for the involuntary discharge in the notice of involuntary discharge provided in accordance with Part 11.17 is nonpayment of monthly services or room and board, (2) The assisted living residence discharged the resident on or after the 31st day after the written notice of involuntary discharge was provided to the resident, and (3) The resident substantially complied with payments due to the residence, as determined through the grievance and appeal process. 13.11 The assisted living residence shall investigate all allegations of abuse, neglect, or exploitation of residents in accordance with Part 5.3 and its written policy which shall include, but not be limited to, the following: (A) Reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator; (B) A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation; (C) The process for investigating such allegations; (D) How the assisted living residence will document the investigation process to evidence the required reporting and that a thorough investigation was conducted; (E) A requirement that the resident shall be protected from potential future abuse and neglect, and/or exploitation while the investigation is being conducted; (F) A requirement that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action; and (G) A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review.

A recertification survey with complaint #CO40843 was completed on 9/10/25. A deficiency was cited.

Based on observation and interview, the facility (residence) failed to ensure the right of privacy, including the right to be free of cameras for all 10 current members (residents). Findings include:During the environmental tour on 9/9/25, it was revealed the residence had three cameras hung in common areas. One camera was pointed toward the dining room table and hallway, where residents enter and exit their rooms. The second camera was posted in the laundry room area, where the exit was for residents to go to the back yard and designated smoking area was, as well as where the hair salon station was, and where residents had to go through to go to the kitchen (to grab snacks) and go to the living room. The third camera was placed in the living room where the residents build puzzles, watch television, or go to the sun room. On 9/10/25 at approximately 4:40 p.m., the administrator stated the cameras were put in about a year ago, and before the cameras were put up, the residence had a verbal discussion with the residents. She continued to say no resident had brought up a concern about the camera and would add it to the resident council meeting agenda to discuss with them on 9/19/25. The administrator was then asked if she was aware that a rights modification was needed in order to have cameras posted. She stated she was unaware and thought they could be put up for safety, and with verbal consent.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The facility was advised it must review and maintain the following processes in accordance with existing program regulations found at 10 CCR 2505-10, Section 8.7000.8.7001 B.2. a. All HCBS Settings must have all of the following qualities and protect all of the following individual rights, based on the needs of the individual as indicated in their Person-Centered Support Plan, subject to the Rights Modification process in Section 8.7001. B.4: iii. The setting ensures an individual's rights of privacy, dignity, and respect, and freedom from coercion and Restraint. 2) The right of privacy includes the right not to have one's name or other confidential items of information posted in common areas of the setting.

A recertification survey was completed on 3/9/23. No deficiencies were cited.

A relicensure survey was completed on 3/9/23. No deficiencies were cited. A change of ownership occurred on 12/29/20.