CAPPELLA OF PUEBLO WEST

A certification complaint, prompted by #CO31114, was completed on 2/20/25. No deficiencies were cited.

A licensure complaint, prompted by #CO31113, was completed on 2/20/25. No deficiencies were cited

A licensure complaint, prompted by #CO30786, was completed on 2/8/23. Deficiencies were cited.

Based on interview and record review, the residence failed to discharge a resident who posed a danger to self or others and the assisted living residence was unable to sufficiently address those issues through therapeutic approach; had incontinence issues that could not be managed by the resident or staff; and who needed more services than could be routinely provided by the assisted living residence or an external service provider, affecting one of three sample residents (#1). (Cross-reference Q1150, Q1312) Findings include:1. Residence Policy and Reference The residence's Move Out/Discharge policy, dated December 2022, read in part: "The Community shall arrange for move out/discharge is a resident has any of the following: Requires more services than can be routinely provided by the community or a third-party provider. Exhibits conduct that would pose a danger to resident or others, unless the AL can reasonably manage conduct through therapeutic approaches." According to the Endocrine Society: "Mismanaged diabetes can also lead to heart disease, stroke, nerve damage, and decreased blood flow, which could cause amputation. People with diabetes may have life-threatening reactions to extremely high blood sugar, as well as extremely low blood sugar caused by diabetes medications." Retrieved from the Endocrine Society 2023: https://www.endocrine.org/patient-engagement/endocrine-library/diabetes-complications#:~:text=Mismanaged%20diabetes%20can%20also%20lead,sugar%20caused%20by%20diabetes%20medications. 2. Resident #1 was admitted to the residence on 12/16/21 with diagnoses including type 2 diabetes and dementia. The residence's assessment for Resident #1, dated 1/31/23, read the resident expressed unmet needs by showing anger, verbal abuse or other extreme tendencies. However, the assessment did not read what interventions could be done for the unmet needs. The assessment read Resident #1 was both continent and incontinent of bladder. The assessment read the resident did not need support services from an external services provider. The residence's care plan for Resident #1, dated 3/13/22, read Resident #1 would not cause harm to herself or others, which contradicted her 1/31/23 assessment and read she could be reluctant to care. However, the care plan did not address her aggression towards staff or others or interventions staff were to use while providing care to Resident #1. The care plan read Resident #1 independent with toileting and used incontinence products, which staff were expected to remind Resident #1 to change, as well as her clothes. Additionally, the care plan did not include Resident #1's diabetic care including the use of an external service provider for diabetes management and read she self-administered insulin. Further, the care plan read Resident #1 required assistance from staff to administer medication. Residence progress notes for Resident #1 read as follows: 9/23/22: "(Resident #1) continues to use vulgar and racist language and throw items at staff and threaten to hit them. She has also threatened to stab staff with her pens. Residents can choose to sit in any of the empty seats in the dining room and have tried to sit with her so she is not alone. (Resident #1) has often told them they are stupid, to shut up, stuck her tongue out at them and has, in the end, pushed them away from sitting with her. In the hallways if anyone is walking too slow for her she will yell loudly 'MOVE OUT OF THE WAY!' There is zero patience or politeness for community living." 10/24/22: "(Resident #1) is in need of 24 hour nursing supervision." The progress note was written by the administrator designee. 12/11/22: "(Resident #1) got up from her chair, quickly walked toward me, and brought her walker down on my foot while trying to throw the container of medication at me. When I asked her again to give me the medication or take it, she left the room and walked toward the kitchen with them. I called (the administrator) then informedher that he would be coming to get the pills from her if she didn't take them. She loudly asked for a cup of water and took the pills before throwing the rest of the water in my face." 2/6/23: "Was told that (Resident #1) was being sent out for a low blood glucose (BG) and was not responsive. I went down to the room and I assisted (emergency response) with showing them her BG/insulin log and getting a change of clothing since her shirt was damp from sweating." 2/7/23: "The person from (external service provider) came in to give insulin and stated (Resident #1) did not have breakfast, her BG was 161 and he was not going to give her insulin until she ate. His plan is to come in later since she eats a little later." 2/8/23: "(Resident #1) returned to us about 830pm. There was no phone call from the hospital for return to report so I was surprised to see her." Progress notes for Resident #1 read she received insulin twice daily from an external service provider. On 2/8/23 at 7:37 a.m., Staff #2 stated Resident #1 was aggressive towards staff, urinated in her recliner chair daily, and needed a high level of care because she was not receiving the care she needed at the residence. She added Resident #2 was only receiving approximately 20 percent of the care that she needed from the residence. On 2/8/23 at 8:02 a.m., Staff #1 stated Resident #1 was aggressive towards staff and residents and had been that way since approximately March 2022. On 2/8/23 at 9:08 a.m., Resident #1's power of attorney (POA) stated the residence had been wanting to move Resident #1 out since approximately four months after admission. She added she believed Resident #1 needed a higher level of care, such as skilled nursing. On 2/8/23 at 9:45 a.m., Resident #1's external service provider stated on 2/1/23 she found Resident #1 drenched in urine when she went to administer insulin to Resident #1. On 2/8/23 at 10:20 a.m., the administrator stated Resident #1 was not appropriate to live at the residence because her diabetes was poorly managed, she showed aggression towards staff, and showed aggression towards other residents. On 2/8/23 at 12:09 p.m., Resident #1's practitioner stated Resident #1 would benefit from a higher level of care due to her dementia, incontinence issues, and difficulty with diabetes management. Further, she stated she had first received reports of Resident #1 having behaviors in January 2022. She stated at the time, Resident #1 still administered her own insulin and Resident #1 attempted to stab a staff member with the insulin pen. The practitioner added there were times where Resident #1 was more compliant. Additionally, the practitioner stated Resdient #1's incontinence had gotten worse. On 2/8/23 at 2:52 p.m., the administrator designee stated Resident #1 had been needing to be discharged from the residence for months due to safety and diabetes management. She stated Resident #1 needed a nurse that could be present for her at all times. The administrator designee added at the time of the onsite visit, she believed Resident #1 needed a high level of care mostly due to diabetes management negatively impacting other areas of care such as incontinence.

Based on record review and interview, the residence failed to develop a care plan that detailed specific personal services needed and preferences along with the staff tasks necessary to meet those needs; and, identify all external service providers along with care coordination arrangements, affecting one of three sample residents (#1). (Cross-reference Q1060, Q1312)Findings include:1. Reference and Residence Policy Chapter II regulations governing assisted living residences, part 2.9, defines "Care plan" as a written description, in lay terminology, of the functional capabilities of an individual, the individual's need for personal assistance, service received from external providers, and the services to be provided by the facility in order to meet the individual's needs. In order to deliver person-centered care, the care plan shall take into account the resident's preferences and desired outcomes. "Care plan" may also mean a service plan for those facilities which are licensed to provide services specifically for the mentally ill. The residence's undated resident agreement read in part: 'Your resident care plan' is a written document that includes a description of your functional physical and mental capabilities, your needs for personal assistance from community staff members, the services you expect to receive from external providers, and the person care service that we will provide directly to you." 2. Resident #1 was admitted to the residence on 12/16/21 with diagnoses including type 2 diabetes and dementia. The residence's care plan for Resident #1, dated 3/13/22, read Resident #1 would not cause harm to herself or others however; the care plan did not address her aggression towards staff or others or interventions staff were to use while providing care to Resident #1. Additionally, the care plan did not include Resident #1's diabetic care including the use of an external service provider for diabetes management. The care plan read she self-administered insulin. On 2/8/23 at approximately 7:14 a.m., Staff #2 stated Resident #1 received external services for diabetes management. She added, Resident #1 had the behavior of being aggressive towards staff, including yelling at the staff members and becoming physically aggressive. Further, Staff #2 added Resident #1 had the behaviors for awhile and it was not new. On 2/8/23 at 9:08 a.m., Resident #1's power of attorney (POA) stated it had been reported on several occasions that Resident #1 had yelled at staff members and become physically aggressive with them. On 2/8/23 at 9:45 a.m., Resident #1's external service provider stated she had been providing diabetes management, including insulin injections, to Resident #1 approximately five days a week. On 2/8/23 at 12:09 p.m., Resident #1's practitioner stated Resident #1's behavioral expressions first began in January 2022 and the resident's behaviors included being aggressive towards staff. On 2/8/23 at approximately 2:52 p.m., the administrator designee confirmed the interventions for Resident #1's aggressive behaviors were not in the care plan. However, she stated how staff should redirect Resident #1 and that the methods of working and communicating with the resident should have been in the care plan. The designee stated the residence was responsible for Resident #1's care but stated the residence did not have nursing services, which made it difficult.

Based on observation, interview, and record review, the residence failed to ensure residents had the right to be free from verbal abuse, affecting one current resident (#1). (Cross-reference Q1360)Specifically, the external service provider for Resident #1 reported an allegation of verbal abuse to the administrator on 2/1/23. The external service provider alleged she witnessed Staff #1 verbally abuse Resident #1 in the resident's bedroom which directly resulted in Resident #1's tearfulness. The administrator interviewed five residence staff to determine if they felt Resident #1 was at risk for harm from Staff #1; however, the residence's policy was not followed. The administrator did not interview Resident #1, her responsible party, or other residents. Staff #1 returned to administering medications and providing care to Resident #1 on 2/7/23. On 2/8/23, both the external service provider and power of attorney (POA) for Resident #1 reported to the administrator their concerns for Resident #1's safety because Staff #1 continued to provide care and services to Resident #1 from 2/1/23 to 2/8/23 and during the onsite visit. This failure created an immediate jeopardy risk of verbal abuse to one current resident (#1) residing in the residence. On 2/8/23, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. Reference and residence policyThe Merriam-Webster dictionary defines verbal abuse as: "harsh and insulting language directed at a person." Merriam-Webster, Verbal abuse, retrieved 2/14/23: from https://www.merriam-webster.com/dictionary/verbal%20abuseThe residence's Abuse Non-Tolerance policy, dated October 2022, read in part: "Residents and clients must be free from abuse by anyone, including associates, other residents or clients, consultants or volunteers, associates from outside agencies, family members or legal guardians, friends, or other individuals. 'Verbal abuse' is defined as the use of oral, written or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance, regardless of their age, ability to comprehend, or disability. Examples of verbal abuse include but are not limited to, threats of harm saying things to frighten a resident, etc." 2. Resident #1 was admitted to the residence on 12/16/21 with a diagnosis of dementia. The residence's assessment for Resident #1, dated 1/31/23, read the resident expressed unmet needs by showing anger, verbal abuse or other extreme tendencies. However, the assessment did not read what interventions could be done for the unmet needs. The residence's care plan for Resident #1, dated 3/13/22, read Resident #1 would not cause harm to herself or others however; the care plan did not address her aggression towards staff or others or interventions staff were to use while providing care to Resident #1. The residence's progress notes for Resident #1 did not include notes about the alleged verbal abuse or about the investigation of the allegation. However, a progress note, dated 1/24/23, read: "Resident woke up pretty sore from the fall she had the day prior. She developed a black eye overnight." The residence's January and February 2023 staff schedule read Staff #1 worked at the residence on 1/29-2/1/23 and 2/4-2/28/23. On 2/8/23 at 7:37 a.m., Staff #2 stated Resident #1 was aggressive both physically and verbally with staff members. Staff #2 confirmed Staff #1 yelled back at Resident #1 on 2/1/23 and stated Staff #1 had still been administering medications and provided care in Resident #1's hallway. On 2/8/23 at 8:07 a.m., Staff #1 stated she had been accused of being verbally abusive towards Resident #1. Approximately one week prior to the onsite visit, Staff #1 stated Resident #1 had called her a vulgar name and she told Resident #1, "Next time you say that, you need to look in the mirror." Immediately following this verbal interaction, Staff #1 stated that Resident #1 had dug her nails into her and she asked Resident #1 to take her medications. Staff #1 stated after she administered the medications to Resident #1, she left the room. Staff #1 confirmed she had not administered medications or provided medications to Resident #1 since the interaction occurred and that the resident's external service provider witnessed the interaction. On 2/8/23 at 9:08 a.m., Resident #1's power of attorney (POA) stated Resident #1's external service provider had witnessed verbal abuse and reported it the same day to staff. The POA added after it was reported, the administrator immediately telephoned her and informed her the residence needed Resident #1 discharged immediately. Further, she stated the administrator asked her, "Wouldn't you yell at her if she (Resident #1) was half naked in a depend (incontinence product) and trying to scratch you?" The POA stated the administrator did not contact her to inform her what they would do to keep Resident #1 safe, instead he was defending Staff #1's actions. The POA added she was worried for Resident #1's safety, particularly since the residence had been reported for the abuse allegation. Furthermore, the POA stated she did not feel comfortable with Staff #1 working with Resident #1. On 2/8/23 at 9:41 a.m., Staff #1 confirmed she had just administered medications to Resident #1. On 2/8/23 at 9:45 a.m., Resident #1's external service provider stated she was providing care to Resident #1 in her room and Resident #1 was yelling because she was in pain from a fall she had sustained. The external service provider stated Staff #1 popped her head into the room and told Resident #1 to stop yelling. The external service provided stated she sang to Resident #1 and cleaned her room in order to calm the resident, which resulted in Resident #1 becoming soft spoken. She added, approximately five minutes later Staff #1 came into the room with herself and Resident #1 to administer medications. She reported Staff #1 told the resident: "'You better not scratch me.'" The external service provider said Staff #1 then called Resident #1 names, and while physically close to the resident's face stated: "'I know how you got that black eye and you deserved it'" to Resident #1 in regards to the black eye Resident #1 had sustained from her fall. The external service provider added that Staff #1 yelled in the resident's face and told her: "'If you scratch me, you'll never do it again.'" The external service provider reported once Staff #1 left the room, Resident #1 had tears in her eyes. The external service provider stated she did not feel Resident #1, or any elderly person, was safe with Staff #1. Further, she added she worried the residence was retaliating against Resident #1 for her behaviors and stated, "I am so scared for her" in regards Resident #1. On 2/8/23 at 10:20 a.m., the administrator stated Resident #1's external service provider reported to him on 2/1/23 that she was concerned with how Staff #1 spoke to Resident #1 when Staff #1 entered the resident's room to administer medications. He stated Resident #1 called Staff #1 a name and Staff #1 told Resident #1 to look into a mirror the next time she said that. The administrator stated the residence reassigned Staff #1 to a different area of the residence to administer medications while he investigated the allegation. He stated he addressed the concern with Staff #1 privately and informed Staff #1 if a similar situation happened again that she should step away and have another staff member work with Resident #1. Additionally, the administrator stated he felt like Staff #1 was "a little verbally aggressive" but at no point were any staff worried for Resident #1's safety. The administrator confirmed he did not ask the external service provider, the POA, or Resident #1 herself if they were concerned about Resident #1's safety. The administrator confirmed he did not ask other residents if they had concerns about Staff #1 or any other staff members. The administrator stated Staff #1 had resumed providing care to Resident #1 on 2/7/23 after she had not been working on Resident #1's cart since the allegation occurred. On 2/8/23 at 11:57 a.m., discrepancies arose when the administrator stated he had discussed the allegation with the POA, which he previously stated he did not, and the potential for a possible discharge for Resident #1. The administrator stated the resident's external service provider had not reported to him at any time directly after the alleged verbal abuse interaction with Staff #1 that Resident #1 had been tearful. On 2/8/23 at 12:09 p.m., Resident #1's practitioner stated she had only seen Resident #1 prior to the allegation of abuse, after she had fallen and bruised her eye on 1/23/23. 3. Immediate Jeopardy - Written Evidence, Immediate CorrectionThe investigation established that the findings above placed one current resident at immediate jeopardy risk for verbal abuse. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 2/8/23 at 12:49 p.m., the administrator designee submitted written evidence which read: "Schedule was created that designates staff on which (medication administration) cart they should be on. Staff in question will be assigned to (both) cart (s) only after interviews of residents on (both carts) have been conducted by (residence) management, to ensure resident safety." However, the written evidence did not indicate the risk had been removed because it did not include training to be completed for staff with the dates of those training's, how monitoring would take place, how the interviews would be documented, when those would be conducted, when the investigation would be completed and where the documentation would be kept. On 2/8/23 at 1:46 p.m., the administrator designee submitted additional written evidence that read in pertinent part: "Schedule was created that designates staff on which cart they should be on. Schedule will be provided. Training though (online system) will be implemented. Modules on understanding abuse and neglect as well as compassion training will be assigned and tracked by management. Completion of this will be mandatory and the due date will be 2/22/23. Staff that have failed to comply will be scheduled to come in and complete with management and receive disciplinary action. Interviews of all residents will be conducted by management and kept with all other documentation of this incident in the (administrator) office. This will be completed by the end of the day on 2/9/23. If any concerns arise from the interviews, (administrator) and HWC (health and wellness coordinator) will decide on a proper course of action going forward."

Based on observation, interview and record review, the residence failed to investigate all allegations of abuse in accordance with their policy and regulation, affecting one sample resident (#1). (Cross-reference Q1150, Q1312) Findings include:1. References and residence policya. Chapter II regulations governing assisted living residences, part 1.1, defines "Abuse" as the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish.b. Chapter II regulations governing assisted living residences, part 4.2.2, the following occurrences shall be reported to the Department within one business day after the occurrence or when the licensee becomes aware of the occurrence, in the format required by the Department:(D) Any occurrence involving physical, sexual, or verbal abuse of a client, by another client, an employee of the licensee or a visitor to the facility or agency.c. The department's Occurrence Reporting Manual read, in part: "Three elements needed: knowingly AND Threat OR physical action (includes threatening gesture) AND Fear of imminent, serious bodily injury ... How is it determined if the victim of verbal abuse is fearful? Victims of verbal abuse can demonstrate fear multiple ways. The victims can verbally state they are fearful, or their behavior can indicate fear. During the verbal abuse, if a witness identifies that the victim appears fearful, either through reactions or body language, the event is reportable as an occurrence as long as the other two elements are met. Similarly, if the victim is interviewed after the verbal abuse and verbally denies fear while exhibiting fearful body language it is also reportable. This is also the case for the victim ' s behavior for any future interactions with the abuser. Staff should observe the victim carefully for any signs of fear after a potential verbal abuse situation." Health Facilities and Emergency Medical Services Division Occurrence Reporting Manual (May 2018), Abuse, Verbal - Statute and Example, retrieved from: https://cdphe.colorado.gov/health-facility-reported-incidentsd. The residence's Abuse Non-Tolerance policy, dated October 2022, read in part: "A detailed investigation will be completed. Assessments of psychosocial and physical harm will be done. Appropriate interviews will be conducted. Appropriate notifications will be made. The investigation will determine if the allegation was verified, not verified or inconclusive. Measures will be instituted so that the resident and any others involved will feel safe, secure, and protected during the investigation. Care planning and corrective action/s will be taken to prevent future occurrences, if applicable. The families/responsible parties will be involved throughout this process. Transfer to another, more appropriate community may be necessary if the offending resident is potentially harmful to self or others. The resident, client, family, and/or involved parties will be informed of the community's decision and informed that they may also contact the authorities on the resident's behalf. (The residence) shall cooperate fully with any external investigation conducted by government authorities." 2. Resident #1 was admitted to the residence on 12/16/21 with a diagnosis of dementia. The residence's assessment for Resident #1, dated 1/31/23, read the resident expressed unmet needs by showing anger, verbal abuse or other extreme tendencies. However, the assessment was not completed. The residence's care plan for Resident #1, dated 3/13/22, read Resident #1 would not cause harm to herself or others; however, the care plan did not address her aggression towards staff or others or interventions staff were to use while providing care to Resident #1. The care plan contradicted what the 1/31/23 assessment read. The care plan was not updated after the alleged abuse had occurred and did not include actions to be taken to prevent future occurrences. The residence's progress notes for Resident #1 did not include notes about the alleged verbal abuse or about the investigation of the allegation. A formal internal grievance form, dated 2/1/23, read Resident #1's external service provided had reported to the administrator that Staff #1 had spoke to Resident #1 in an elevated tone in close proximity to Resident #1's face. The form read interviews were conducted with five staff and the five staff members did not feel Resident #1 was harmed while she received care from Staff #1. Further, it read education had been provided to Staff #1 and other team members about care for Resident #1 during an all staff meeting. However, the documentation did not read the residence had included the resident or responsible party during the investigation process nor did it include how the resident was being kept safe during the investigation. Review of the All Staff Meeting document, dated 2/1/23, read: "Received complaints about how we are talking to (Resident #1). We need to rise above. Try to write good notes when she is cooperating or being nice, to balance out the bad. If you are having a hard time working with her, ensure she is safe and ask for another team member to assist you. Take a step back if needed." The documentation did not read what interventions staff were trained to use. On 2/8/23 at 10:10 a.m., the administrator designee stated the allegation of abuse had been reported to the administrator on 2/1/23. She confirmed Staff #1 had continued to work with Resident #1 since the allegation had been made. On 2/8/23 at 10:20 a.m., the administrator confirmed he did not ask the external service provider, POA, or the resident if they were concerned about Resident #1's safety and confirmed he did not ask other residents if they had concerns about Staff #1 or any other staff members. On 2/8/23 at 11:57 a.m., the administrator stated he believed he had more documentation of the investigation in his desk; however, the documentation was never providedOn 2/8/23 at 12:09 p.m., Resident #1's practitioner stated she had not done an assessment on Resident #1 after the allegation of abuse had occurred. Further, she stated she was not aware of any allegations of abuse. The practitioner added she had only seen her prior to the allegation after she had fallen and bruised her eye on 1/23/23.

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 7.11.13 Where a resident has demonstrated that he or she has become a danger to self or others, the assisted living residence shall promptly implement the following process pending discharge:(A) Take all appropriate measures necessary to protect other residents;(B) Reassess the resident to be discharged and revise his or her care plan to identify the resident's current needs and what services the assisted living residence will provide to meet those needs; and(C) Ensure all staff are aware of any new directives placed in the care plan and are properly trained to provide supervision and actions consistent with the care plan.

A certification complaint, prompted by #CO30788, was completed on 2/8/23. Deficiencies were cited.

Based on observation, record review and interview, the facility (residence) failed to ensure special health or behavioral management needs that support the participant's (resident's) individual needs were documented on the care plan, affecting one of three sample residents (#1). (Cross-reference P0657)Findings include:1. Reference and Residence Policy a. Regulations governing Alternative Care Facilities (ACFs), Volume 8.495.1, defines a Care Plan as the individualized goal-oriented plan of services, supports, and preferences developed collaboratively with the participant and/or the designated or legal representative and the service provider, as outlined in 6 CCR 1011-1, Chapter VII, Section 2 and , Section 8.495.6. F.b. Chapter II regulations governing assisted living residences, part 2.9, defines "Care plan" as a written description, in lay terminology, of the functional capabilities of an individual, the individual's need for personal assistance, service received from external providers, and the services to be provided by the facility in order to meet the individual's needs. In order to deliver person-centered care, the care plan shall take into account the resident's preferences and desired outcomes. "Care plan" may also mean a service plan for those facilities which are licensed to provide services specifically for the mentally ill.c. The residence's undated resident agreement read in part: "Your 'resident care plan' is a written document that includes a description of your functional physical and mental capabilities, your needs for personal assistance from community staff members, the services you expect to receive from external providers, and the person care service that we will provide directly to you." 2. Resident #1 was admitted to the residence on 12/16/21 with diagnoses including type 2 diabetes and dementia. The residence's care plan for Resident #1, dated 3/13/22, read Resident #1 would not cause harm to herself or others however; the care plan did not address her aggression towards staff or others or interventions staff were to use while providing care to Resident #1. Additionally, the care plan did not include Resident #1's diabetic care including the use of an external service provider for diabetes management. The care plan read she self-administered insulin. On 2/8/23 at approximately 7:14 a.m., Staff #2 stated Resident #1 received external services for diabetes management. She added, Resident #1 had the behavior of being aggressive towards staff, including yelling at the staff members and becoming physically aggressive. Further, Staff #2 added Resident #1 had the behaviors for awhile and it was not new. On 2/8/23 at 9:08 a.m., Resident #1's power of attorney (POA) stated it had been reported on several occasions that Resident #1 had yelled at staff members and become physically aggressive with them. On 2/8/23 at 9:45 a.m., Resident #1's external service provider stated she had been providing diabetes management, including insulin injections, to Resident #1 approximately five days a week. On 2/8/23 at 12:09 p.m., Resident #1's practitioner stated Resident #1's behavioral expressions first began in January 2022 and the resident's behaviors included being aggressive towards staff. On 2/8/23 at approximately 2:52 p.m., the administrator designee confirmed the interventions for Resident #1's aggressive behaviors were not in the care plan. However, she stated how staff should redirect Resident #1 and that the methods of working and communicating with the resident should have been in the care plan. The designee stated the residence was responsible for Resident #1's care but stated the residence did not have nursing services, which made it difficult.

Based on observation, interview and record review, the facility (residence) failed to discharge a participant (resident) who posed a physical threat to self or others, and failed to respond to interventions, as outlined in the participant's (resident's) care plan, affecting one of three sample residents (#1). (Cross-reference P0625) Findings include:1. Residence Policy and Reference a. The residence's Move Out/Discharge policy, dated December 2022, read in part: "The Community shall arrange for move out/discharge is a resident has any of the following: Requires more services than can be routinely provided by the community or a third-party provider. Exhibits conduct that would pose a danger to resident or others, unless the AL can reasonably manage conduct through therapeutic approaches." b. According to the Endocrine Society: "Mismanaged diabetes can also lead to heart disease, stroke, nerve damage, and decreased blood flow, which could cause amputation. People with diabetes may have life-threatening reactions to extremely high blood sugar, as well as extremely low blood sugar caused by diabetes medications." Retrieved from the Endocrine Society 2023: https://www.endocrine.org/patient-engagement/endocrine-library/diabetes-complications#:~:text=Mismanaged%20diabetes%20can%20also%20lead,sugar%20caused%20by%20diabetes%20medications. 2. Resident #1 was admitted to the residence on 12/16/21 with diagnoses including type 2 diabetes and dementia. The residence's assessment for Resident #1, dated 1/31/23, read the resident expressed unmet needs by showing anger, verbal abuse or other extreme tendencies. However, the assessment did not read what interventions could be done for the unmet needs. The assessment read Resident #1 was both continent and incontinent of bladder. The assessment read the resident did not need support services from an external services provider. The residence's care plan for Resident #1, dated 3/13/22, read Resident #1 would not cause harm to herself or others, which contradicted her 1/31/23 assessment and read she could be reluctant to care. However, the care plan did not address her aggression towards staff or others or interventions staff were to use while providing care to Resident #1. The care plan read Resident #1 independent with toileting and used incontinence products, which staff were expected to remind Resident #1 to change, as well as her clothes. Additionally, the care plan did not include Resident #1's diabetic care including the use of an external service provider for diabetes management and read she self-administered insulin. Further, the care plan read Resident #1 required assistance from staff to administer medication. Residence progress notes for Resident #1 read as follows: 9/23/22: "(Resident #1) continues to use vulgar and racist language and throw items at staff and threaten to hit them. She has also threatened to stab staff with her pens. Residents can choose to sit in any of the empty seats in the dining room and have tried to sit with her so she is not alone. (Resident #1) has often told them they are stupid, to shut up, stuck her tongue out at them and has, in the end, pushed them away from sitting with her. In the hallways if anyone is walking too slow for her she will yell loudly 'MOVE OUT OF THE WAY!' There is zero patience or politeness for community living." 10/24/22: "(Resident #1) is in need of 24 hour nursing supervision." The progress note was written by the administrator designee. 12/11/22: "(Resident #1) got up from her chair, quickly walked toward me, and brought her walker down on my foot while trying to throw the container of medication at me. When I asked her again to give me the medication or take it, she left the room and walked toward the kitchen with them. I called (the administrator) then informed her that he would be coming to get the pills from her if she didn't take them. She loudly asked for a cup of water and took the pills before throwing the rest of the waterin my face." 2/6/23: "Was told that (Resident #1) was being sent out for a low blood glucose (BG) and was not responsive. I went down to the room and I assisted (emergency response) with showing them her BG/insulin log and getting a change of clothing since her shirt was damp from sweating." 2/7/23: "The person from (external service provider) came in to give insulin and stated (Resident #1) did not have breakfast, her BG was 161 and he was not going to give her insulin until she ate. His plan is to come in later since she eats a little later." 2/8/23: "(Resident #1) returned to us about 830pm. There was no phone call from the hospital for return to report so I was surprised to see her." Progress notes for Resident #1 read she received insulin twice daily from an external service provider. On 2/8/23 at 7:37 a.m., Staff #2 stated Resident #1 was aggressive towards staff, urinated in her recliner chair daily, and needed a high level of care because she was not receiving the care she needed at the residence. She added Resident #2 was only receiving approximately 20 percent of the care that she needed from the residence. On 2/8/23 at 8:02 a.m., Staff #1 stated Resident #1 was aggressive towards staff and residents and had been that way since approximately March 2022. On 2/8/23 at 9:08 a.m., Resident #1's power of attorney (POA) stated the residence had been wanting to move Resident #1 out since approximately four months after admission. She added she believed Resident #1 needed a higher level of care, such as skilled nursing. On 2/8/23 at 9:45 a.m., Resident #1's external service provider stated on 2/1/23 she found Resident #1 drenched in urine when she went to administer insulin to Resident #1. On 2/8/23 at 10:20 a.m., the administrator stated Resident #1 was not appropriate to live at the residence because her diabetes was poorly managed, she showed aggression towards staff, and showed aggression towards other residents. On 2/8/23 at 12:09 p.m., Resident #1's practitioner stated Resident #1 would benefit from a higher level of care due to her dementia, incontinence issues, and difficulty with diabetes management. Further, she stated she had first received reports of Resident #1 having behaviors in January 2022. She stated at the time, Resident #1 still administered her own insulin and Resident #1 attempted to stab a staff member with the insulin pen. The practitioner added there were times where Resident #1 was more compliant. Additionally, the practitioner stated Resdient #1's incontinence had gotten worse. On 2/8/23 at 2:52 p.m., the administrator designee stated Resident #1 had been needing to be discharged from the residence for months due to safety and diabetes management. She stated Resident #1 needed a nurse that could be present for her at all times. The administrator designee added at the time of the onsite visit, she believed Resident #1 needed a high level of care mostly due to diabetes management negatively impacting other areas of care such as incontinence.