SUNSHINE GARDENS WEST ASSISTED LIVING

A relicensure survey with complaints #CO34711, #CO34607, #CO34232, #CO34229, and #CO34172 was completed on 10/23/24. Deficiencies were cited.

Based on record review and interview, the residence failed to have personnel files for current employees readily available and onsite for department review for four of five staff (#15, #16, #19, and #20), affecting 48 current residents. Findings include:1. Resident PolicyThe residence's 7/30/22 staff orientation and training policy read in part that all methods to ensure staff was competent in training will be documented and kept in employee files. 2. Record ReviewOn 10/22/24 at 7:36 a.m., complete staff files for Staff #15, #16, #19, and #20 were requested, specifically their staff orientation and training documentation. On 10/22/24 at 4:30 p.m., complete staff files for Staff #15, #16, #19, and #20 were requested again. On 10/23/24 at 7:30 a.m., staff files were provided; however, no documentation of orientation and training was included. 3. Interviews On 10/23/24 at 8:19 a.m., the administrator stated she did not have documentation of staff orientation or training and was not able to provide any documentation. She acknowledged documentation of staff files was an area for improvement and stated it was because of a lack of documentation efforts.

Based on record review and interview the residence failed to develop and implement an involuntary discharge grievance policy which included all required elements, affecting 48 current residents. Findings include:The residence's involuntary discharge and grievance policies both dated 7/22/22, failed to include the following required elements:1. The ability of any of the persons in the assisted living residence is required to notify under 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 the assisted living residence provides written notice of the involuntary discharge. 2. 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. 3. A requirement that grievances related to involuntary discharge be submitted to the individual designated by the facility under subpart (A) as follows: In writing, or Orally submitted to the individual designated under 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. 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. 4. A requirement that no later than 5 business days after the submission of a grievance under subpart (D), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall respond to the grievance as follows: An oral explanation of the written response shall be provided to the resident and/or person filing the grievance, as appropriate. 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." 5. A requirement that the assisted living residence does not take any punitive or retaliatory action against a resident due to the resident filing a grievance or appeal under this Part. 6. 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. 7. A requirement that the resident be allowed to return to the assisted living residence if all of the following apply: The stated reason for the involuntary discharge in the notice of involuntary discharge provided under Part 11.17 is nonpayment of monthly services or room and board, 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 The resident substantially complied with payments due to the residence, as determined through the grievance and appeal process. On 10/23/24 at 2:00 p.m., the administrator stated that she was aware the policy did not meet the requirements.

Based on record review, observation, and interview, the residence failed to make available a physically safe and sanitary environment, either directly or indirectly through a resident agreement affecting three of three sample residents (#39, #40, and #45). Findings include: 1. Observations On 10/22/24 at 7:45 a.m., Resident #40 ' s bathroom had five soiled incontinence products in the trash can, smeared feces on the edge of the toilet, and feces on the floor directly under the toilet. On 10/22/24 at approximately 8:10 a.m., Staff #15 served Residents #39 and #40 breakfast, when Resident #34 thanked Staff #15, she said "yeah, whatever," then walked away from the residents. 2. Interview On 10/23/24 at approximately 1:45 p.m., the administrator stated she expected resident rooms and bathrooms to be clean and free of feces as well as trash, which staff were to take out at least once a day. The Administrator acknowledged it was unsanitary to have feces smeared in the residents bathroom.

Based on record review and interview, the residence failed to keep annually updated comprehensive assessments for each resident or update comprehensive assessments after a resident's condition changed from baseline status, affecting three of 17 sample residents (#32, #33, and #38). Findings include:1. Record ReviewResident #32 was admitted to the residence on 1/3/20 with diagnoses of dementia, major depressive disorder, and hypertension. A comprehensive assessment for Resident #32, dated 6/6/24, read in part that Resident #32 displayed unsafe behaviors such as stealing and hoarding colorful items which did not belong to the resident. Resident #32 could become verbally abusive when upset. Resident #32 also wandered but did not elope. A progress note, dated 9/20/24 at 1:00 p.m., read in part that Resident #32 was "rude" to an external service provider (ESP). Resident #32 made "mean" statements to the ESP and stated she did not like them. A progress note, dated 10/16/24 at 1:00 a.m., read in part that Resident #32 hit another resident in the back with a closed fist in the dining room at 8:02 a.m. This was verified on a video recording. The other resident told her not to do that. Resident #32 then went back to the table she was sitting at with her family, and the other resident went back to the table to tell them that kind of behavior was not acceptable. A progress note, dated 10/16/24 at 10:30 a.m., read in part that Resident #32 was observed kicking another resident in the back in the dining room. The other resident was using a walker, and walking to a table. This was on a video recording as well. 2. InterviewOn 10/23/24 at 11:00 a.m., the administrator acknowledged that the residence should have updated the comprehensive assessment after Resident #32's behavior issues started escalating. She stated that several of the resident's assessments should have been updated, but she had yet to have the opportunity to do so. 3. Evidence revealed similar deficient practices for Residents #33 and #38.

Based on record review, observation, and interview, the residence failed to ensure all medications were stored in a locked storage area when unattended by a qualified medication administration person (QMAP) or other licensed staff, affecting one current resident (#40). Findings include: On 10/22/24 at 7:40 a.m., an environmental tour revealed a bottle of acetaminophen for Resident #40 on the dresser in the resident's bedroom. The staff did not store the medication in a locked storage area; therefore, the medication was accessible to the resident. On 10/22/24 at 1:05 p.m., the acetaminophen bottle was seen on the table next to the resident's chair. Resident #40 took two capsules out of the bottle and swallowed them. On 10/22/24 at approximately 1:05 p.m., Resident #40 stated she took acetaminophen a few times a day but could not remember what time she last took it. On 10/23/24 at 1:45 p.m., the administrator acknowledged the bottle of acetaminophen was in Resident #40 ' s room and stated the family often provided over-the-counter medications without notifying staff. She stated staff should have been more vigilant for medications not stored in the medication cart.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.6 At the time a new resident moves in, the assisted living residence shall complete a comprehensive assessment that reflects information requested and received from the resident, the resident's representative if requested by the resident, and a practitioner. Information from the comprehensive assessment shall be used to establish an individualized care plan. 14.31 The administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence's Quality Management Program assessment and review.

A change of ownership survey was completed on 6/28/23. No deficiencies were cited. A change of ownership occurred on 6/7/23.

A second initial secure licensure survey was completed on 6//28/23. Deficiencies were cited.

Based on observation, record review, and interview, the residence failed to immediately comply with all conditions issued by the department, affecting 55 current residents. Findings include:1. RecordsDepartment records read the residence was currently required to retain a consultant for six months. Following the completion of event CU0211 on 12/7/22, an initial secure licensure, the Department imposed a consultant for six months to address corrective measures for all citations and to also ensure compliance with all other pertinent regulations. The intermediate condition read the consultant was required to complete the following, during the first month of the contract period:Review cited deficiencies identified in the deficiency list and evaluate the residence's current compliance with regulations as outlined in Chapters 2, 7 and 24. The consultant was required to complete the following, during the first two months of the contract period:Evaluate the residence's current compliance with corresponding regulations as outlined in Chapters 2, 7, and 24. Provide recommendations to the administrator on any additional areas of noncompliance. Implement a monitor program to be completed at least monthly to ensure the residence remains in compliance with previously cited deficiencies. The consultant was required to complete the following, during the first through third months of the contract period: Conduct onsite visits at least weekly. The consultant was required to complete the following, during the fourth through sixth months of the contract period:Conduct onsite visits at least twice monthly, increasing the frequency as necessary to assist the residence in maintaining compliance with 6 CCR 1011-1 Chapter 2, Chapter 7, and Chapter 24 and, to prepare the Administrator to independently manage the residence. Additionally, the consultant was required to ensure, during the entire six month contract period, for each of the deficiencies identified in the Deficiency List, for Event CU0211 and dated December 7, 2022, as well as any other areas of identified deficient practice, that the Administrator had a process in place to correct the identified deficiencies, which included utilizing the above-referenced monitoring program to ensure the deficient practice did not reoccur. The consultant will make certain that the monitoring identified the scope of review, how a sample was identified for monitoring purposes, the total length of time the monitoring would continue, and how the monitoring would be documented. Department records read the following deadlines were required for this intermediate condition:- Letter to department to identify possible consultant, due by 3/9/23.- Submit executed consultant contract to the department, due by 3/17/23.- Submit final consultant report, due by 9/15/23. The residence did not appeal the intermediate condition. Department records read the residence had chosen a consultant on 3/21/23. On 3/27/23, the residence submitted a consultant contract for a consultant and the contract for the consultant was received on 3/17/23. Therefore, on the day of the completion of the complaint investigation, (6/28/23), the consultant would have been in her third month as consultant for the residence. 2. Current deficient practice During the 6/28/23 revisit, it was established there was current deficient practice. Two deficiencies were cited: 2930 and 2972. (Cross-reference Q2930, Q2972) 3. InterviewsOn 6//23 at 12:14 p.m., a consultant said the reason the residence was out of compliance with the intermediate condition was because the administrator did not have assistance from a management team with completing her plan of correction and was doing it on her own. The consultant stated she was not aware of the requirement for the residence to not have deficiencies, adding that she had provided directives and tasks for the administrator to complete in order to bring the residence into compliance. She acknowledged that this included updating comprehensive assessments when resident's had a change in their baseline status. The consultant stated, however, that she expected the administrator to complete the tasks and did not complete them for her. On 6//23 at p.m., the administrator stated she was aware of the requirement to be in compliance with the intermediate condition. She stated that she was still working on bringing the residence into compliance after the on site visit.

Based on record review and interview, the residence failed to complete a pre-admission assessment to determine the appropriateness and need for secure environment residency that included detailed information from the resident's family and/or representative concerning the resident's recent relevant history and patterns of reduced safety awareness and wandering, along with any strategies used to prevent unsafe wandering or successful exiting, and any other known types of conduct; and, an evaluation by a licensed practitioner that described residents' medical condition and any cognitive deficits that contributed to wandering, compromised safety awareness, and other types of conduct, affecting one sample resident (#31) who was newly admitted to the residence's secure environment. This deficiency was cited previously during a state licensure survey on 12/7/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 12.7, requires the residence to ensure a comprehensive assessment include all the following items:(A) Information from the comprehensive pre-admission assessment described in Part 11.1;(B) Information regarding the resident's overall health and physical functioning ability;(D) Communication ability and any specific needs to facilitate effective communication;(E) Current diagnoses and any known or anticipated need or impact related to the diagnoses;(K) Safety awareness;(L) Types of physical, mental, and social support required; and(M) Personal background, including information regarding any other individuals who are supportive of the resident, cultural preferences, and spiritual needs.b. The residence's Pre-Admission Assessment Policy for the residence's secure environment, dated 7/30/22, read in part that that the residence's pre-admission assessment included an evaluation by a licensed practitioner completed within 90 days prior to admission. The evaluation described the resident's medical condition and any cognitive deficits that contributed to wandering, compromised safety awareness, and other types of conduct. 2. Record ReviewA practitioner's health assessment, dated 2/6/23, read in part that Resident #31 had a diagnosis of dementia and cognitive decline. The practitioner hand wrote the following: "Patient is having worsening dementia/cognitive decline. I would recommend (a) higher level of care/ SNF (skilled nursing facility) placement/24 hour supervision." The practitioner's assessment did not address the appropriateness and need for Resident #31 to be moved from the nonsecure environment to the secure environment. There was no evidence provided that the resident had any relevant history and patterns of reduced or compromised safety awareness and wandering prior to moving from the nonsecure environment to the secure environment. Resident #31 was admitted to the residence's secure environment on 3/8/23.3. InterviewsOn 6/28/23 at 12:14 p.m., a consultant stated that the administrator did not inform her that the residence was admitting Resident #31 into the residence's secure environment. She stated she was not aware of a specific form required for a practitioner's assessment for a resident to be placed in a secure environment. The nurse consultant stated she did not see the documentation and did not know why it was not corrected. On 6/28/23 at 2:03 p.m., the administrator stated she had not yet updated the residence's practitioner's health assessment form to include verbiage regarding placement of a resident in the residence's secure environment. She stated that this deficiency that was previously cited was not corrected because she thought the practitioner recommended a secure environment in the documentation. The administrator stated, however, that she did not check the documentation thoroughly and did not notice that the practitioner's recommendation was for a SNF and not for a secure environment.

Based on observations, record review and interview, the residence failed to ensure staff assigned to the secure environment received training and education on the residence's policies and procedures specific to the secure environment resident care, services and protections, affecting eight residents (#9, #20, #22-#24, #26, #27, #31) in the secure environment. This deficiency was cited previously during a state licensure survey on 12/7/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. ReferenceChapter VII regulations governing assisted living residences, part 7.12, requires that each personnel file shall include, but not be limited to, written documentation regarding the following items:(C) Orientation and training, including first aid and CPR certification, if applicable. 2. ObservationsOn 6/27/23 from approximately 9:30 a.m. to approximately 4:00 p.m. and on 6/28/23 from approximately 11:30 a.m. to approximately 1:00 p.m., Staff #15 was observed working in the secure environment. 3. Record ReviewThe residence's 5/28/23 through 6/27/23 staff schedule revealed the following:Staff #15 worked in the secure environment on 5/29, 5/30, 6/2-6/4, 6/6-6/8, 6/10-6/14, 6/16-6/21, and 6/23-6/27/23. Staff #17 worked in the secure environment on 5/28, 6/1-6/4, 6/9-6/11, 6/16-6/18, and 6/21-6/25/23. Staff #18 worked in the secure environment on 5/28-5/30, 6/4-6/6, 6//11-6/13, 6/18-6/20, and 6/25-6/27/23. Review of personnel files for Staff #15, #17, and #18 revealed no documentation that they were trained on information on the secure environment that identified and described the areas where residents had free passage, where passage may be restricted, and where passage was prohibited; information regarding the current mobility status of all residents so that they were prepared to successfully evacuate all residents in the event of an emergency; nor information on the equipment and devices used to secure the environment, including how to override or disarm such devices, along with expectations for response if they were alerted to an alarm. 4. InterviewsOn 6/27/23 at 12:56 p.m., the administrator stated she verbally trained some staff but she did not document the training at all. She stated this deficiency that was previously cited was not corrected because she was still working on the training materials and had not yet formally implemented the training to all staff. On 6/27/23 at approximately 2:00 p.m., Staff #15 stated she did not receive training regarding the areas where residents had free passage, where passage may be restricted, nor where passage was prohibited. Staff #15 also stated she had received no training on the current mobility status of all residents prior to working with them. On 6/28/23 at 12:14 p.m., a nurse consultant acknowledged that the administrator had not yet provided training to Staff #15, #17, and #18 . She stated she felt as though the administrator was overwhelmed and did not have the time. The consultant stated this deficiency that was previously cited was not corrected because the administrator had created training packets but had not yet trained the staff despite her recommendation to make staff training a priority

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally

A licensure complaint, prompted by #CO31376, #CO31464, and #CO31567 was completed on 6/28/23. Deficiencies were cited.

Based on observation, record review, and interview, the residence failed to immediately comply with all conditions issued by the department, affecting 55 current residents. Findings include:1. RecordsDepartment records read the residence was currently required to retain a consultant for six months. Following the completion of event CU0211 on 12/7/22, an initial secure licensure, the Department imposed a consultant for six months to address corrective measures for all citations and to also ensure compliance with all other pertinent regulations. The intermediate condition read the consultant was required to complete the following, during the first month of the contract period:Review cited deficiencies identified in the deficiency list and evaluate the residence's current compliance with regulations as outlined in Chapters 2, 7 and 24. The consultant was required to complete the following, during the first two months of the contract period:Evaluate the residence's current compliance with corresponding regulations as outlined in Chapters 2, 7, and 24. Provide recommendations to the administrator on any additional areas of noncompliance. Implement a monitor program to be completed at least monthly to ensure the residence remains in compliance with previously cited deficiencies. The consultant was required to complete the following, during the first through third months of the contract period: Conduct onsite visits at least weekly. The consultant was required to complete the following, during the fourth through sixth months of the contract period:Conduct onsite visits at least twice monthly, increasing the frequency as necessary to assist the residence in maintaining compliance with 6 CCR 1011-1 Chapter 2, Chapter 7, and Chapter 24 and, to prepare the Administrator to independently manage the residence. Additionally, the consultant was required to ensure, during the entire six month contract period, for each of the deficiencies identified in the Deficiency List, for Event CU0211 and dated December 7, 2022, as well as any other areas of identified deficient practice, that the Administrator had a process in place to correct the identified deficiencies, which included utilizing the above-referenced monitoring program to ensure the deficient practice did not reoccur. The consultant will make certain that the monitoring identified the scope of review, how a sample was identified for monitoring purposes, the total length of time the monitoring would continue, and how the monitoring would be documented. Department records read the following deadlines were required for this intermediate condition:- Letter to department to identify possible consultant, due by 3/9/23.- Submit executed consultant contract to the department, due by 3/17/23.- Submit final consultant report, due by 9/15/23. The residence did not appeal the intermediate condition. Department records read the residence had chosen a consultant on 3/21/23. On 3/27/23, the residence submitted a consultant contract for a consultant and the contract for the consultant was received on 3/17/23. Therefore, on the day of the completion of the complaint investigation, (6/28/23), the consultant would have been in her third month as consultant for the residence. 2. Current deficient practice During the 6/28/23 revisit, it was established there was current deficient practice. Five deficiencies were cited: 1146, 1180, 1212, 2130 and 2972. (Cross-reference Q1146, Q1180, Q1212. Q2130, Q2972) 3. InterviewsOn 6//23 at 12:14 p.m., a consultant said the reason the residence was out of compliance with the intermediate condition was because the administrator did not have assistance from a management team with completing her plan of correction and was doing it on her own. The consultant stated she was not aware of the requirement for the residence to not have deficiencies, adding that she had provided directives and tasks for the administrator to complete in order to bring the residence into compliance. She acknowledged that this included updating comprehensive assessments when resident's had a change in their baseline status. The consultant stated, however, that she expected the administrator to complete the tasks and did not complete them for her. On 6//23 at p.m., the administrator stated she was aware of the requirement to be in compliance with the intermediate condition. She stated that she was still working on bringing the residence into compliance after the on site visit.

Based on interview and record review, the residence failed to update the comprehensive assessment when the residents' condition changed from baseline status, affecting two of two sample residents (#20, #29) who experienced changes in their baseline status. (Cross-reference Q1180)Findings include:1. Residence PolicyThe residence's Resident Rules and Regulations Handbook, dated 2021, read in part that the residence updated an assessment whenever there was a change in baseline status and prior to the resident's return to the residence from a hospital or other healthcare facility. 2. Resident #29 was admitted to the residence on 3/8/23 with diagnoses including a history of two hip replacements and arthritis of the knee. A Level of Care Evaluation, dated 3/8/23, read in part that the resident sustained a recent fall and experienced knee pain. It further read that the resident had edema/swelling in her legs and ankles due to lack of exercise. Resident #29 required one staff to assist when transferring, and used a wheelchair and a walker for mobility. An assessment, dated 3/28/23 read in part that Resident #29 was not at risk of falling. Further, it read there were no current musculoskeletal issues, and no history of such issues, including joint replacements or fractures. Additionally, it read the resident did not report any pain. A hospital visit summary, dated 5/14/23, read in part that Resident #29 was seen at the hospital for sacral pain and a closed fracture of the coccyx. There was no evidence that the comprehensive assessment for Resident #29 was updated to reflect the change in baseline status. 3. Resident #20 was admitted to the residence on 4/19/22 with diagnoses including dementia. An assessment, dated 5/8/23, read in part that the resident had no known falls and no known recent injuries in the three months prior 5/8/23. A progress note, dated 6/20/23, read in part that Resident #20 was wandering in the common area when she fell on her bottom. The resident stated she had pain on her bottom. A progress note, dated 6/22/23, read in part that staff noticed a bruise starting to form near Resident #20's tailbone, which could have been a result of a fall onto her bottom that she sustained on 6/20/23. There was no evidence that the comprehensive assessment for Resident #20 was updated to reflect the change in baseline status 4. InterviewOn 6/28/23 at 12:14 p.m., a consultant acknowledged that she had provided guidance to the administrator to update comprehensive assessments when resident's had a change in their baseline status. The consultant stated that she expected the adminstrator and her team, but the administrator had no assistance from a management team. On 6/28/23 at 2:03 p.m., the administrator stated newly found resident injuries were a change in the residents' baseline status. She stated that she was responsible for updating resident assessments, and acknowledged she had not done so for Residents #20 and #29.

Based on interview and record review, the residence failed to develop policies and procedures to establish a fall management program, affecting 55 current residents. (Cross-reference Q1146, Q1212, Q2130)Findings include:1. ReferenceChapter VII regulations governing assisted living residences, part 12.10, requires that each resident care plan shall:(B) Reflect the most current assessment information;(C) Promote resident choice, mobility, independence and safety. 2. Failure to develop a policy and procedure that included the required elementsOn 6/27/23 at approximately 2:35 p.m., the administrator was asked to provide the residence's policy and procedure for fall management. The provided policy was titled Resident Fall, dated 7/30/22. The policy read in part: The residence ensured resident safety and well-being before, during , and after lifting or transferring residents. When a resident fell, the residence followed this policy to determine when to assist a resident who fell. The policy was missing the following required elements:-Providing fall management education and materials to residents and family members;-Detailing in each resident's care plan the individualized approach necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive resident assessment;-Providing resident engagement activities to improve strength and balance as specified in Part 12.22(C);-Routinely inspecting and maintaining a safe exterior and interior environment as specified in Parts 21 and 22; and-Providing staff training related to fall prevention as specified in Part 7.8(B)(6). No additional policies related to a fall management program were provided. 3. Resident #29 was admitted to the residence on 3/8/23 with diagnoses including arthritis and history of having both hips replaced.a. Record ReviewA Level of Care Evaluation, dated 3/8/23, read in part that the resident sustained a recent fall and experienced knee pain. It further read that the resident had edema/swelling in her legs and ankles due to lack of exercise. Resident #29 required one staff to assist when transferring, and used a wheelchair and a walker for mobility. A physician notification, dated 3/9/23, read in part that the resident slipped out of her bed and was found on the floor. The resident had body aches from the cold floor. A physician notification, dated 3/13/23, read in part that Resident #29 slid out of her chair while adjusting it. An assessment/care plan, dated 3/28/23, read in part that Resident #29 was not at risk of falling. Further, it read the resident had no current musculoskeletal issues, and no history of such issues, including joint replacements or fractures. Additionally, it read the resident did not report any pain and did not exercise. An incident report, dated 5/1/23, read in part that Resident #29 slipped on the tile while transferring into her wheelchair, landing on her bottom. The resident stated her socks slipped on the floor when she was transferring into her wheelchair. A hospital visit summary, dated 5/14/23, read in part that Resident #29 was seen at the hospital for sacral pain and a closed fracture of the coccyx. A physician notification, dated 5/16/23, read in part that the resident sustained an unwitnessed fall while transferring herself. An incident report, dated 5/20/23, read in part that Resident #29 fell between her recliner and her wheelchair when she attempted to transfer herself. An incident report. dated 6/9/23, read in part that Resident #29 stated she slowly slipped off the bed while transferring herself into her wheelchair. There were no details in the assessment/care plan regarding the individualized approach necessary to address Resident #29's fall risks related to deficits in strength, balance, and eyesight, nor the potential effects of medication. b. InterviewOn 6/27/23 at 11:57 a.m., Resident #29 stated she had sustained multiple falls since her admission to the residence (approximately three months prior to the on site investigation). She stated that she usually fell transferring herself from one chair to another. She stated the residence did not provide fall management education or materials to try to mitigate future falls. 4. Resident #20 was admitted to the residence on 4/19/22 with diagnoses including dementia and general weakness.a. Record ReviewA progress note, dated 6/20/23, read in part that Resident #20 was wandering in the common area when she fell on her bottom. The resident stated she had pain on her bottom. A progress note, dated 6/22/23, read in part that staff noticed a bruise starting to form near Resident #20's tailbone, which could have been a result of a fall onto her bottom that she sustained on 6/20/23. There were no details in the assessment/care plan regarding the individualized approach necessary to address Resident #29's fall risks related to deficits in strength, balance, and eyesight, nor the potential effects of medication. b. InterviewsOn 6/27/23 at 12:30 p.m., a family member for Resident #20 stated the resident had sustained two falls within the month prior to the on-site investigation. He stated she sustained a fall on 12/24/22 at 5:30 a.m., hitting the back of her head. The family member stated she fell on 6/26/23 because she was ambulating without the use of her walker. He stated the residence did not provide any fall prevention education to him and did not provide any opportunities for the residents to exercise, so he walked with her up and down the hallway of the secure environment to maintain her strength. On 6/27/23 at 12:546 p.m., the administrator stated she was working on the training program but had not implemented new training processes. She stated she was unable to provide documentation regarding any staff training related to fall prevention. On 6/27/23 at approximately 2:00 p.m., Staff #15 stated she tried to keep residents in the common living room to keep a closer eye on the residents and prevent falls. She stated Resident #20 sustained a fall on 6/26/23 because she was up and about. Staff #15 stated she and Staff #14 were on duty but were in another part of the secure environment moving furniture. Staff #15 stated that the residence did not implement any changes in their approach to Resident #20's care to mitigate future falls. On 6/28/23 at 11:30 a.m., Staff #15 stated that to her knowledge, the residence did not inspect the environment to determine any obstacles for fall management and safety. On 6/28/23 at 11:50 a.m., Staff #16 stated she had been working at the residence for approximately one month. She stated the residence did not provide training specifically about preventing falls, only what to do after residents sustained falls. 5. Resident #30 was admitted to the residence on 8/14/22 with diagnoses including history of falls.a. Record ReviewAn incident report, dated 3/4/23, read in part that Resident #30 was transferring from her wheelchair to the bed and fell on her bottom onto the floor. An assessment/care plan, dated 3/28/23, read the resident was not at risk of falling, but had a balance problem when standing. Furthermore, it read that the resident did not exercise and reported no pain. An incident report, dated 4/30/23, read in part that Resident #30 fell out of bed. No bruising, skin tears or pain was noted, except in the palms of her hands. An incident report, dated 6/7/23, read in part that Resident #30 was transferring into her wheelchair, missed the chair, and fell on her bottom. There were no details in the assessment/care plan regarding the individualized approach necessary to address Resident #29's fall risks related to deficits in strength, balance, and eyesight, nor the potential effects of medication. b. InterviewsOn 6/28/23 at 12:14 p.m., the consultant stated she had not seen the residence's fall management policy. She added she was not aware of the elements required to be in the residence's fall management policy. On 6/28/23 at 2:03 p.m., the administrator acknowledged the residence's current fall management program policy that she provided did not contain the required regulatory elements. She stated she had not updated the care plans for Residents #20, #29, and #30 to include new fall interventions and the individualized approach to address and mitigate fall risks.

Based on observations, record review, and interview, the residence failed to provide all residents with regular opportunities to participate in structured engagement and support the pursuit of each resident's interests, affecting eight current residents (#9, #20, #22-#24, #26, #27, #31) residing in the secure environment. (Cross-Reference Q1180)Findings include:1. References and Residence Policya. The residence's resident agreement, dated 2021, read in part that the residence provided monthly activity programming, cognitively appropriate spontaneous activities, and life skills areas.b. The residence's engagement policy, dated 7/30/22, read in part that the residence encouraged all residents to maintain and develop their fullest potential through individual and group engagement activities. The residence provided all residents with regular opportunities to participate in structured activities and utilized resident input and interests to create activities geared to the specific residents currently residing at the residence.c. The residence's secure environment policy, dated 7/30/22, read in part that the residence provided daily activities specific to people with cognitive impairment, ensured regular exercise, cognitive stimulation, and spiritual and emotional support. Residents who could safely exit the secure environment under staff supervision were able to participate in activities, such as bingo, in the non-secure environment.d. According to the Alzheimer's Association, "A person living with Alzheimer's or other dementia doesn't have to give up the activities that he or she loves. Many activities can be modified to the person's ability. In addition to enhancing quality of life, activities can reduce behaviors like wandering or agitation." Alzheimer's Association (2023) Activities, retrieved from: https://www.alz.org/help-support/caregiving/daily-care/activities#:~:text=A%20person%20living%20with%20Alzheimer's,behaviors%20like%20wandering%20or%20agitation. e. According to the Advocate, "Researchers at the institute (Lighting Research Center at Rensselaer Polytechnic Institute in New York) found that exposure to a bluish-white light during the daytime for four weeks significantly increased sleep quality, total sleep time and reduced agitation and depression. Improved sleep means improved behavior among those affected by Alzheimer's or dementia. Additionally, the study showed that light interventions led to improvement in appetite and calmer and more manageable behaviors. A growing number of studies have shown that better and brighter lighting can improve sundowning behaviors and also reduce sleep/wake disturbances." Advocate (1/26/20) How Does Light Affect Someone with Alzheimer's or Dementia, retrieved from: https://www.theadvocate.com/baton_rouge/entertainment_life/health_fitness/alzheimers-q-a-how-does-light-affect-someone-with-alzheimers-or-dementia/article_b8d8a440-2d98-11ea-a317-a7441fa351ea.html 2. Observations in the Secure EnvironmentOn 6/27/23 at approximately 12:50 p.m., a monthly activities calendar was posted on a bulletin board in the hallway of the secure environment. It read that on Tuesdays, the activity schedule was as follows:7:30 a.m. Breakfast9:30 a.m. to 10:00 a.m. Let's Move to Music10:00 a.m. Coffee and snacks11:30 a.m. Lunch1:00 p.m. to 2:00 p.m. Let's Read Some Books2:00 p.m. to 3:00 p.m. Movie Time3:00 p.m. to 4:00 p.m. It's Fidget (sic) Time4:30 p.m. Dinner5:30 p.m. to 6:00 p.m. Book TimeThe posted activity calendar read that on Wednesdays, the activity schedule was as follows:7:30 a.m. Breakfast9:30 a.m. to 10:00 a.m. Let's Move to Music10:00 a.m. Coffee and snacks11:30 a.m. Lunch1:00 p.m. Painting2:00 p.m. to 3:00 p.m. Movie Time3:00 p.m. Dancing with the Stars4:30 p.m. Dinner5:30 p.m. to 6:00 p.m. Book TimeOn Tuesday 6/27/23, the following was observed:9:50 a.m. - three residents were seated in the common living room. The television was on. 12:50 p.m. - a movie was playing on the television in the common area living room. The lights in the room were off. 2:00 p.m. - In the common area living room, Resident #27 slept in a recliner with her feet up. Resident #24 sat on a sofa that was not facing the television, looking straight forward and tapping her fingers on the sofa. Resident #26 sat in a chair with her arms folded. Resident #23 sat in a chair with her arms and legs crossed, yawned, closed her eyes, and laid her head back. The lights were dim, and a staff member played another movie on the television. 2:25 p.m. - Residents in the unsecure environment played bingo in the unsecure environment's common dining room. No residents from the secure environment attended this activity. 3:30 p.m. - The secure environment common living room had a movie on the television and the lights were off. Resident #24 sat on a sofa with a blanket over her and a stuffed toy next to her. The sofa did not face the television, so she was not engaged in the movie. Resident #27 was seated in a recliner with her legs up as she was at 2:00 p.m.; she was not engaged in the movie. Resident #26 sat in a chair and was bent over with her elbows on her legs, looking at her lap, and combing through her hair with her fingers. Resident #23 sat in the same chair as she was at 2:00 p.m., looking around the room and not appearing to be engaged in the movie. On 6/27/23 at approximately 2:15 p.m., a posting in a staff office in the secure environment read "Memory Unit Day Shift Schedule." Underneath this was a schedule of staff duties from 6:00 a.m. to 6:00 p.m. Another posting read "Memory Unit Night Shift Schedule." Underneath this was a schedule of staff duties from 6:00 p.m. to 6:00 a.m. Neither of these schedules assigned any allotted time for staff to conduct any activities with residents. On Wednesday 6/28/23, the following was observed:8:58 a.m. - The secure environment common living room television was playing a movie. Residents #23 and #24 were meeting with external service providers (ESP). Resident #26 was sitting in a chair with a blanket on top of her. Resident #26 sat on the right side of a sofa with her arms crossed, legs crossed, her head laid back, and her eyes closed. Resident #22 sat in a chair with a blanket on top of her rocking back and forth in what appeared to be an attempt to stand. 9:02 a.m. - a staff member brought Resident #27 into the living room via wheelchair. She transferred the resident into the same recliner she was seated in the day prior, and elevated her legs. Resident #27 shortly thereafter closed her eyes. 10:44 a.m. - Resident #9 sat in a chair in the secure environment's common living room. She looked off in the distance (not at the television) and was manipulating her lips with her fingers. An animated movie was on the television. Resident #27 was in the same recliner as at 9:02 a.m. Resident #26 was yelling "Ahh" repeatedly. Resident #24 was on the sofa with a blanket on top of her and her eyes closed. Resident #23 sat on a couch asleep leaning over the arm of the couch, her arms crossed, and her legs crossed. 3. InterviewsOn 6/27/23 at 12:20 p.m., Staff #13 stated that she was not aware of the activity schedule posted on the bulletin board for the residents in the secure environment. She stated that the staff in the secure environment did not follow an activity schedule, adding that she had not ever noticed an activities calendar solely for the secure environment posted on the bulletin board. Staff #13 stated there were two residents who sometimes went to the unsecure environment to participate in activities. She stated she was not aware of what "Fidget Time" meant, but residents were not offered an activity from 3:00 p.m. to 4:00 p.m. because staff needed that time to prepare for dinner. Staff #13 added that the residence provided no activities after dinner because staff was providing resident care and cleaning. On 6/27/23 at 12:30 p.m., family member of Resident #20 stated he was aware of people who came to the secure environment twice weekly to sing with the residents. He stated, however, the main activities for the residents residing in the secure environment consisted mainly of watching television and sleeping. On 6/27/23 at approximately 12:50 p.m., a family member for Resident #27 stated he did not observe anyone conducting any activities when he came to visit Resident #27 daily. On 6/27/23 at 12:56 p.m., the administrator acknowledged that the residence lacked a robust activities program in the secure environment. She stated the activities coordinator started working at the residence in April 2023, focusing on increasing the number and quality of activities in the unsecure environment. The administrator stated, however, that there was opportunity for improvement in activities in the secure environment. On 6/27/23 at 2:00 p.m., Staff #15 stated Residents #9, #22, and #31 were sleeping in their prospective rooms. She stated activities in the secure environment consisted of visits from residents in the unsecure environment on Tuesdays (and sometimes on Mondays) to sing with the residents. She stated Residents #9 and #31 went to the unsecure environment to participate in activities four times weekly. Staff #15 stated sometimes staff took residents outside for fresh air and vitamin D, but otherwise, residents watched movies all day. She acknowledged that no activities were scheduled on the posted day and night staff schedules. Staff #15 stated that when the residents were in really "good moods," staff brought out games to play with them, adding, however, that it had been over one month. On 6/28/23 at 9:05 a.m., an ESP stated she visited Resident #24 in the secure environment at least once weekly. She stated that every time she came, the residents were in the living room with the television on and the lights off. The ESP stated Resident #24 could not participate in puzzles because she could not see nor hear well. She acknowledged, however, that holding hands, hair combing, and hand massages were activities she would benefit from. The ESP stated that keeping the lights on in the common areas, along with increased activities, could help with the residents' moods, wandering, and behaviors. On 6/28/23 at 12:14 p.m., the consultant stated two of the residents in the secure environment go to activities in the unsecure environment. She stated the residents watched a lot of movies with the lights dimmed. The nurse consultant stated if the residents spent more time in the light, they would sleep better at night. She added she did not see anyone conducting any organized activities when she visited weekly up to four hours at a time.

Based on record review and interview, the residence failed to ensure that resident records contained progress notes, affecting four of four sample residents (#20, #29-#31). (Cross-reference Q1180)Findings include:The residence's Resident Health Information Records policy, dated 7/22/22, read in part that the residence maintained resident records in a manner that ensured accuracy of information. Resident records were kept on site utilizing both paper-based and electronic systems. Resident records contained progress notes which included information on the residents' status and wellbeing, as well as documentation regarding out of the ordinary events and issues that affected a resident's physical, behavioral, cognitive, and/or functional condition, along with the action taken by staff to address the resident's changing needs. On 6/27/23 at 3:48 p.m., progress notes from 3/1/23 to 6/27/23 for Residents #29, #30, #31 were requested. Additionally, progress notes for Resident #20 11/1/22 to 6/27/23 were requested. On 6/28/23 at 8:01 a.m., the administrator stated the residence had used an electronic information management system until 5/5/23 before switching to another electronic information management system. She stated the residence did not have access to any progress notes for Residents #20 and #29-#31 dated on or before 4/2/23. This included progress notes with regard to the fall Resident #20 had sustained on 12/24/22. At 10:22 a.m., the administrator stated Resident #29 had sustained two or three falls since her admission on 3/8/23, adding that Resident #30 also had sustained falls. She stated, however, that the resident records for Residents #29 and #30 contained no progress notes at all. On 6/28/23 at 12:14 p.m., the consultant stated the residence had difficulties with their electronic information management system, adding that she was unaware as to why. She stated that she was relying on the residence's corporate offices to help mitigate the problems with their electronic information management system.

Based on observations, record review and interview, the residence failed to ensure staff assigned to the secure environment received training and education on the residence's policies and procedures specific to the secure environment resident care, services and protections, affecting eight residents (#9, #20, #22-#24, #26, #27, #31) in the secure environment. Findings include:1. ReferenceChapter VII regulations governing assisted living residences, part 7.12, requires that each personnel file shall include, but not be limited to, written documentation regarding the following items:(C) Orientation and training, including first aid and CPR certification, if applicable. 2. ObservationsOn 6/27/23 from approximately 9:30 a.m. to approximately 4:00 p.m. and on 6/28/23 from approximately 11:30 a.m. to approximately 1:00 p.m., Staff #15 was observed working in the secure environment. 3. Record ReviewThe residence's 5/28/23 through 6/27/23 staff schedule revealed the following:Staff #15 worked in the secure environment on 5/29, 5/30, 6/2-6/4, 6/6-6/8, 6/10-6/14, 6/16-6/21, and 6/23-6/27/23. Staff #17 worked in the secure environment on 5/28, 6/1-6/4, 6/9-6/11, 6/16-6/18, and 6/21-6/25/23. Staff #18 worked in the secure environment on 5/28-5/30, 6/4-6/6, 6//11-6/13, 6/18-6/20, and 6/25-6/27/23. Review of personnel files for Staff #15, #17, and #18 revealed no documentation that they were trained on information on the secure environment that identified and described the areas where residents had free passage, where passage may be restricted, and where passage was prohibited; information regarding the current mobility status of all residents so that they were prepared to successfully evacuate all residents in the event of an emergency; nor information on the equipment and devices used to secure the environment, including how to override or disarm such devices, along with expectations for response if they were alerted to an alarm. 4. InterviewsOn 6/27/23 at 12:56 p.m., the administrator stated she verbally trained some staff but she did not document the training at all. She stated she was still working on the training materials and had not yet formally implemented the training to all staff. On 6/27/23 at approximately 2:00 p.m., Staff #15 stated she did not receive training regarding the areas where residents had free passage, where passage may be restricted, nor where passage was prohibited. Staff #15 also stated she had received no training on the current mobility status of all residents prior to working with them. On 6/28/23 at 12:14 p.m., the consultant acknowledged that the administrator had not yet provided training to Staff #15, #17, and #18. She stated she felt as though the administrator was overwhelmed and did not have the time. The nurse consultant stated the administrator had created training packets but had not yet trained the staff despite her recommendation to make staff training a priority.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.7.12 Each personnel file shall include, but not be limited to, written documentation regarding the following items:(A) A description of the employee or volunteer duties;(B) Date of hire or acceptance of volunteer service and date duties commenced;(C) Orientation and training, including first aid and CPR certification, if applicable;(D) Verification from the Department of Regulatory Agencies, or other state agency, of an active license or certification, if applicable;(E) Results of background checks and follow up, as applicable; and(F) Tuberculin test results, if applicable. 18.9 The face sheet shall be updated at least annually and contain the following information:(A) Resident's full name, including maiden name, if applicable;(B) Resident's sex, date of birth, and marital status;(C) Resident's most recent former address;(D) Resident's medical insurance information and Medicaid number, if applicable;(E) Date of admission and readmission, if applicable;(F) Name, address and contact information for family members, legal representatives, and/or other persons to be notified in case of emergency;(G) Name, address, and contact information for resident's practitioner and case manager, if applicable;(H) Resident's primary spoken language and any issues with oral communication;(I) Indication of resident's religious preference, if any;(J) Resident's current diagnoses; and(K) Notation of resident's allergies, if any.

A certification complaint, prompted by #CO31377, #CO31465, #CO31568 was completed on 6/28/23. Deficiencies were cited.

Based on interview and record review, the facility (residence) failed to conduct an assessment whenever there was a significant change in the participants' (residents') physical, cognitive, or behavioral needs, affecting two of two sample residents (#20, #29) who experienced significant changes. Findings include:1. Residence PolicyThe residence's Resident Rules and Regulations Handbook, dated 2021, read in part that the residence updated an assessment whenever there was a change in baseline status and prior to the resident's return to the residence from a hospital or other healthcare facility. 2. Resident #29 was admitted to the residence on 3/8/23 with diagnoses including a history of two hip replacements and arthritis of the knee. A Level of Care Evaluation, dated 3/8/23, read in part that the resident sustained a recent fall and experienced knee pain. It further read that the resident had edema/swelling in her legs and ankles due to lack of exercise. Resident #29 required one staff to assist when transferring, and used a wheelchair and a walker for mobility. An assessment, dated 3/28/23 read in part that Resident #29 was not at risk of falling. Further, it read there were no current musculoskeletal issues, and no history of such issues, including joint replacements or fractures. Additionally, it read the resident did not report any pain. A hospital visit summary, dated 5/14/23, read in part that Resident #29 was seen at the hospital for sacral pain and a closed fracture of the coccyx. There was no evidence that the comprehensive assessment for Resident #29 was updated to reflect the change in baseline status. 3. Resident #20 was admitted to the residence on 4/19/22 with diagnoses including dementia. An assessment, dated 5/8/23, read in part that the resident had no known falls and no known recent injuries in the three months prior 5/8/23. A progress note, dated 6/20/23, read in part that Resident #20 was wandering in the common area when she fell on her bottom. The resident stated she had pain on her bottom. A progress note, dated 6/22/23, read in part that staff noticed a bruise starting to form near Resident #20's tailbone, which could have been a result of a fall onto her bottom that she sustained on 6/20/23. There was no evidence that the comprehensive assessment for Resident #20 was updated to reflect the change in baseline status 4. InterviewOn 6/28/23 at 12:14 p.m., a consultant acknowledged that she had provided guidance to the administrator to update comprehensive assessments when resident's had a change in their baseline status. The consultant stated that she expected the adminstrator and her team, but the administrator had no assistance from a management team. On 6/28/23 at 2:03 p.m., the administrator stated newly found resident injuries were a change in the residents' baseline status. She stated that she was responsible for updating resident assessments, and acknowledged she had not done so for Residents #20 and #29.

Based on observation, record review, and interview, the facility (residence) failed to provide social and recreational engagement both within and outside the facility, affecting eight current participants (residents) (#9, #20, #22-#24, #26, #27, #31) residing in the secure environment. Findings include:1. References and Residence Policya. The residence's resident agreement, dated 2021, read in part that the residence provided monthly activity programming, cognitively appropriate spontaneous activities, and life skills areas.b. The residence's engagement policy, dated 7/30/22, read in part that the residence encouraged all residents to maintain and develop their fullest potential through individual and group engagement activities. The residence provided all residents with regular opportunities to participate in structured activities and utilized resident input and interests to create activities geared to the specific residents currently residing at the residence.c. The residence's secure environment policy, dated 7/30/22, read in part that the residence provided daily activities specific to people with cognitive impairment, ensured regular exercise, cognitive stimulation, and spiritual and emotional support. Residents who could safely exit the secure environment under staff supervision were able to participate in activities, such as bingo, in the non-secure environment.d. According to the Alzheimer's Association, "A person living with Alzheimer's or other dementia doesn't have to give up the activities that he or she loves. Many activities can be modified to the person's ability. In addition to enhancing quality of life, activities can reduce behaviors like wandering or agitation." Alzheimer's Association (2023) Activities, retrieved from: https://www.alz.org/help-support/caregiving/daily-care/activities#:~:text=A%20person%20living%20with%20Alzheimer's,behaviors%20like%20wandering%20or%20agitation. e. According to the Advocate, "Researchers at the institute (Lighting Research Center at Rensselaer Polytechnic Institute in New York) found that exposure to a bluish-white light during the daytime for four weeks significantly increased sleep quality, total sleep time and reduced agitation and depression. Improved sleep means improved behavior among those affected by Alzheimer's or dementia. Additionally, the study showed that light interventions led to improvement in appetite and calmer and more manageable behaviors. A growing number of studies have shown that better and brighter lighting can improve sundowning behaviors and also reduce sleep/wake disturbances." Advocate (1/26/20) How Does Light Affect Someone with Alzheimer's or Dementia, retrieved from: https://www.theadvocate.com/baton_rouge/entertainment_life/health_fitness/alzheimers-q-a-how-does-light-affect-someone-with-alzheimers-or-dementia/article_b8d8a440-2d98-11ea-a317-a7441fa351ea.html 2. Observations in the Secure EnvironmentOn 6/27/23 at approximately 12:50 p.m., a monthly activities calendar was posted on a bulletin board in the hallway of the secure environment. It read that on Tuesdays, the activity schedule was as follows:7:30 a.m. Breakfast9:30 a.m. to 10:00 a.m. Let's Move to Music10:00 a.m. Coffee and snacks11:30 a.m. Lunch1:00 p.m. to 2:00 p.m. Let's Read Some Books2:00 p.m. to 3:00 p.m. Movie Time3:00 p.m. to 4:00 p.m. It's Fidget (sic) Time4:30 p.m. Dinner5:30 p.m. to 6:00 p.m. Book TimeThe posted activity calendar read that on Wednesdays, the activity schedule was as follows:7:30 a.m. Breakfast9:30 a.m. to 10:00 a.m. Let's Move to Music10:00 a.m. Coffee and snacks11:30 a.m. Lunch1:00 p.m. Painting2:00 p.m. to 3:00 p.m. Movie Time3:00 p.m. Dancing with the Stars4:30 p.m. Dinner5:30 p.m. to 6:00 p.m. Book TimeOn Tuesday 6/27/23, the following was observed:9:50 a.m. - three residents were seated in the common living room. The television was on. 12:50 p.m. - a movie was playing on the television in the common area living room. The lights in the room were off. 2:00 p.m. - In the common area living room, Resident #27 slept in a recliner with her feet up. Resident #24 sat on a sofa that was not facing the television, looking straight forward and tapping her fingers on the sofa. Resident #26 sat in a chair with her arms folded. Resident #23 sat in a chair with her arms and legs crossed, yawned, closed her eyes, and laid her head back. The lights were dim, and a staff member played another movie on the television. 2:25 p.m. - Residents in the unsecure environment played bingo in the unsecure environment's common dining room. No residents from the secure environment attended this activity. 3:30 p.m. - The secure environment common living room had a movie on the television and the lights were off. Resident #24 sat on a sofa with a blanket over her and a stuffed toy next to her. The sofa did not face the television, so she was not engaged in the movie. Resident #27 was seated in a recliner with her legs up as she was at 2:00 p.m.; she was not engaged in the movie. Resident #26 sat in a chair and was bent over with her elbows on her legs, looking at her lap, and combing through her hair with her fingers. Resident #23 sat in the same chair as she was at 2:00 p.m., looking around the room and not appearing to be engaged in the movie. On 6/27/23 at approximately 2:15 p.m., a posting in a staff office in the secure environment read "Memory Unit Day Shift Schedule." Underneath this was a schedule of staff duties from 6:00 a.m. to 6:00 p.m. Another posting read "Memory Unit Night Shift Schedule." Underneath this was a schedule of staff duties from 6:00 p.m. to 6:00 a.m. Neither of these schedules assigned any allotted time for staff to conduct any activities with residents. On Wednesday 6/28/23, the following was observed:8:58 a.m. - The secure environment common living room television was playing a movie. Residents #23 and #24 were meeting with external service providers (ESP). Resident #26 was sitting in a chair with a blanket on top of her. Resident #26 sat on the right side of a sofa with her arms crossed, legs crossed, her head laid back, and her eyes closed. Resident #22 sat in a chair with a blanket on top of her rocking back and forth in what appeared to be an attempt to stand. 9:02 a.m. - a staff member brought Resident #27 into the living room via wheelchair. She transferred the resident into the same recliner she was seated in the day prior, and elevated her legs. Resident #27 shortly thereafter closed her eyes. 10:44 a.m. - Resident #9 sat in a chair in the secure environment's common living room. She looked off in the distance (not at the television) and was manipulating her lips with her fingers. An animated movie was on the television. Resident #27 was in the same recliner as at 9:02 a.m. Resident #26 was yelling "Ahh" repeatedly. Resident #24 was on the sofa with a blanket on top of her and her eyes closed. Resident #23 sat on a couch asleep leaning over the arm of the couch, her arms crossed, and her legs crossed. 3. InterviewsOn 6/27/23 at 12:20 p.m., Staff #13 stated that she was not aware of the activity schedule posted on the bulletin board for the residents in the secure environment. She stated that the staff in the secure environment did not follow an activity schedule, adding that she had not ever noticed an activities calendar solely for the secure environment posted on the bulletin board. Staff #13 stated there were two residents who sometimes went to the unsecure environment to participate in activities. She stated she was not aware of what "Fidget Time" meant, but residents were not offered an activity from 3:00 p.m. to 4:00 p.m. because staff needed that time to prepare for dinner. Staff #13 added that the residence provided no activities after dinner because staff was providing resident care and cleaning. On 6/27/23 at 12:30 p.m., family member of Resident #20 stated he was aware of people who came to the secure environment twice weekly to sing with the residents. He stated, however, the main activities for the residents residing in the secure environment consisted mainly of watching television and sleeping. On 6/27/23 at approximately 12:50 p.m., a family member for Resident #27 stated he did not observe anyone conducting any activities when he came to visit Resident #27 daily. On 6/27/23 at 12:56 p.m., the administrator acknowledged that the residence lacked a robust activities program in the secure environment. She stated the activities coordinator started working at the residence in April 2023, focusing on increasing the number and quality of activities in the unsecure environment. The administrator stated, however, that there was opportunity for improvement in activities in the secure environment. On 6/27/23 at 2:00 p.m., Staff #15 stated Residents #9, #22, and #31 were sleeping in their prospective rooms. She stated activities in the secure environment consisted of visits from residents in the unsecure environment on Tuesdays (and sometimes on Mondays) to sing with the residents. She stated Residents #9 and #31 went to the unsecure environment to participate in activities four times weekly. Staff #15 stated sometimes staff took residents outside for fresh air and vitamin D, but otherwise, residents watched movies all day. She acknowledged that no activities were scheduled on the posted day and night staff schedules. Staff #15 stated that when the residents were in really "good moods," staff brought out games to play with them, adding, however, that it had been over one month. On 6/28/23 at 9:05 a.m., an ESP stated she visited Resident #24 in the secure environment at least once weekly. She stated that every time she came, the residents were in the living room with the television on and the lights off. The ESP stated Resident #24 could not participate in puzzles because she could not see nor hear well. She acknowledged, however, that holding hands, hair combing, and hand massages were activities she would benefit from. The ESP stated that keeping the lights on in the common areas, along with increased activities, could help with the residents' moods, wandering, and behaviors. On 6/28/23 at 12:14 p.m., the consultant stated two of the residents in the secure environment go to activities in the unsecure environment. She stated the residents watched a lot of movies with the lights dimmed. The nurse consultant stated if the residents spent more time in the light, they would sleep better at night. She added she did not see anyone conducting any organized activities when she visited weekly up to four hours at a time.

Based on record review and interview the facility (residence) failed to document in the care plan all health management needs to support the participant's (resident's) individual needs, affecting three of five sample residents (#20, #29, #30). Findings include:1. Residence PolicyThe residence's care plan policy, dated 7/23/22, read in part that the residence utilized the care plan to identify individual resident needs, evaluate the effectiveness of previous interventions and resident status, and to develop resident-centered interventions and methods of care for each resident. 2. Resident #29 was admitted to the residence on 3/8/23 with diagnoses including arthritis and history of having both hips replaced.a. Record ReviewA Level of Care Evaluation, dated 3/8/23, read in part that the resident sustained a recent fall and experienced knee pain. It further read that the resident had edema/swelling in her legs and ankles due to lack of exercise. Resident #29 required one staff to assist when transferring, and used a wheelchair and a walker for mobility. A physician notification, dated 3/9/23, read in part that the resident slipped out of her bed and was found on the floor. The resident had body aches from the cold floor. A physician notification, dated 3/13/23, read in part that Resident #29 slid out of her chair while adjusting it. An assessment/care plan, dated 3/28/23, read in part that Resident #29 was not at risk of falling. Further, it read the resident had no current musculoskeletal issues, and no history of such issues, including joint replacements or fractures. Additionally, it read the resident did not report any pain and did not exercise. An incident report, dated 5/1/23, read in part that Resident #29 slipped on the tile while transferring into her wheelchair, landing on her bottom. The resident stated her socks slipped on the floor when she was transferring into her wheelchair. A hospital visit summary, dated 5/14/23, read in part that Resident #29 was seen at the hospital for sacral pain and a closed fracture of the coccyx. A physician notification, dated 5/16/23, read in part that the resident sustained an unwitnessed fall while transferring herself. An incident report, dated 5/20/23, read in part that Resident #29 fell between her recliner and her wheelchair when she attempted to transfer herself. An incident report. dated 6/9/23, read in part that Resident #29 stated she slowly slipped off the bed while transferring herself into her wheelchair. There were no details in the assessment/care plan regarding the individualized approach necessary to address Resident #29's fall risks related to deficits in strength, balance, and eyesight, nor the potential effects of medication. b. InterviewOn 6/27/23 at 11:57 a.m., Resident #29 stated she had sustained multiple falls since her admission to the residence (approximately three months prior to the on site investigation). She stated that she usually fell transferring herself from one chair to another. She stated the residence did not provide fall management education or materials to try to mitigate future falls. 3. Resident #20 was admitted to the residence on 4/19/22 with diagnoses including dementia and general weakness.a. Record ReviewA progress note, dated 6/20/23, read in part that Resident #20 was wandering in the common area when she fell on her bottom. The resident stated she had pain on her bottom. A progress note, dated 6/22/23, read in part that staff noticed a bruise starting to form near Resident #20's tailbone, which could have been a result of a fall onto her bottom that she sustained on 6/20/23. There were no details in the assessment/care plan regarding the individualized approach necessary to address Resident #29's fall risks related to deficits in strength, balance, and eyesight, nor the potential effects of medication. b. InterviewsOn 6/27/23 at 12:30 p.m., a family member for Resident #20 stated the resident had sustained two falls within the month prior to the on-site investigation. He stated she sustained a fall on 12/24/22 at 5:30 a.m., hitting the back of her head. The family member stated she fell on 6/26/23 because she was ambulating without the use of her walker. He stated the residence did not provide any fall prevention education to him and did not provide any opportunities for the residents to exercise, so he walked with her up and down the hallway of the secure environment to maintain her strength. On 6/27/23 at 12:546 p.m., the administrator stated she was working on the training program but had not implemented new training processes. She stated she was unable to provide documentation regarding any staff training related to fall prevention. On 6/27/23 at approximately 2:00 p.m., Staff #15 stated she tried to keep residents in the common living room to keep a closer eye on the residents and prevent falls. She stated Resident #20 sustained a fall on 6/26/23 because she was up and about. Staff #15 stated she and Staff #14 were on duty but were in another part of the secure environment moving furniture. Staff #15 stated that the residence did not implement any changes in their approach to Resident #20's care to mitigate future falls. On 6/28/23 at 11:30 a.m., Staff #15 stated that to her knowledge, the residence did not inspect the environment to determine any obstacles for fall management and safety. On 6/28/23 at 11:50 a.m., Staff #16 stated she had been working at the residence for approximately one month. She stated the residence did not provide training specifically about preventing falls, only what to do after residents sustained falls. 4. Resident #30 was admitted to the residence on 8/14/22 with diagnoses including history of falls.a. Record ReviewAn incident report, dated 3/4/23, read in part that Resident #30 was transferring from her wheelchair to the bed and fell on her bottom onto the floor. An assessment/care plan, dated 3/28/23, read the resident was not at risk of falling, but had a balance problem when standing. Furthermore, it read that the resident did not exercise and reported no pain. An incident report, dated 4/30/23, read in part that Resident #30 fell out of bed. No bruising, skin tears or pain was noted, except in the palms of her hands. An incident report, dated 6/7/23, read in part that Resident #30 was transferring into her wheelchair, missed the chair, and fell on her bottom. There were no details in the assessment/care plan regarding the individualized approach necessary to address Resident #29's fall risks related to deficits in strength, balance, and eyesight, nor the potential effects of medication. b. InterviewsOn 6/28/23 at 12:14 p.m., the consultant stated she had not seen the residence's fall management policy. She added she was not aware of the elements required to be in the residence's fall management policy. On 6/28/23 at 2:03 p.m., the administrator acknowledged the residence's current fall management program policy that she provided did not contain the required regulatory elements. She stated she had not updated the care plans for Residents #20, #29, and #30 to include new fall interventions and the individualized approach to address and mitigate fall risks.

Based on record review and interview, the facility (residence) failed to ensure staff assigned to the secure environment received training within the first thirty days of employment, affecting six participants (residents) (#9, #20, #23, #26, #27, #31) in the secure environment. Findings include:Findings include:1. ObservationsOn 6/27/23 from approximately 9:30 a.m. to approximately 4:00 p.m. and on 6/28/23 from approximately 11:30 a.m. to approximately 1:00 p.m., Staff #15 was observed working in the secure environment. 2. Record ReviewThe residence's 5/28/23 through 6/27/23 staff schedule revealed the following:Staff #15 worked in the secure environment on 5/29, 5/30, 6/2-6/4, 6/6-6/8, 6/10-6/14, 6/16-6/21, and 6/23-6/27/23. Staff #17 worked in the secure environment on 5/28, 6/1-6/4, 6/9-6/11, 6/16-6/18, and 6/21-6/25/23. Staff #18 worked in the secure environment on 5/28-5/30, 6/4-6/6, 6//11-6/13, 6/18-6/20, and 6/25-6/27/23. Review of personnel files for Staff #15, #17, and #18 revealed no documentation that they were trained on information on the secure environment that identified and described the areas where residents had free passage, where passage may be restricted, and where passage was prohibited; information regarding the current mobility status of all residents so that they were prepared to successfully evacuate all residents in the event of an emergency; nor information on the equipment and devices used to secure the environment, including how to override or disarm such devices, along with expectations for response if they were alerted to an alarm. 3. InterviewsOn 6/27/23 at 12:56 p.m., the administrator stated she verbally trained some staff but she did not document the training at all. She stated she was still working on the training materials and had not yet formally implemented the training to all staff. The administrator stated she was unable to provide documentation regarding any staff training related to fall prevention. On 6/27/23 at approximately 2:00 p.m., Staff #15 stated she did not receive training regarding the areas where residents had free passage, where passage may be restricted, nor where passage was prohibited. Staff #15 also stated she had received no training on the current mobility status of all residents prior to working with them. On 6/28/23 at 11:50 a.m., Staff #16 stated she had been working at the residence for approximately one month. She stated the residence did not provide training specifically about preventing falls, only what to do after residents sustained falls. On 6/28/23 at 12:14 p.m., the consultant acknowledged that the administrator had not yet provided training to Staff #15, #17, and #18. She stated she felt as though the administrator was overwhelmed and did not have the time. The nurse consultant stated the administrator had created training packets but had not yet trained the staff despite her recommendation to make staff training a priority.