LIVE WELL COMMUNITY CARE

A certification complaint, prompted by #CO31641 was completed on 5/1/23. Deficiencies were cited.

Based on observation, interview and record review, the facility (residence) failed to ensure participants (residents) had access to food at all times, affecting six current residents. Findings include:1. Residence policiesAn undated resident agreement, read in part, the residence provided residents with snacks. 2. ObservationsOn 5/1/23 from approximately 10:00 a.m. to 3:00 p.m., the residence did not have snacks accessible to residents at all times. There was a box full of snacks located in the garage which was not accessible to residents. 3. InterviewsOn 5/1/23 at 10:25 a.m., Resident #2 stated snacks were not available at all times and that residents had to request snacks from staff because they did not have access to the garage. He also stated sometimes staff would not give them snacks. On 5/1/23 at 10:56 a.m., Resident #4 stated she was required to request snacks from the staff, however, sometimes staff refused to give her a snack. Further, she stated food was not available at all times to the residents because it was stored in the garage that they were unable to access. She also stated she bought herself snacks at the store independently because the residence did not always provide snacks. On 5/1/23 at approximately 2:00 p.m., the administrator stated residents should have had access to snacks at all times. He also stated staff should never refuse snack requests from residents.

Based on observation, record review and interview, the facility (residence) failed to ensure all participants (residents) were encouraged to participate in engagement opportunities and activities, affecting six current residents. Findings include:1. Residence policyThe undated resident agreement, read in part, the residence provided residents with opportunities for social and recreational activities. 2. ObservationsOn 4/24/23 between 10:00 a.m. and 3:00 p.m., the staff did not offer resident engagement activities to residents. There was no posted engagement activity calendar. 3. InterviewsOn 5/1/23 at 10:25 a.m., Resident #2 stated the residence did not offer any engagement opportunities. He stated he would like to participate in outings to parks. On 5/1/23 at 10:56 a.m., Resident #4 stated the residence did not offer any engagement opportunities for any residents. She stated she would like to engage in movie nights and games with other residents. On 5/1/23 at 2:00 p.m., the administrator stated the residence did not provide any of the residents with regular opportunities to participate in structured engagement activities in support of each resident's interests. He was not sure why they were not offered opportunities for engagement.

Based on record review and interview, the facility (residence) failed to comply with written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, affecting six current participants (residents). Findings include:Chapter VII regulations governing assisted living residences, part 14.40, requires all refrigerated medications shall be stored in a refrigerator that does not contain food and that is not accessible to residents. The residence's Medication Administration policy, dated 7/1/19, read in part, the residence would ensure all refrigerated medications would be stored in a separate locked container. On 5/1/23 from 10:00 a.m. to 3:00 p.m., the common refrigerator that was located in the kitchen remained unlocked. The refrigerator contained Resident #2's insulin pens and insulin. All six current residents had breakfast and lunch at the dining room table and had access to the refrigerator. Additionally, the refrigerator contained food, such as milk, leftovers, juice, and condiments. On 5/1/23 from 11:00 a.m. to 11:30 a.m., Staff #4 was in the garage and was not within eyesight of the unlocked refrigerator. On 5/1/23 at 2:00 p.m., the administrator stated he was aware that medications could not be stored in a refrigerator that was accessible to residents and contained food. He confirmed the refrigerated medications were accessible to all residents. He stated staff should have put the insulin in the medication refrigerator.

A certification revisit was completed on 5/1/23 for all previous deficiencies cited on 1/17/23. A deficiency was cited.

Based on record review and interview, the facility (residence) failed to comply with written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, affecting six current participants (residents). Findings include:Chapter VII regulations governing assisted living residences, part 14.40, requires all refrigerated medications shall be stored in a refrigerator that does not contain food and that is not accessible to residents. The residence's Medication Administration policy, dated 7/1/19, read in part, the residence would ensure all refrigerated medications would be stored in a separate locked container. On 5/1/23 from 10:00 a.m. to 3:00 p.m., the common refrigerator that was located in the kitchen remained unlocked. The refrigerator contained Resident #2's insulin pens and insulin. All six current residents had breakfast and lunch at the dining room table and had access to the refrigerator. Additionally, the refrigerator contained food, such as milk, leftovers, juice, and condiments. On 5/1/23 from 11:00 a.m. to 11:30 a.m., Staff #4 was in the garage and was not within eyesight of the unlocked refrigerator. On 5/1/23 at 2:00 p.m., the administrator stated he was aware that medications could not be stored in a refrigerator that was accessible to residents and contained food. He confirmed the refrigerated medications were accessible to all residents. He stated staff should have put the insulin in the medication refrigerator. Additionally, he stated the previous deficient practice was not corrected because he had put a lock on the medication refrigerator so staff put the insulin in the other unlocked refrigerator. He stated staff should have put the insulin in the medication refrigerator.

A licensure revisit was completed on 5/1/23 for the previous deficiency cited on 1/17/23. The residence is in compliance with all regulations surveyed.

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

A licensure revisit was completed on 5/1/23 for all previous deficiencies cited on 1/17/23. Deficiencies were cited.

Based on interview and record review, the residence failed to comply with conditions imposed by the department on the license, affecting six 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 OGRR11 on 1/17/23, the department imposed a consultant for six months to address the cited deficiencies and to also ensure compliance with all other pertinent regulations. The consultant was required to complete, during the first two months of the contract period:- Evaluate the residence's compliance with the other regulations in Chapters 2, 7, and 24, and provide recommendations to the Administrator on any additional areas of noncompliance. The Consultant would also implement a monitoring program, to be completed at least monthly, to ensure the Residence remains in compliance with previously cited deficiencies. The monitoring program will be incorporated into the Residence's ongoing quality management program (QMP), in accordance with 6 CCR 1011-1 Chapter 2, Section 4. The Consultant will make certain that the QMP was designed to improve resident safety and well-being, and promoted continued quality improvement to enhance service delivery. The consultant was required to complete, during the first through the sixth months of the contract period:- Conduct onsite visits at least weekly. 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 OGRR11, dated 1/17/23, 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 3/23/23.- Pay a civil fine of $1000, due by 3/30/23.- Submit executed consultant contract to the department, due by 3/31/23.- Submit final consultant report, due by 9/15/23. The residence did not appeal the intermediate condition. Department records revealed the residence had not submitted a letter to the Department that identified a consultant or submitted a copy of the fully signed consultant contract as of the date of the 5/1/23 onsite visit. Department records also read the residence had not paid the civil fine as of the date of the 5/1/23 onsite visit. 2. InterviewOn 5/1/23 at 2:00 p.m., the administrator stated he was not aware the residence was required to identify a consultant or pay a $1000 fine. He stated he had not read the intermediate condition letter from the department, dated 2/28/23.

Based on observation, interview and record review, the residence failed to make available a safe and sanitary environment, affecting six current residents. This deficiency was cited previously during a state licensure survey 1/17/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident AgreementAn undated, sample resident agreement, read in part, the residence agreed to make available, either directly or indirectly through provider agreement, a safe and sanitary environment. 2. ObservationsDuring an environmental tour on 5/1/23 from 10:00 a.m. to 12:30 p.m., the following was observed:The white kitchen cabinets had dark residue on them throughout the kitchen. The kitchen stove/oven had a grimy layer on it as well as white debris on the front of it. There was also food residue on the stove and oven. Both kitchen microwaves had the same grime layer on it. The air fryer and dishwasher had a layer of debris on them as well. The kitchen appliances and surfaces were sticky to the touch. The white baseboards in the kitchen and the kitchen floors had a layer of black residue on them as well as food debris. 3. InterviewsOn 5/1/23 at 10:25 a.m., Resident #2 stated the kitchen was unsanitary because everything was sticky to the touch. On 5/1/23 at 10:56 a.m., Resident #4 stated the kitchen was not thoroughly cleaned. She stated it was an ongoing issue. On 5/1/23 at 2:00 p.m., the administrator stated staff were responsible for ensuring the kitchen was sanitary. However, he stated the staff were too busy caring for residents during the day to ensure the kitchen was sanitary at all times. He also stated the staff used bleach to clean surfaces so he was not sure why there was a greasy and sticky residue on all the surfaces. Additionally, the administrator stated the deficient practice was not corrected because the cleaning compounds staff used did not work properly.

Based on observation, interview and record review, the residence failed to ensure all refrigerated medication were stored in a refrigerator that was not accessible to residents, affecting six current residents. This deficiency was cited previously during a state licensure survey 1/17/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:The residence's Medication Administration policy, dated 7/1/19, read in part, the residence would ensure all refrigerated medications would be stored in a separate locked container. On 5/1/23 from 10:00 a.m. to 3:00 p.m., the common refrigerator that was located in the kitchen remained unlocked. The refrigerator contained Resident #2's insulin pens and insulin. All six current residents had breakfast and lunch at the dining room table and had access to the refrigerator. Additionally, the refrigerator contained food, such as milk, leftovers, juice, and condiments. On 5/1/23 from 11:00 a.m. to 11:30 a.m., Staff #4 was in the garage and was not within eyesight of the unlocked refrigerator. On 5/1/23 at 2:00 p.m., the administrator stated he was aware that medications could not be stored in a refrigerator that was accessible to residents and contained food. He confirmed the refrigerated medications were accessible to all residents. He stated staff should have put the insulin in the medication refrigerator. Additionally, he stated the previous deficient practice was not corrected because he had put a lock on the medication refrigerator so staff put the insulin in the other unlocked refrigerator. He stated staff should have put the insulin in the medication refrigerator.

Based on observation, interview, and record review, the residence failed to ensure refrigerated foods opened or prepared and not used within 24 hours were marked with a "use by" or "discard by" date, affecting six current residents. This deficiency was cited previously during a state licensure survey 1/17/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. ObservationsOn 5/1/23 at 10:00 a.m., a posting on the refrigerator door read in part, "Refrigerated foods opened or prepared and not used within 24 hours must be marked with a 'use by' or 'discard by' date."On 5/1/23 from 10:00 a.m. to 12:45 p.m., the following foods were observed in the fridge with no "use by" or "discard by" date:A container of opened coleslawA container of cut up pineappleA cottage cheese container with noodles inside 2. InterviewsOn 5/1/23 at 1:16 p.m., Staff #4 stated he was not aware how long the unlabeled foods had been in the fridge. He was unable to confirm if the foods were opened or prepared in the last 24 hours. However, he could confirm that some of the foods were more than 24 hours old, but he was not sure which foods. Additionally, he stated he did not label the foods with a "use by" or "discard by" date. On 5/1/23 at 2:00 p.m., the administrator stated all the food in the refrigerator was eaten within seven days; therefore, the food was not required to be labeled with a "use by" or "discard by" date.

Based on observation and interview, the residence failed to ensure residence grounds were kept free of rubbish, affecting six current residents. This deficiency was cited previously during a state licensure survey 1/17/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. ObservationsOn 5/1/23 from 10:00 a.m. to 3:00 p.m., the backyard contained the following rubbish:Next to the back door there was a snow shovel, a broom and a mop. Next to the garage there was a shopping cart with a blue tarp and two metal walkers inside the cart. Next to the garage there was also a bench with objects such as empty containers, painting supplies, propane tanks, bug spray, empty paint cans and other various rubbish. Near the smoking area there were three coolers, a stool, metal chairs, a mop, a broomstick, and a headboard for a bed. 2. InterviewsOn 5/1/23 at 2:00 p.m., the administrator stated staff were responsible for ensuring the residence grounds were kept free of rubbish. He stated with all the other job responsibilities that staff had, it was hard to maintain a well kept backyard. He also stated staff tried to clean out the backyard every summer; however, the previous deficient practice was not corrected because he had not been able to clean the backyard yet.

Based on observation and interview, the residence failed to ensure designated smoking areas were equipped with fire resistance wastebaskets and resident rooms occupied by smokers had fire resistant wastebaskets, affecting three of three sample residents who smoked (#2, #6, #7). This deficiency was cited previously during a state licensure survey 1/17/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:An environmental tour of the residence on 5/1/23 from 10:00 a.m to 10:30 a.m., revealed Residents #2, #6 and #7 did not have fire resistant wastebaskets. The residents each had a metal can in their rooms and the cans were not labeled as fire resistant. On 5/1/23 at 10:20 a.m., Resident #2 was observed smoking in the designated smoking area. On 5/1/23 at 11:17 a.m., the administrator stated Residents #2, #6 and #7 smoked. During a second interview on 5/1/23 at 2:00 p.m., the administrator stated he was aware that the three residents who smoked were required to also have fire resistant wastebaskets in their rooms. He stated the previous deficient practice was not corrected because he was not aware the metal cans he put in the residents' rooms were not fire resistant as required.

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 #CO31640 was completed on 5/1/23. Deficiencies were cited.

Based on interview and record review, the residence failed to comply with conditions imposed by the department on the license, affecting six 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 OGRR11 on 1/17/23, the department imposed a consultant for six months to address the cited deficiencies and to also ensure compliance with all other pertinent regulations. The consultant was required to complete, during the first two months of the contract period:- Evaluate the residence's compliance with the other regulations in Chapters 2, 7, and 24, and provide recommendations to the Administrator on any additional areas of noncompliance. The Consultant would also implement a monitoring program, to be completed at least monthly, to ensure the Residence remains in compliance with previously cited deficiencies. The monitoring program will be incorporated into the Residence's ongoing quality management program (QMP), in accordance with 6 CCR 1011-1 Chapter 2, Section 4. The Consultant will make certain that the QMP was designed to improve resident safety and well-being, and promoted continued quality improvement to enhance service delivery. The consultant was required to complete, during the first through the sixth months of the contract period:- Conduct onsite visits at least weekly. 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 OGRR11, dated 1/17/23, 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 3/23/23.- Submit executed consultant contract to the department, due by 3/31/23.- Submit final consultant report, due by 9/15/23. The residence did not appeal the intermediate condition. Department records revealed the residence had not submitted a letter to the Department that identified a consultant or submitted a copy of the fully signed consultant contract as of the date of the 5/1/23 onsite visit. 2. InterviewOn 5/1/23 at 2:00 p.m., the administrator stated he was not aware the residence was required to identify a consultant. He stated she had not read the intermediate condition letter from the department, dated 2/28/23.

Based on observation, interview and record review, the residence failed to make available a safe and sanitary environment, affecting six current residents. Findings include:1. Resident AgreementAn undated, sample resident agreement, read in part, the residence agreed to make available, either directly or indirectly through provider agreement, a safe and sanitary environment. 2. ObservationsDuring an environmental tour on 5/1/23 from 10:00 a.m. to 12:30 p.m., the following was observed:The white kitchen cabinets had dark residue on them throughout the kitchen. The kitchen stove/oven had a grimy layer on it as well as white debris on the front of it. There was also food residue on the stove and oven. Both kitchen microwaves had the same grime layer on it. The air fryer and dishwasher had a layer of debris on them as well. The kitchen appliances and surfaces were sticky to the touch. The white baseboards in the kitchen and the kitchen floors had a layer of black residue on them as well as food debris. 3. InterviewsOn 5/1/23 at 10:25 a.m., Resident #2 stated the kitchen was unsanitary because everything was sticky to the touch. On 5/1/23 at 10:56 a.m., Resident #4 stated the kitchen was not thoroughly cleaned. She stated it was an ongoing issue. On 5/1/23 at 2:00 p.m., the administrator stated staff were responsible for ensuring the kitchen was sanitary. However, he stated the staff were too busy caring for residents during the day to ensure the kitchen was sanitary at all times. He also stated the staff used bleach to clean surfaces so he was not sure why there was a greasy and sticky residue on all the surfaces.

Based on observation, record review and interview, the residence failed to ensure all residents were provided regular opportunities to participate in structured engagement activities in support of each resident's interests, affecting six current residents. Findings include:1. Residence policyThe undated resident agreement, read in part, the residence provided residents with opportunities for social and recreational activities. 2. ObservationsOn 5/1/23 between 10:00 a.m. and 3:00 p.m., the staff did not offer resident engagement activities to residents. There was no posted engagement activity calendar. 3. InterviewsOn 5/1/23 at 10:25 a.m., Resident #2 stated the residence did not offer any engagement opportunities. He stated he would like to participate in outings to parks. On 5/1/23 at 10:56 a.m., Resident #4 stated the residence did not offer any engagement opportunities for any residents. She stated she would like to engage in movie nights and games with other residents. On 5/1/23 at 2:00 p.m., the administrator stated the residence did not provide any of the residents with regular opportunities to participate in structured engagement activities in support of each resident's interests. He was not sure why they were not offered opportunities for engagement.

Based on observation, interview and record review, the residence failed to ensure all refrigerated medication were stored in a refrigerator that was not accessible to residents, affecting six current residents. Findings include:The residence's Medication Administration policy, dated 7/1/19, read in part, the residence would ensure all refrigerated medications would be stored in a separate locked container. On 5/1/23 from 10:00 a.m. to 3:00 p.m., the common refrigerator that was located in the kitchen remained unlocked. The refrigerator contained Resident #2's insulin pens and insulin. All six current residents had breakfast and lunch at the dining room table and had access to the refrigerator. Additionally, the refrigerator contained food, such as milk, leftovers, juice, and condiments. On 5/1/23 from 11:00 a.m. to 11:30 a.m., Staff #4 was in the garage and was not within eyesight of the unlocked refrigerator. On 5/1/23 at 2:00 p.m., the administrator stated he was aware that medications could not be stored in a refrigerator that was accessible to residents and contained food. He confirmed the refrigerated medications were accessible to all residents. He stated staff should have put the insulin in the medication refrigerator.

A licensure complaint, prompted by #CO30936, was completed on 3/1/23. Deficiencies were cited.

Based on observation, record review and interview, the residence failed to ensure the department was able to efficiently complete an unannounced review, affecting six current residents. (Cross-reference Q0542, Q0640, Q1312) Findings include: On 3/1/23 at approximately 7:30 a.m., a surveyor arrived at the residence to conduct a complaint investigation. Staff #2 was present and contacted the administrator via telephone. On 3/1/23 from 7:30 a.m. to 12:00 p.m., the administrator was not present at the residence for the unannounced review. On 3/1/23 at 7:45 a.m., the administrator stated, via telephone, he was about to board an airplane and would not be at the residence for approximately one week. He stated his designee would be at the residence on 3/3/23, but that he and his designee were not available for the 3/1/23 onsite visit. Further, the administrator stated surveyors from the department "show up without warning" and stated the department had showed up at the residence unannounced approximately one month prior. The administrator was unaware department inspections were unannounced. On 3/1/23 at approximately 8:00 a.m., the administrator stated the designee would arrive at the residence at approximately 12:00 p.m, contrary to his previous statement. On 3/1/23 at approximately 8:30 a.m., Resident #2 stated the residence had expected the administrator designee to arrive on 3/3/23, as the administrator had told them that was when the designee would be at the residence. On 1/3/23 at approximately 10:45 a.m., the administrator designee arrived at the residence, which delayed the investigation process as the surveyor could not get needed documentation and interviews until the administrator designee had arrived. The surveyor did not receive a staff list from the administrator designee or completed trainings for Staff #1 and Staff #3. Further, the administrator designee was unable to answer all questions related to the onsite visit due to her not being a consistent employee at the residence. On 1/3/23 at approximately 10:50 a.m., the administrator designee stated she was aware the residence was required to comply with unannounced reviews conducted by the department. She added she was unaware what the residence's orientation and training included.

Based on observation and interview, the residence failed to ensure the administrator appointed a qualified designee who was capable of satisfactorily fulfilling the administrator's duties when the administrator was unavailable; and, ensure the name and contact information for the administrator or the qualified designee on duty was readily available to residents and the public, affecting six current residents. (Cross-reference Q0640, Q1312, B0286) Findings include: On 3/1/23 at approximately 7:45 a.m., the administrator and the administrator designee were not present at the residence. On 3/1/23 at approximately 7:30 a.m., a surveyor arrived at the residence to conduct a complaint investigation. Staff #2 was present and contacted the administrator via telephone. On 3/1/23 at 7:45 a.m., the administrator stated, via telephone, he was about to board an airplane and would not be at the residence for approximately one week or available to assist with the onsite visit. He stated the administrator designee would be at the residence on 3/3/23. On 3/1/23 at 8:07 a.m., Resident #4 stated when the administrator was away from the residence, there was no administrator present, such as a designee. On 3/1/23 at approximately 8:30 a.m., Resident #2 stated when the administrator was gone, there was no administrator present, such as a designee. On 3/1/23 at 10:33 a.m., an environmental tour revealed there was no contact information for the administrator or administrator designee posted at the residence. However, an administrator training program certificate for an unknown staff, who was not the administrator designee, was posted. On 3/1/23 at 10:36 a.m., Resident #1, Resident #3 and Staff #2 confirmed the administrator designee was expected to work at the residence on 3/3/23, but was not expected to be present at the residence prior to then. On 3/1/23 at 10:43 a.m., the administrator designee arrived at the residence after she had been contacted by the administrator via telephone. She stated she was unsure where any of the residence documents were located. The administrator designee stated at the time of the onsite visit, she was not working regularly at the residence but would try to answer questions and provide assistance with the onsite visit to her best ability. On 3/1/23 at 10:52 a.m., the administrator designee stated she had worked at the residence one day in January and had not consistently worked at the residence since October 2022. The administrator designee confirmed she did not know where the residence's records were located; however, she stated she knew what care the residents needed.

Based on observation and interview, the residence failed to ensure direct care staff were selected with the ability to read, write, carry out directions, communicate, and demonstrate competency to safely and effectively provide care and services, affecting six current residents. (Cross-reference Q0640 and Q1312) Findings include:Staff #1 worked as a caregiver at the residence. Her primary language was not English. However, facesheets for Residents #1-#4 read their primary language was English. On 3/1/23 at approximately 8:30 a.m., Resident #2 stated it was difficult to communicate with Staff #1 due to her inability to communicate effectively in English. He added it was difficult to get items, such as a glass of water, from her due to communication skills. On 3/1/23 at 9:34 a.m., Staff #1 was contacted via telephone, as she was not working at the residence. Staff #1 answered the telephone call but could not understand the surveyor and stated her English was not good. Staff #1 gave the telephone to her family member to translate for her. The family member did not work at the residence. The family member translated information about resident care, staff training and interactions with residents. On 3/1/23 at approximately 10:00 a.m., Resident #1 stated there was a "very bad communication barrier" with Staff #1 and stated when it was brought up to Staff #1, Staff #1 would get angry, which created an unsafe environment for care and services. On 3/1/23 at 10:02 a.m., Resident #4 stated residents could not talk with Staff #1 because of a "big communication barrier." On 3/1/23 at 10:59 a.m., the administrator designee stated the expectation was for staff to be able to ask residents what they want and need to meet their needs. She added residents had complained about not being able to understand Staff #1.

Based on record review and interview, the residence failed to ensure each staff member received orientation and training, affecting six current residents. (Cross-reference Q0542, Q0632 and B0286) Findings include: 1. Residence Policy The residence's Staff Education and Training policy, dated 7/1/29, read in part: "All training/education activities are documented in each staff member's permanent personnel file. The assisted living facility (residence) provides orientation, on-the-job training, in-service education and other continuing education programs to assure that staff is properly trained in the care and treatment of residents." 2. Staff #1 was hired by the residence on an unknown date. The residence's staff schedule read Staff #1 worked at the residence on Wednesdays and Thursdays, weekly. She worked 24 hour shifts. On 3/1/23 at 9:34 a.m., Staff #1 stated, through her translator, she had received training on resident rights to be free from abuse and neglect. The translator was a family member who did not work at the residence. The family member had to assist Staff #1 with answering the questions about training due to her difficulty with verbal communication in English. However, the residence's personnel file for Staff #1's read she had not received any orientation or training at the residence. 3. Staff #2 was hired by the residence on 5/21/19. The residence's staff schedule read Staff #2 worked at the residence on Saturday through Tuesday, weekly. He worked 24 hour shifts. On 3/1/23 at 9:56 a.m., Staff #2 stated he was not aware of what to do if abuse or neglect was alleged. Further, he stated in order to know what to do, he would ask the administrator for the abuse and neglect policy. However, the residence's personnel file for Staff #2's read he had not completed all orientation and training required by the residence. 4. Interview On 3/1/23 at approximately 10:50 a.m., the administrator designee stated she was unaware what the residence's orientation and training included.

Based on observation, record review and interview, the residence failed to ensure residents had the right to be free from verbal or emotional abuse and humiliation, affecting four of four sample residents (#1-#4). (Cross-reference Q0542, Q0632, Q0640, B0286)Specifically, Resident #4 stated Staff #1 yelled at multiple residents. Resident #4 reported to the administrator that Staff #1 had been "mentally hurtful" and called her "fat." Resident #4 stated Staff #1's actions made her feel belittled, undignified and that she was not a person. Resident #2 alleged Staff #1 treated residents like children and he experienced increased anxiety as a result. Resident #1 and other residents alleged Staff #1 yelled at Resident #1 while she provided care to her. The administrator designee reported Resident #1 was upset as a result. Staff #1 regularly worked at the residence on Wednesdays and Thursdays with residents. Findings include: 1. Residence Policy and Referencesa. 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. The residence's undated Resident Rights read, in part, that residents had the right not to be verbally or emotionally abused, humiliated, intimidated, or punished; and, the right to be treated with respect and dignity.c. The Merriam-Webster dictionary defines abuse as: "language that condemns or vilifies usually unjustly, intemperately, and angrily." Merriam-Webster, Abuse (2023), retrieved from: https://www.merriam-webster.com/dictionary/abused. According to Psychology Today, "Emotional abuse is pattern of behavior in which the perpetrator insults, humiliates, and generally instills fear in an individual in order to control them. The individual's reality may become distorted as they internalize the abuse as their own failings. Such mistreatment can occur in a range of interpersonal contexts, including ... a professional relationship ... Long-term repercussions may include anxiety ... Emotional abuse centers around control, manipulation, isolation, and demeaning or threatening behavior ... Signs of abuse include: Demeaning, shaming, or humiliating a person ... regular ridicule or teasing." Psychology Today (2023) Emotional Abuse, retrieved from: https://www.psychologytoday.com/us/basics/emotional-abusee. "Anxiety and high blood pressure can be symptoms of each other. Anxiety may lead to high blood pressure, and high blood pressure can trigger feelings of anxiety. The American Psychological Association (APA) defines anxiety as feelings of worry or tension ... The APA also notes that anxiety may increase a person ' s blood pressure." Medical News Today (2023) What is the link between anxiety and high blood pressure?, retrieved from: https://www.medicalnewstoday.com/articles/3223962. Resident #4 was admitted to the residence on 10/1/22 with a diagnosis of anxiety. a. The residence's assessment for Resident #4, dated 9/18/22, read Resident #4 needed a temporary safe place to live after an abusive relationship. b. Email Documentation On 3/1/23 at 8:23 a.m., Resident #4 provided an email between herself and the administrator regarding Staff #1's treatment toward residents, dated 2/3/23. The email read Resident #4 had attempted to discuss the concerns with Staff #1; however, when she had tried to talk to her, Staff #1 raised her voice and said hurtful things. Resident #4's email read Staff #1 had been "mentally hurtful. Last week she called me fat."The administrator replied to Resident #4, via email on 2/3/23. The response read the administrator had given Staff #1 a warning, although there was no documentation of the warning. He added he told Resident #1 to not jump to conclusions about what the staff had said to her and stated he told Staff #1 to refrain from commenting. c. Interview On 3/1/23 at 8:07 a.m., Resident #4 stated Staff #1 made "fat jokes and took food" from herself, Resident #1 and Resident #3 during meal service. She stated Staff #1 would yell at residents and tell Resident #4 she was overweight and was not allowed to eat more food. She stated on one occasion, Resident #2 was watching television so Resident #1 turned up her music to hear it better and Staff #1 yelled at Resident #1 for it. Resident #4 added she had just gotten out of an abusive relationship and Staff #1 made her feel like she was not a person, was undignified, and felt belittled by Staff #1. Further, Resident #4 stated approximately two months prior, and on a continued basis, the verbal abuse was reported to the administrator. However, there was no documentation of the abuse. 3. Resident #2 was admitted to the residence on 2/12/22 with a diagnosis of depression and diabetes. The care plan for Resident #2, dated 3/31/22, read Resident #2 had reflux issues and would occasionally have bowel incontinence due to his diabetes. On 3/1/23 at approximately 8:30 a.m., Resident #2 stated Staff #1 used to call him a "bad person" and would tell him he was "no good for women." He added, Staff #1 would get frustrated with him when he would request different food items due to his stomach sensitivities. Resident #2 stated Staff #1 treated the residents like children and made him feel anxious from the first shift of the week when she arrived at the residence until she left a few days later when her shift ended. 4. Resident #1 was admitted to the residence on 9/29/21 with diagnoses including affective psychosis and bipolar affective disorder. On 3/1/23 at 8:25 a.m., Resident #1 stated interactions with herself and Staff #1 had improved since the first time Staff #1 showered her. However, she stated the first time Staff #1 had done so that "(Staff #1) was cranky" while she provided the care. On 3/1/23 at approximately 8:30 a.m., Resident #2 stated when Staff #1 had given Resident #1 her first shower, he had heard Staff #1 "yelling" and "snapping" in a raised voice at Resident #1 in the bathroom. On 3/1/23 at approximately 10:50 a.m., the administrator designee stated Resident #1 informed her Staff #1 had yelled at Resident #1 while she gave the resident a shower. The administrator designee stated Resident #1 was upset. She added she was not sure what was done about the incident between Staff #1 and Resident #1.5. Resident #3 was admitted to the residence on 5/23/22 with diagnoses including depressive disorder, developmental disorder and epilepsy. On 3/1/23 at 8:01 a.m., Resident #3 stated Staff #1 was "mean" to all of the residents and raised her voice at Resident #3 for things such as the toilet being clogged. Resident #3 added Staff #1's actions "raised her blood pressure." Resident #3 stated she had been trying to keep her blood pressure down because she had been hospitalized for high blood pressure three or four times. Further, Resident #3 stated if a resident said something "the wrong way" to Staff #1, she would yell at the resident. Resident #3 added the administrator was aware of the allegations but stated Staff #1 would deny the allegations. On 3/1/23 at 10:39 a.m., Resident #3 was overheard telling the administrator designee: "I am not looking forward to (Staff #1) coming tonight. I don't want her to yell at me."6. Staff Schedule On 3/1/23 at 9:02 a.m., the residence's posted staff schedule read Staff #1 worked at the residence on Wednesdays and Thursdays, weekly. On 3/1/23 at 9:01 a.m., Staff #2 confirmed the schedule posted on the wall was the residence's accurate staff schedule. On 3/1/23 at approximately 10:45 a.m., the administrator designee confirmed, after speaking with the administrator designee, that the schedule posted was accurate. 7. Personnel Files On 3/1/23 at 8:58 a.m., the residence's personnel file for Staff #1 revealed no evidence of the administrator providing reeducation or counseling to Staff #1. 8. Interview On 3/1/23 at 7:45 a.m., the administrator stated, via telephone, he was about to board an airplane and would not be at the residence for approximately one week or available to assist with the onsite visit. On 3/1/23 at 9:34 a.m., contrary to resident interviews, Staff #1 stated with translation assistance from her family member that she had not ever yelled at Resident #1 and that Resident #1 had "lied" about this. Further, she stated, "Everything was okay, there was no hitting or yelling at each other." She stated no residents had reported to her that she was mean. On 3/1/23 at 9:01 a.m., Staff #2 stated the surveyor should ask the residents themselves about the care that Staff #1 provided to them, as he could not talk about other staff. On 3/1/23 at approximately 10:50 a.m., the administrator designee stated she only knew hearsay that residents were verbally abusing Staff #1. She stated it was because Staff #1 did not understand what needs or services the residents wanted due to Staff #1's language barrier. The administrator designee stated she was told Staff #1 called Resident #4 a name and added she did not report it to the administrator. Further, the administrator designee stated under no circumstances should staff members disrespect residents. The administrator designee added considered Staff #1's treatment of Resident #1 and Resident #4 to be verbal abuse.

A certification complaint, prompted by #CO30937, was completed on 3/1/23. Deficiencies were cited.

Based on record review and interview, the facility (residence) failed to ensure participants (residents) had the right to dignity; and, to receive communication with staff that was respectful and in a dignified manner, affecting four of four sample residents (#1-#4). (Cross-reference P0652) Specifically, Resident #4 stated Staff #1 yelled at multiple residents. Resident #4 reported to the administrator that Staff #1 had been "mentally hurtful" and called her "fat." Resident #4 stated Staff #1's actions made her feel belittled, undignified and that she was not a person. Resident #2 alleged Staff #1 treated residents like children and he experienced increased anxiety as a result. Resident #1 and other residents alleged Staff #1 yelled at Resident #1 while she provided care to her. The administrator designee reported Resident #1 was upset as a result. Staff #1 regularly worked at the residence on Wednesdays and Thursdays with residents. Findings include: 1. Residence Policy and Referencesa. The residence's undated Resident Rights read, in part, that residents had the right not to be verbally or emotionally abused, humiliated, intimidated, or punished; and, the right to be treated with respect and dignity.b. The Merriam-Webster dictionary defines abuse as: "language that condemns or vilifies usually unjustly, intemperately, and angrily." Merriam-Webster, Abuse (2023), retrieved from: https://www.merriam-webster.com/dictionary/abusec. According to Psychology Today, "Emotional abuse is pattern of behavior in which the perpetrator insults, humiliates, and generally instills fear in an individual in order to control them. The individual's reality may become distorted as they internalize the abuse as their own failings. Such mistreatment can occur in a range of interpersonal contexts, including ... a professional relationship ... Long-term repercussions may include anxiety ... Emotional abuse centers around control, manipulation, isolation, and demeaning or threatening behavior ... Signs of abuse include: Demeaning, shaming, or humiliating a person ... regular ridicule or teasing." Psychology Today (2023) Emotional Abuse, retrieved from: https://www.psychologytoday.com/us/basics/emotional-abused. "Anxiety and high blood pressure can be symptoms of each other. Anxiety may lead to high blood pressure, and high blood pressure can trigger feelings of anxiety. The American Psychological Association (APA) defines anxiety as feelings of worry or tension ... The APA also notes that anxiety may increase a person ' s blood pressure." Medical News Today (2023) What is the link between anxiety and high blood pressure?, retrieved from: https://www.medicalnewstoday.com/articles/3223962. Resident #4 was admitted to the residence on 10/1/22 with a diagnosis of anxiety. a. The residence's assessment for Resident #4, dated 9/18/22, read Resident #4 needed a temporary safe place to live after an abusive relationship. b. Email Documentation On 3/1/23 at 8:23 a.m., Resident #4 provided an email between herself and the administrator regarding Staff #1's treatment toward residents, dated 2/3/23. The email read Resident #4 had attempted to discuss the concerns with Staff #1; however, when she had tried to talk to her, Staff #1 raised her voice and said hurtful things. Resident #4's email read Staff #1 had been "mentally hurtful. Last week she called me fat."The administrator replied to Resident #4, via email on 2/3/23. The response read the administrator had given Staff #1 a warning, although there was no documentation of the warning. He added he told Resident #1 to not jump to conclusions about what the staff had said to her and stated he told Staff #1 to refrain from commenting. c. Interview On 3/1/23 at 8:07 a.m., Resident #4 stated Staff #1 made "fat jokes and took food" from herself, Resident #1 and Resident #3 during meal service. She stated Staff #1 would yell at residents and tell Resident #4 she was overweight and was not allowed to eatmore food. She stated on one occasion, Resident #2 was watching television so Resident #1 turned up her music to hear it better and Staff #1 yelled at Resident #1 for it. Resident #4 added she had just gotten out of an abusive relationship and Staff #1 made her feel like she was not a person, was undignified, and felt belittled by Staff #1. Further, Resident #4 stated approximately two months prior, and on a continued basis, the verbal abuse was reported to the administrator. However, there was no documentation of the abuse. 3. Resident #2 was admitted to the residence on 2/12/22 with a diagnosis of depression and diabetes. The care plan for Resident #2, dated 3/31/22, read Resident #2 had reflux issues and would occasionally have bowel incontinence due to his diabetes. On 3/1/23 at approximately 8:30 a.m., Resident #2 stated Staff #1 used to call him a "bad person" and would tell him he was "no good for women." He added, Staff #1 would get frustrated with him when he would request different food items due to his stomach sensitivities. Resident #2 stated Staff #1 treated the residents like children and made him feel anxious from the first shift of the week when she arrived at the residence until she left a few days later when her shift ended. 4. Resident #1 was admitted to the residence on 9/29/21 with diagnoses including affective psychosis and bipolar affective disorder. On 3/1/23 at 8:25 a.m., Resident #1 stated interactions with herself and Staff #1 had improved since the first time Staff #1 showered her. However, she stated the first time Staff #1 had done so that "(Staff #1) was cranky" while she provided the care. On 3/1/23 at approximately 8:30 a.m., Resident #2 stated when Staff #1 had given Resident #1 her first shower, he had heard Staff #1 "yelling" and "snapping" in a raised voice at Resident #1 in the bathroom. On 3/1/23 at approximately 10:50 a.m., the administrator designee stated Resident #1 informed her Staff #1 had yelled at Resident #1 while she gave the resident a shower. The administrator designee stated Resident #1 was upset. She added she was not sure what was done about the incident between Staff #1 and Resident #1.5. Resident #3 was admitted to the residence on 5/23/22 with diagnoses including depressive disorder, developmental disorder and epilepsy. On 3/1/23 at 8:01 a.m., Resident #3 stated Staff #1 was "mean" to all of the residents and raised her voice at Resident #3 for things such as the toilet being clogged. Resident #3 added Staff #1's actions "raised her blood pressure." Resident #3 stated she had been trying to keep her blood pressure down because she had been hospitalized for high blood pressure three or four times. Further, Resident #3 stated if a resident said something "the wrong way" to Staff #1, she would yell at the resident. Resident #3 added the administrator was aware of the allegations but stated Staff #1 would deny the allegations. On 3/1/23 at 10:39 a.m., Resident #3 was overheard telling the administrator designee: "I am not looking forward to (Staff #1) coming tonight. I don't want her to yell at me."6. Staff Schedule On 3/1/23 at 9:02 a.m., the residence's posted staff schedule read Staff #1 worked at the residence on Wednesdays and Thursdays, weekly. On 3/1/23 at 9:01 a.m., Staff #2 confirmed the schedule posted on the wall was the residence's accurate staff schedule. On 3/1/23 at approximately 10:45 a.m., the administrator designee confirmed, after speaking with the administrator designee, that the schedule posted was accurate. 7. Personnel Files On 3/1/23 at 8:58 a.m., the residence's personnel file for Staff #1 revealed no evidence of the administrator providing reeducation or counseling to Staff #1. 8. Interview On 3/1/23 at 7:45 a.m., the administrator stated, via telephone, he was about to board an airplane and would not be at the residence for approximately one week or available to assist with the onsite visit. On 3/1/23 at 9:34 a.m., contrary to resident interviews, Staff #1 stated with translation assistance from her family member that she had not ever yelled at Resident #1 and that Resident #1 had "lied" about this. Further, she stated, "Everything was okay, there was no hitting or yelling at each other." She stated no residents had reported to her that she was mean. On 3/1/23 at 9:01 a.m., Staff #2 stated the surveyor should ask the residents themselves about the care that Staff #1 provided to them, as he could not talk about other staff. On 3/1/23 at approximately 10:50 a.m., the administrator designee stated she only knew hearsay that residents were verbally abusing Staff #1. She stated it was because Staff #1 did not understand what needs or services the residents wanted due to Staff #1's language barrier. The administrator designee stated she was told Staff #1 called Resident #4 a name and added she did not report it to the administrator. Further, the administrator designee stated under no circumstances should staff members disrespect residents. The administrator designee added considered Staff #1's treatment of Resident #1 and Resident #4 to be verbal abuse.

Based on observation, record review and interview, the facility (residence) failed to ensure all staff met the qualifications and employment standards set forth in 6 CCR 1011-1, Chapter VII, Section 7.4-7, affecting six current participants (residents). (Cross-reference P0414)Findings include:Chapter VII regulations governing assisted living residences, part 7.5, requires that the assisted living residence shall select direct care staff based on such factors as the ability to read, write, carry out directions, communicate, and demonstrate competency to safely and effectively provide care and services. Staff #1 worked as a caregiver at the residence. Her primary language was not English. However, facesheets for Residents #1-#4 read their primary language was English. On 3/1/23 at approximately 8:30 a.m., Resident #2 stated it was difficult to communicate with Staff #1 due to her inability to communicate effectively in English. He added it was difficult to get items, such as a glass of water, from her due to communication skills. On 3/1/23 at 9:34 a.m., Staff #1 was contacted via telephone, as she was not working at the residence. Staff #1 answered the telephone call but could not understand the surveyor and stated her English was not good. Staff #1 gave the telephone to her family member to translate for her. The family member did not work at the residence. The family member translated information about resident care, staff training and interactions with residents. On 3/1/23 at approximately 10:00 a.m., Resident #1 stated there was a "very bad communication barrier" with Staff #1 and stated when it was brought up to Staff #1, Staff #1 would get angry, which created an unsafe environment for care and services. On 3/1/23 at 10:02 a.m., Resident #4 stated residents could not talk with Staff #1 because of a "big communication barrier." On 3/1/23 at 10:59 a.m., the administrator designee stated the expectation was for staff to be able to ask residents what they want and need to meet their needs. She added residents had complained about not being able to understand Staff #1.

A licensure revisit was completed on 1/17/23 for the previous deficiency cited on 8/10/22. A deficiency was cited.

Based on interviews and record review, the residence failed to ensure the administrator complied with all applicable state laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting six current residents. Findings include:1. Referencesa. The Assisted Living Residences and Group Homes Mitigation and Outbreak Guidance, updated 1/12/23, required residences to:As outlined in CDC's guidance, facilities should assign at least one person with training in infection prevention control (IPC) to provide on-site management of infection prevention and control activities within the facility. Ensure timely and accurate reporting of all EMResource reporting requirements. Reporting should occur once during each bi-monthly reporting period (period one) and (period two). Multiple reports within the same reporting period will overwrite previous reporting and does not meet requirements for future reporting periods. Reporting period one (defined as days 1-14 of each month). Complete all facility questions. Reporting period two (defined as days 15-31 of each month). Complete all facility questions. b. The Ninth Amended Public Health Order, dated 10/11/21, read in part, Each residence shall maintain a COVID-19 vaccination and treatment plan as outlined in the Assisted Living and Group Home COVID-19 Mitigation and Outbreak Guidance. The plan must be readily available for review by county and state disease control staff and state health facility inspectors. 2. EMResourceOn 1/17/23, the department database revealed EMResource was last updated on 12/1/22. The database read the residence had seven current residents and four staff. However, on 1/17/23 at 8:10 a.,m., the administrator stated there were currently six residents who resided in the residence and two staff who were employed. On 1/17/23 at 12:53 p.m. the administrator stated EMResource was supposed to be updated by him twice a month, however, he was not aware it was not updated since 12/1/22. 3. IPCOn 1/17/23, review of the EMResource database revealed the administrator was the IPC staff member, however, it also read he had not yet completed the training. On 1/17/23 at 12:53 p.m., the administrator stated he was aware the IPC training had not been completed yet. He stated he planned on completing it in the near future.

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 second intial licensure survey with complaints #CO30504, #CO30506, #CO30515 was completed on 1/17/23. Deficiencies were cited.

Based on record review and interview, the residence failed to show compliance with Colorado Adult Protective Services Data System (CAPS Check) requirements, affecting six current residents. Findings include:1. Referencesa. According to Colorado Revised Statutes (2017) Title 26 Human Services Code, " ... individuals receiving care and services from persons employed in programs or facilities ... are vulnerable to mistreatment, including abuse, neglect, and exploitation. It is the intent of the general assembly to minimize the potential for employment of persons with a history of mistreatment of at-risk adults in positions that would allow those persons unsupervised access to these adults. As a result, the general assembly finds it necessary to strengthen protections for vulnerable adults by requiring certain employers to request a CAPS check by the state department to determine if a person who will provide direct care to an at-risk adult has been substantiated in a case of mistreatment of an at-risk adult."b. C.R.S. 26-3.1-101 (1.8) reads a "CAPS check" means a check of the Colorado adult protective services data system pursuant to section 26-3.1-111.c. Chapter VII regulations governing assisted living residences, part 2.7, defines an "At-risk person" as any person who is 70 years of age or older, or any person who is 18 years of age or older and meets one or more of the following criteria: (D) Is a person with an intellectual and developmental disability as defined in Section 25.5-10-202, C.R.S.; (E) Is a person with a mental health disorder as defined in Section 27-65-102(11.5), C.R.S.2. The personnel file for Staff #4 read he was hired on 5/21/19 as a qualified medication administration personnel (QMAP). The staff schedule revealed Staff #4 worked 13 times in January 2023 on the following dates: 1/1-1/3, 1/6-1/10, and 1/13-1/17/23. 3. The personnel file for Staff #5 read she was hired 3/1/22 as a QMAP.The staff schedule revealed Staff #5 worked four times in January 2023 on the following dates: 1/4, 1/5, 1/11, and 1/12/23. On 1/17/22 at 12:53 p.m., the administrator confirmed there were no CAPS checks available for Staff #4 and #5. He stated he was unaware that CAPS checks were completed prior to staff providing resident care. The administrator confirmed the six current residents were all at-risk due to their age or their intellectual disability.

Based on interviews and record review, the residence failed to ensure the administrator complied with all applicable state laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting six current residents. Findings include:1. Referencesa. The Assisted Living Residences and Group Homes Mitigation and Outbreak Guidance, updated 1/12/23, required residences to:As outlined in CDC's guidance, facilities should assign at least one person with training in infection prevention control (IPC) to provide on-site management of infection prevention and control activities within the facility. Ensure timely and accurate reporting of all EMResource reporting requirements. Reporting should occur once during each bi-monthly reporting period (period one) and (period two). Multiple reports within the same reporting period will overwrite previous reporting and does not meet requirements for future reporting periods. Reporting period one (defined as days 1-14 of each month). Complete all facility questions. Reporting period two (defined as days 15-31 of each month). Complete all facility questions. b. The Ninth Amended Public Health Order, dated 10/11/21, read in part, Each residence shall maintain a COVID-19 vaccination and treatment plan as outlined in the Assisted Living and Group Home COVID-19 Mitigation and Outbreak Guidance. The plan must be readily available for review by county and state disease control staff and state health facility inspectors. 2. EMResourceOn 1/17/23, the department database revealed EMResource was last updated on 12/1/22. The database read the residence had seven current residents and four staff. However, on 1/17/23 at 8:10 a.,m., the administrator stated there were currently six residents who resided in the residence and two staff who were employed. On 1/17/23 at 12:53 p.m. the administrator stated EMResource was supposed to be updated by him twice a month, however, he was not aware it was not updated since 12/1/22. 3. IPCOn 1/17/23, review of the EMResource database revealed the administrator was the IPC staff member, however, it also read he had not yet completed the training. On 1/17/23 at 12:53 p.m., the administrator stated he was aware the IPC training had not been completed yet. He stated he planned on completing it in the near future.

Based on observation, interview and record review, the residence failed to make available a safe and sanitary environment, affecting six current residents. Findings include:1. Resident AgreementAn undated, sample resident agreement, read in part, the residence agreed to make available, either directly or indirectly through provider agreement, a safe and sanitary environment. 2. ObservationsDuring an environmental tour on 1/17/23 from 7:30 a.m. to 12:30 p.m., the following was observed:The laundry washing machine had debris, such as lint and black buildup, in the door seal. The basement bathroom had white residue on the floor and the shower had residue on it that was dark in color. The white kitchen cabinets had dark residue on them throughout the kitchen. The kitchen stove/over had a grimy layer on it as well as white debris on the front of it. There was also food residue on the stove and oven. Both kitchen microwaves had the same grime layer on it. The air fryer and dishwasher had a layer of debris on them as well. The kitchen appliances and surfaces were sticky to the touch. The white baseboards in the kitchen and the kitchen floors had a layer of black residue on them as well as food debris. 3. InterviewsOn 1/17/23 at 7:35 a.m., Resident #5 stated she thought the kitchen was dirty every day. She stated there was a grime and sticky residue on every surface that felt unsanitary. On 1/17/23 at 12:07 p.m., Resident #2 stated the kitchen was unsanitary because everything was sticky to the touch. He also stated his clothes were not cleaned the proper way because the washing machine had black buildup inside of it. He stated they did not smell good after being washed. On 1/17/23 at 12:27 p.m., Resident #1 stated the kitchen was unsanitary because all the surfaces felt sticky and greasy to the touch. On 1/17/23 at 12:53 p.m., the administrator stated staff were responsible for ensuring the kitchen and washer were sanitary. However, he stated the staff were too busy during the day to ensure the kitchen was sanitary at all times. He also stated the staff used bleach to clean surfaces so he was not sure why there was a greasy and sticky residue on all the surfaces. Additionally, the administrator stated he noticed the washer had black residue on it, however, he had not had time to clean it.

Based on observation, interview and record review, the residence failed to detail in each resident's care plan the individualized approach necessary to address fall risk, afecting one of three sample residents (#2). (Cross-reference Q2130)Specifically, Resident #2 was admitted to the residence on 2/12/22 with diagnoses including an amputated left leg. The resident experienced up to four falls since admission to the residence including one fall on 12/12 or 12/13/22 that resulted in a cut on his hand. The care plan, dated 7/12/22, read in part the resident was prone to falls. However, the care plan did not reflect the individualized approach necessary to address fall risks. Findings include:1. Residence policyThe residence's Fall Prevention Policy and Program, undated, read in part, "In order to maintain residents' mobility and assist with fall prevention, the facility adopt the following policies: (B) 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."2. Resident #2 was admitted to the residence on 2/12/22 with diagnoses including an amputated left leg. The residence's care plan, dated 7/12/22, read in part the resident was prone to falls, however, the care plan did not detail the individualized approach necessary to address fall risk. Additionally, the care plan was not updated since his previous fall in December 2022. A photograph, provided by Resident #5, revealed Resident #2's hand had a cut on his right hand approximately half an inch long. On 1/17/22 at 12:07 p.m., Resident #2 wore a prosthetic leg. On 1/17/22 at 12:07 p.m., Resident #2 stated he fell on 12/12 or 12/13/22 during the overnight shift while trying to use the common restroom. Additionally, he stated the fall resulted in a cut on his hand. He also stated he had fallen approximately four times since his admission to the residence in February 2022 and he was not aware of the individualized approach necessary to address fall risk. On 1/17/22 at 12:53 p.m., the administrator confirmed the resident has had falls in the past. He also stated that the resident was at risk for falls due to the resident's left leg amputation. Further he stated the resident wore a prosthetic during awake hours. The administrator stated he was not aware of the interventions in place to mitigate falls. Additionally, the administrator stated he was responsible for updating care plans and was not aware the care plan was required to detail the individualized approach necessary to address fall risk. The administrator also confirmed the resident sustained a cut on his hand from the fall. He stated the resident had several falls at the residence and the care plan for Resident #2 was not updated after each fall.

Based on interview and record review, the residence failed to ensure resident's had the right to be treated with dignity and respect, affecting one of three sample residents (#4). (Cross-reference Q2130)Specifically, Resident #4 was admitted to the residence on 5/23/22 with diagnoses including major depressive disorder. On 12/17/22, the administrator spoke to the resident in an undignified and disrespectful manner which caused the resident to feel scared and anxious. Furthermore, the resident, as well as a witness resident, stated the administrator became upset with Resident #4 easily and raised his voice at her throughout the previous few months. Findings include:1. Reference The residence's Resident Rights policy, undated, read in part, residents had the right to be treated with respect and dignity. 2. Resident #4 was admitted to the residence on 5/23/22 with diagnoses including major depressive disorder. On 1/17/23 at 2:48 p.m., Resident #4 stated the administrator often spoke to her in an undignified manner because he raised his voice at her and made her feel scared and anxious. She also stated on 12/17/22 he raised his voice at her and told her she was acting out in front of the outside agency representative. Further, she stated from time to time he would talk to her in an undignified and disrespectful manner and she stated it made her feel scared and anxious when this occurred in December 2022 and still did. On 1/17/23 at approximately 2:48 p.m., Resident #5 stated she witnessed the administrator raise his voice and speak to Resident #4 in an undignified manner on 12/17/22. She stated she saw the administrator yell and raise his voice at Resident #4 because he was frustrated. She confirmed the administrator spoke to Resident #5 in an undignified and disrespectful manner at times when he was frustrated. She confirmed the administrator yelled at Resident #4 since the incident in December 2022 and it caused the resident to feel scared. On 1/17/23 at 2:51 p.m., the administrator denied raising his voice to Resident #4. He stated he treated her with respect and dignity at all times.

Based on interview and record review, the residence failed to ensure only medication that had been ordered by an authorized practitioner was prepared for a resident, affecting one of three sample residents (#4). Findings include:1. Residence policyThe residence's Medication Administration policy, dated 7/1/19, read in part, the residence would only administer medications upon the written order of a licensed physician. 2. Resident #4 was admitted to the resident on 5/23/22 with diagnosis including major depressive disorder. A written practitioner's order, dated 8/4/22, directed the residence to discontinue trazodone. However, the January 2023 medication administration record read trazodone 25 mg was administered without an order on 1/1-1/17/23, for a total of 17 additional doses. On 1/17/23, a medication cart audit revealed the medication was in stock. On 1/17/23 at approximately 2:48 p.m., Resident #4 stated she was administered trazodone daily. On 1/17/23 at approximately 2:51 p.m., the administrator stated he was not aware the medication had been discontinued on 8/4/22. He confirmed the medication was not to be administered.

Based on observation, interview and record review, the residence failed to ensure all refrigerated medication were stored in a refrigerator that was not accessible to residents, affecting six current residents. Findings include:The residence's Medication Administration policy, dated 7/1/19, read in part, the residence would ensure all refrigerated medications would be stored in a separate locked container. On 1/17/23 from 7:30 a.m. to 3:00 p.m., the medication refrigerator that was located next to the dining room table remained unlocked. The refrigerator contained insulin pens and insulin. All six current residents had breakfast and lunch at the dining room table and had access to the refrigerator. On 1/17/23 from 8:00 a.m. to 8:30 a.m., Staff #4 administered medications to residents and was not within eyesight of the unlocked medication refrigerator. On 1/17/23 at 12:53 p.m., the administrator stated he was not aware the refrigerated medications were prohibited from being accessible to other residents. He confirmed the refrigerated medications were accessible to all residents.

Based on observation and interview, the residence failed to prohibit staff members from using common towels and other multiple use linen to dry their hands, affecting six current residents. Findings include:1. ObservationOn 1/17/23 at approximately 7:35 a.m., Staff #4 prepared food for six current residents. During which, he washed his hands in the kitchen sink then dried his hands on a common towel. The common towel was hanging on a kitchen cabinet below the sink. On 1/17/23 at approximately 7:55 a.m., Staff #4 washed his hands again then used a common towel to dry his hands. On 1/17/23 at approximately 8:15 a.m., Staff #4 rinsed his hands in the kitchen sink then used the same common towel to dry his hands. On 1/17/23 at approximately 11:12 a.m., Staff #4 prepared lunch for six current residents. He rinsed and washed his hands several times in the kitchen sink then used a common towel to dry his hands. 2. InterviewOn 1/17/23 at 7:35 a.m., Resident #5 stated the common towels in the kitchen were not washed often and that Staff #4 and #5 used the towels to dry their hands frequently. She said the common towels always appeared to be dirty. On 1/17/23 at 12:53 p.m., the administrator confirmed that staff often used the common towels in the kitchen to dry their hands. He stated he was not aware staff should have been prohibited from using common towels. On 1/17/23 at 2:39 p.m., Staff #4 confirmed he used the common towels to dry his hands often. He stated he was not sure how often the hand towels were washed in the washing machine.

Based on observation, interview, and record review, the residence failed to ensure refrigerated foods opened or prepared and not used within 24 hours were marked with a "use by" or "discard by" date, affecting six current residents. 1. ObservationsO 1/17/23 at 7:53 a.m., a posting on the refrigerator door read in part, "Refrigerated foods opened or prepared and not used within 24 hours must be marked with a 'use by' or 'discard by' date."On 1/17/23 from 7:30 a.m. to 12:45 p.m., the following foods were observed in the fridge with no "use by" or "discard by" date:A casserole in a food toteA container of opened coleslawA hamburger with a bun in a plastic bagA container of red lentil soupAn opened block of butter with no containerBeef stroganoff in an old cottage cheese containerAn opened container of cottage cheeseAn opened container of margarine 2. InterviewsOn 1/17/23 at 12:53 p.m., the administrator stated all the food in the refrigerator was eaten within seven days, therefore, the food was not required to be labeled with a "use by" or "discard by" date. On 1/17/23 at 2:39 p.m., Staff #4 stated he was not aware how long the unlabeled foods had been in the fridge. He was unable to confirm if the foods were opened or prepared in the last 24 hours. However, he could confirm that some of the foods were more than 24 hours old. Additionally, he stated he did not label the foods with a "use by" or "discard by" date.

Based on record review and interview, the residence failed to ensure the residence failed to ensure there were appealing substitutes of similar nutritive value available, affecting six current residents. Findings include:The residence's menu, labeled week one and three and week two and four, alternated between two weekly menus. The menus did not include alternates. On 1/17/23 at 7:35 a.m., Resident #5 stated the residence did not have a variety of menu choices. She stated if she did not like the meal, then a peanut butter and jelly sandwich was the only food offered as a replacement of the entire meal. On 1/17/23 at 12:07 p.m., Resident #2 stated the residence did not have a variety of menu choices. He also stated a peanut butter and jelly sandwich was the only food offered as a replacement of the entire meal. On 1/17/23 at 12:27 p.m., Resident #1 stated the residence did not have a variety of menu choices. She also stated a peanut butter and jelly sandwich was the only food offered as a replacement of the entire meal. On 1/17/23 at 2:51 p.m., the administrator stated residents were offered a peanut butter and jelly sandwich as an alternative if they did not like the meal that was served. He stated he believed the menu to be nutritionally balanced with variety.

Based on interview and record review, the residence failed to ensure resident records contained progress notes, affecting two of three sample residents (#2, #4). (Cross-reference Q1180, Q1312)Findings include: 1. Residence policyThe residence's Resident Record policy, dated 7/1/19, read in part, resident records should contain progress notes. 2. Resident #4 was admitted to the residence on 5/23/22 with diagnoses including major depressive disorder. On 1/17/23 at 8:15 a.m., progress notes for Resident #4 were requested. However, the residence was unable to provide progress notes for the resident. On 1/17/23 at approximately 8:10 a.m., the administrator stated Resident #4 would sit on the ground frequently when she was dizzy. He stated the practitioner was not sure why the resident got dizzy. Further, he confirmed there were no progress notes for Resident #4 regarding her dizzy spell. The administrator confirmed that staff should have written progress notes when the resident experienced dizziness because it was an out of the ordinary event. On 1/17/23 at 2:48 p.m., Resident #4 stated an outside agency representative visited the residence about one month prior due to resident complaints. She stated the administrator was very rude to her and to the outside agency representative. On 1/17/23 at 2:51 p.m., the administrator stated the outside agency representative visited the residence. He confirmed the visit from the outside agency representative was out of the ordinary because she did not visit very often and he should have documented it in the progress notes. 3. Resident #2 was admitted to the residence on 2/12/22 with diagnoses including an amputated left leg. On 1/17/23 at 8:15 a.m., progress notes for Resident #2 were requested. However, the residence was unable to provide progress notes for the resident. On 1/17/23 at 12:07 p.m., Resident #2 confirmed he had a few falls since his admission in May 2022 and his last fall was on approximately 12/16/22. He stated the fall resulted in a cut on his hand. On 1/17/23 at 12:53 p.m., the administrator stated there were no progress notes for Resident #2 because he was unable to determine if the resident really fell. However, he confirmed that staff should have documented progress notes regarding the fall incidents. He confirmed the resident had a few falls at the residence since May 2022 and none of the falls were documented as required.

Based on observation and interview, the residence failed to ensure residence grounds were kept free of rubbish, affecting six current residents. Findings include:1. ObservationsOn 1/17/23 from 7:35 to 3:00 p.m., the backyard contained the following rubbish:Next to the back door there was a snow shovel, a broom and a mop. Next to the garage there was a shopping cart with a blue tarp and two metal walkers inside the cart. Next to the garage there was also a bench with objects such as empty containers, painting supplies, propane tanks, bug spray, empty paint cans and other various rubbish. Next to a different back door there was an empty kitchen trash can, a plastic chair, and a cardboard box with a blanket and television tray on top of it. Next to the refuse area there was a plastic laundry hamper on the ground. Near the smoking area there was a back of charcoal on the ground, three coolers, a stool, a metal chair and a pillow. 2. InterviewsOn 1/17/23 at 12:53 p.m., the administrator stated staff were responsible for ensuring the residence grounds were kept free of rubbish. He stated with all the other job responsibilities that staff had, it was hard to maintain a well kept backyard. He also stated staff tried to clean out the backyard every summer, however, it was hard to maintain in the winter due to the cold weather. On 1/17/23 at approximately 2:48 p.m., Resident #5 stated that the backyard consistently had rubbish all over.

Based on observation and interview, the residence failed to ensure designated smoking areas were equipped with fire resistance wastebaskets and resident rooms occupied by smokers had fire resistant wastebaskets, affecting three of three sample residents who smoked (#2, #5, #6). Findings include:An environmental tour of the residence on 1/17/23 from 8:30 a.m to 9:00 a.m., revealed Residents #2, #5 and #6 did not have fire resistant wastebaskets. On 1/17/23 at 2:48 p.m., Resident #5 was observed smoking in the designated smoking area. On 1/17/23 at 8:10 a.m., the administrator stated Residents #2, #5 and #6 smoked. During a second interview on 1/17/23 at 12:53 p.m., the administrator stated stated he was not aware that the three smoking residents were required to also have fire resistant wastebaskets in their rooms. On 1/17/23 at 2:48 p.m., Resident #5 confirmed she and Residents #2 and #6 were smokers and she was not aware if the wastebaskets in their rooms were fire resistant.

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: (C) Orientation and training, including first aid and CPR certification, if applicable; (F) Tuberculin test results, if applicable. 22.27 The assisted living residence shall prohibit the use of portable heaters in resident rooms. The use of fireplaces, space heaters, and like units that generate heat shall be prohibited in the common areas of the assisted living residence unless the ALR is able to ensure that such devices have a UL (Underwriters Laboratory) or similar certification label, do not present a resident burn risk, and are used in accordance with manufacturer instructions. 22.37 Designated outdoor smoking areas shall have fire resistant waste disposal containers.

A second initial survey with complaints #CO30505, #CO30507 and #CO30516 was completed on 1/17/23. A deficiency was cited.

Based on interview and record review, the facility (residence) failed to ensure resident's had the right to be treated with dignity, affecting one of three sample participants (residents) (#4). Specifically, Resident #4 was admitted to the residence on 5/23/22 with diagnoses including major depressive disorder. On 12/17/22, the administrator spoke to the resident in an undignified and disrespectful manner which caused the resident to feel scared and anxious. Furthermore, the resident, as well as a witness resident, stated the administrator would get upset with Resident #4 easily and raised his voice at her throughout the previous few months. Findings include:1. Reference The residence's Resident Rights policy, undated, read in part, residents had the right to be treated with respect and dignity. 2. Resident #4 was admitted to the residence on 5/23/22 with diagnoses including major depressive disorder. On 1/17/23 at 2:48 p.m., Resident #4 stated the administrator often spoke to her in an undignified manner because he raised his voice at her and made her feel scared and anxious. She also stated on 12/17/22 he raised his voice at her and told her she was acting out in front of the outside agency representative. Further, she stated from time to time he would talk to her in an undignified and disrespectful manner and she stated it made her feel scared and anxious when this occurred in December 2022 and still did. On 1/17/23 at approximately 2:48 p.m., Resident #5 stated she witnessed the administrator raise his voice and speak to Resident #4 in an undignified manner on 12/17/22. She stated she saw the administrator yell and raise his voice at Resident #4 because he was frustrated. She confirmed the administrator spoke to Resident #5 in an undignified and disrespectful manner at times when he was frustrated. She confirmed the administrator yelled at Resident #4 since the incident in Decemeber 2022 and it caused the resident to feel scared. On 1/17/23 at 2:51 p.m., the administrator denied raising his voice to Resident #4. He stated he treated her with respect and dignity at all times.

Based on record review and interview, the facility (residence) failed to comply with written policies and procedures for the administration of medication in accordance with 6 CCR 1011-1, Chapter VII, affecting six current residents. Findings include:1. Chapter VII regulations governing assisted living residences, part 14.40, requires all refrigerated medications shall be stored in a refrigerator that does not contain food and that is not accessible to residents. The residence's Medication Administration policy, dated 7/1/19, read in part, the residence would ensure all refrigerated medications would be stored in a separate locked container. On 1/17/23 from 7:30 a.m. to 3:00 p.m., the medication refrigerator that was located next to the dining room table remained unlocked. The refrigerator contained insulin pens and insulin. All six current residents had breakfast and lunch at the dining room table and had access to the refrigerator. On 1/17/23 from 8:00-8:30 a.m., Staff #4 administered medications to residents and was not within eyesight of the unlocked medication refrigerator. On 1/17/23 at 12:53 p.m., the administrator stated he was not aware the refrigerated medications were prohibited from being accessible to other residents. He confirmed the refrigerated medications were accessible to all residents. 2. Chapter VII regulations governing assisted living residences, part 14.11, requires that only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents.a. Residence policyThe residence's Medication Administration policy, dated 7/1/19, read in part, the residence would only administer medications upon the written order of a licensed physician.b. Resident #4 was admitted to the resident on 5/23/22 with diagnosis including major depressive disorder. A written practitioner's order, dated 8/4/22, directed the residence to discontinue trazodone. However, the January 2023 medication administration record read trazodone 25 mg was administered without an order on 1/1-1/17/22, for a total of 17 additional doses. On 1/17/23, a medication cart audit revealed the medication was in stock. On 1/17/23 at approximately 2:48 p.m., Resident #4 stated she was administered trazodone daily. On 1/17/23 at approximately 2:51 p.m., the administrator stated he was not aware the medication had been discontinued on 8/4/22. He confirmed the medication was not to be administered.