LINCOLN MEADOWS SENIOR LIVING

An administrative relicensure survey was completed on 3/18/26. No deficiencies were cited.

A licensure complaint, prompted by #CO40140, #CO40477 and #CO41177, was completed on 12/2/25. No deficiencies were cited.

A revisit survey was completed on 3/4/25 for all previous deficiencies cited on 9/4/24. The facility is in compliance with all deficiencies that were cited.

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 9/4/23 for all previous deficiencies cited on 8/22/23. The residence is in compliance with all regulations surveyed. The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24.

A licensure complaint revisit was completed on 9/4/24 for all previous deficiencies cited on 8/22/23. The residence is in compliance with all regulations surveyed. The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24.

A relicensure survey with complaint #CO34181 was completed on 9/4/24. A deficiency was cited.

Based on observation, record review, and interview, the residence failed to maintain the residence's water temperature, which was accessible by residents, at or below 120 degrees Fahrenheit at taps, affecting 71 current residents. Findings include:On 9/4/24 at 10:47 a.m., the water temperature was taken in a common kitchenette on the first floor that any resident could access at 133.2 degrees Fahrenheit. A review of the residence water temperature logs from June to September 2024 revealed the following days on which the temperature exceeded the threshold:On 6/11/24, the water temperature was recorded as 130 degrees Fahrenheit. On 7/2/24, the water temperature was recorded as 130 degrees Fahrenheit. On 8/13/24, the water temperature was recorded as 121 degrees Fahrenheit. On 9/3/24 water temperature was recorded as 130 degrees Fahrenheit. On 9/4/24 at 3:43 p.m., the administrator stated he was unaware of the water temperature requirement in the regulations.

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 725.10 In addition to the information required for a resident care plan at Part 12.10, the care plan for each resident in a secure environment shall include the following: (B) A description of how the resident will have continuous independent access to his or her individual room, along with the ALR ' s plan to protect the resident from unwanted visitation by other residents.

A licensure revisit was completed on 9/4/24 for the previous deficiency cited on 8/22/23. The residence is in compliance with all regulations surveyed. The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24.

A licensure complaint, prompted by #CO34138 was completed on 11/14/23. No deficiencies were cited.

A licensure revisit was completed on 8/22/23 for all previous deficiencies cited on 10/21/22. Deficiencies were cited.

Based on observation, record review and interview, the residence failed to establish a fall management program that included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting two of two sample residents (#31 and #32). This deficiency was cited previously during a state licensure survey 10/21/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Resident #32 was at risk of falling and had a fall without injury on 5/4/23. The residence failed to update the care plan to include individualized approaches necessary to address Resident #32's risk for falls. Subsequently, Resident #32 sustained a fall that resulted in a skin tear on 5/31/23. Additionally, Resident #32 sustained falls on 6/4/23, 6/21/23 and 6/30/23, one of which resulted in a bruise on her right eye. Findings include: 1. Residence Policy The residence's Fall Management policy, dated 7/12/22, read in part: "All communities must have a Fall Management Plan including fall prevention training for staff and individualized resident care plans addressing fall risk."2. Resident #32 was admitted to the residence on 7/3/22, with diagnoses that included repeated falls and hypertension. The residence's most recent care plan, dated 3/20/23, and updated 8/22/23 (the day of the onsite investigation), read that Resident #32 was a potential fall risk, staff were to check for appropriate lighting, clutter, spills in apartment, and encourage proper footwear, educate the resident to push her pendant as needed for assistance and mobility. Interventions read that Resident #32 was to use a walker at all times, receive reminders to keep feet on the ground, encourage fluids, and rounding three times daily. The care plan further read that Resident #32 was independent with mobility, did not require transfer assistance and utilized a walker. However, the care plan was updated the day of the onsite investigation and had not been updated to include individualized approaches necessary to address fall risks after Resident #32 fell on 5/4, 5/31, 6/4, 6/21, or 6/30/23. A progress note, dated 5/4/23, read Resident #32 had a witnessed fall. A progress note, dated 5/31/23, read Resident #32 was found on the floor after she had tripped on her walker. There was a small skin tear found on her left arm and wrist. A progress note, dated 6/4/23, read Resident #32 was found on the floor next to her walker and stated she had tripped on her walker. A progress note, dated 6/21/23, read Resident #32 fell in the dining room, emergency medical services was called and the resident was sent to the emergency room. A progress note, dated 6/22/23, read Resident #32 was sent to the emergency room after she fell on 6/21/23 and reported she felt dizzy. Resident #32 returned from the hospital with a diagnosis of a urinary tract infection (UTI). A progress note, dated 6/30/23, read Resident #32 slid out of her recliner to the floor with no injuries or pain. Bruising was observed around the right eye from a previous fall. On 8/22/23 at 1:59 p.m., Staff #10 stated Resident #32 used a walker. Staff #10 further stated Resident #32 also had a wheelchair; however, she did not use it. Staff #10 stated she was unaware of any other fall interventions. On 8/22/23 at 2:00 p.m., Staff #13 stated Resident #32 was in the hospital for four hours on 6/21/23. Staff #13 stated Resident #32 did not have an injury from her fall; however, was sent to the hospital because she felt dizzy. Staff #13 further stated Resident #32 was diagnosed with a UTI. Staff #13 stated Resident #32 had no other fall interventions besides her wheelchair. On 8/22/23 at 2:13 p.m., the assisted living director stated that care plans were updated by the director of nursing (DON) every time a resident fell, and was unsure why it had not been done for Resident #32. On 8/22/23 at 2:24 p.m., the family member for Resident #32 stated Resident #32 had a history of falls when she had lived in assisted living prior to moving to the secure environment. The family member for Resident #32 stated Resident #32 had lived at the residence for three years and did not recall being provided fall management education when Resident #32 was admitted. The family member stated Resident #32 was admitted to the hospital on 6/21/23 because there was concern she sustained a head injury. The family member stated Resident #32 was diagnosed with a UTI and not a head injury. Resident #32's family member stated that Resident #32 used a walker and refused to use her wheelchair. The family member stated they were unaware of any other fall interventions. On 8/22/23 at 2:42 p.m., the administrator stated Resident #32 was at risk for falls. He stated the DON updated resident care plans. The administrator stated that he was unaware what individual fall interventions were in place for Resident #32 and stated the DON updated care plans after every fall. He stated he was not sure why the care plan for Resident #32 had not been updated since March 2023. The administrator acknowledged that Resident #32's care plan should have been updated to reflect her current needs and interventions. On 8/22/23 at 3:05 p.m., the regional nurse stated she recieved a list of residents that had frequently fallen from the administrator. She stated she editted Resident #32's care plan to add interventions and confirmed the care plan was updated the day of the onsite visit. She confirmed prior to the onsite visit the care plan for Resident #32 had not been updated since March 2023. 3. Resident #31 was admitted to the residence on 7/26/23, with a diagnosis of Alzheimer's disease. The residence's most recent care plan for Resident #31, dated 7/4/23, read that Resident #31 was at risk for falls, staff were to check for appropriate lighting, clutter, spills in apartment and encourage proper footwear. Additionally, the care plan read Resident #31 was independent with ambulation, used a walker and pushed her pendant for assistance. However, Resident #31 used a wheelchair and not a walker, did not use a call pendant and was dependent on one staff member for transfer assistance. The care plan further read, to modify for individual fall interventions. However, the care plan had no modifications made. No individualized approaches necessary to address fall risk were updated unto the care plan, after Resident #31 fell on 8/1, 8/9 or 8/20/23. A progress note, dated 7/26/23, read on 7/22/23 Resident #31 was sent to the hospital after a change in condition, increased confusion, fever, and inability to ambulate on her own. The resident required one person for transfer assistance, utilized a wheelchair and was admitted to external hospice services. A progress note, dated 8/1/23, read Resident #31 screamed for help and was found on the floor. There was no pain or injuries noted. "The (resident) was stressed however."A progress note, dated 8/9/23, read Resident #31 had an unwitnessed fall and yelled for help. The resident expressed agitation and the resident's external hospice provider stated they would monitor the resident for a few days. A progress note, dated 8/20/23, read at 10:30 a.m., Staff #14 heard a scream from Resident #31's room. Resident #31 was found laying flat on the floor in front of her recliner. Staff #14 attempted to lift Resident #31 off the floor independently without success. Staff #14 called Staff #13 for help, and they were able to get her back in her recliner. On 8/22/23 at 2:02 p.m., the external hospice nurse for Resident #31 stated Resident #31 only had a wheelchair and a hospital bed as fall interventions. She stated the interventions were put in place by external hospice agency after Resident #31 was hospitalized at the end of July 2023. She stated she was not aware of any additional fall interventions implemented by the residence. On 8/22/23 at 2:09 p.m., Staff #13 stated that Resident #31 fell on 8/20/23 and hit her head. Staff #13 stated Resident #31 fell due to holding her rolling bedside table to stand by herself. Staff #13 stated Resident #31 had a wheelchair and required transfer assistance from one person. Staff #13 stated she was unaware of any other fall interventions put in place, and acknowledged there weren't any new interventions put in place after Resident #31's falls on 8/1, 8/9 and 8/20/23. On 8/22/23 at 2:13 p.m., the assisted living director stated that care plans were updated by the DON every time a resident fell, and was unsure why it had not been done for Resident #31. On 8/22/23 at 2:38 p.m., the family member for Resident #31 stated that Resident #31 had resided at the residence since 2021. The family member stated Resident #31 had a cognitive and physical change in condition on 7/22/23 that resulted in having been hospitalized. She stated Resident #31 was no longer able to ambulate independently. The family member for Resident #31 stated she removed Resident #31's walker from the residence on 7/26/23, since she was no longer able to use it and utilized a wheelchair. The family member further stated that Resident #31 had not had a call pendant since she was admitted to the residence and added she was not capable of using one. The family member for Resident #31 stated after Resident #31's falls on 8/1, 8/9 and 8/20/23 the residence had not implemented any fall interventions, there was only the wheelchair that external hospice implemented on 7/26/23. On 8/22/23 at 2:42 p.m., the administrator stated Resident #31 was at risk for falls. The administrator stated he was unaware what individual fall interventions were in place for Resident #31. He stated the DON updated care plans after every fall and he was not sure why it had not been updated for Resident #31. The administrator acknowledged that the care plan for Resident #31 should have been updated to reflect current interventions. The administrator stated it was the responsibility of the DON to update care plans; however, she was on vacation.

Based on interview and record review, the residence failed to ensure progress notes were included in the resident record, affecting three of four sample residents (#31, #33, #34) and one former resident (#35). (Cross-reference Q1180)This deficiency was cited previously during a state licensure survey 10/21/22. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #33 was admitted to the residence on 3/10/22. A progress note, dated 8/12/23, read in part the resident had symptoms for COVID-19. On 8/22/23 at 7:35 a.m., the legal representative for Resident #33 stated the resident experienced symptoms of COVID-19 on 8/12/23 and later tested for COVID-19 on 8/16/23. On 8/22/23 at 2:42 p.m., the administrator stated all staff were responsible for ensuring progress notes were documented. He confirmed all out of the ordinary events were required to be documented in a progress note. Further, he stated the resident getting tested for COVID-19 and the results of the test should have been documented in a progress note for the resident. 2. Resident #34 was admitted to the residence on 3/10/23. A hospital note for Resident #34, dated 8/13/23, read in part, the resident was symptomatic and positive for COVID-19. The resident experienced a 105 degree fever. A progress note, dated 8/19/23, read in part, on 8/13/23 the resident's legal representative visited the resident and checked her temperature. The legal representative contacted emergency medical services because the resident had a temperature. However, there was no progress note regarding the resident testing positive for COVID-19 or that she was admitted to the emergency department. Additionally, there was no progress note that the resident resided in a skilled nursing facility for physical therapy. On 8/22/23 at 7:35 a.m., the legal representative for Resident #34 stated the resident tested positive for COVID-19 after being admitted to the hospital on 8/13/23. She stated the resident resided at a skilled nursing facility for physical therapy, but would return to the assisted living residence in a few weeks. On 8/22/23 at 2:42 p.m., the administrator stated the residence staff should have written a progress note regarding the positive test result for Resident #34, that she was admitted to the emergency department and that she resided in a skilled nursing facility. He confirmed the aforementioned events were out of the ordinary and should have been in a progress note. 3. Resident #31 was admitted to the residence on 7/26/23, with a diagnosis of Alzheimer's disease. A progress note, dated 8/20/23, read that at 10:30 a.m., Staff #14 heard a scream from Resident #31's room, and she was found laying flat on the floor in front of her recliner. Staff #14 attempted to lift Resident #31 off the floor independently without success. Staff #14 called Staff #13 for help, and were able to get her back in her recliner. On 8/22/23 at 2:09 p.m., Staff #13 stated that she was on shift when Resident #31 fell on 8/20/23. Staff #13 stated Resident #31 fell due to holding on her rolling bedside table to stand by herself and stated she had hit her head. However, there was no progress note of Resident #31 having hit her head. On 8/22/23 at 2:13 p.m., the assisted living director (ALD) stated that it should have been included in progress notes that Resident #31 hit her head during a fall on 8/20/23. On 8/22/23 at 2:42 p.m., the administrator stated any out of the ordinary event which included Resident #31 having hit her head in a fall, should have been included in progress notes. 4. Former Resident #35 was admitted to the residence on 3/21/23 with a diagnosis of Alzheimer's Disease. A progress note, dated 3/31/23, read that Former Resident #35 had a fall when leaning out of his chair. The note read he hit his elbow and sustained a skin tear. Former Resident #35 was put on alert charting every two hours. A progress note, dated 4/3/23, read that the family member of Former Resident #35 was called for an update, and the family member stated "the goal is to bring my dad back to memory care." However, there was no progress note that read that Former Resident #35 had been sent to the hospital. On 8/22/23 at 7:48 a.m., Staff #10 stated Former Resident #35 was sent out to the hospital after a fall in March 2023, and never came back to the residence. On 8/22/23 at 11:22 a.m., the family member for Former Resident #35 stated that she was there when Former Resident #35 fell on 3/31/23 and stated he was sent to the hospital to be evaluated. On 8/22/23 at 2:16 p.m., the ALD stated that she was aware there was no progress note about Former Resident #35 being sent out to the hospital on 3/31/23, and stated there should have been a progress note. The ALD further stated the qualified medication administration person or caregiver who wrote the note failed to include that Former Resident #35 was sent out to the hospital. On 8/22/23 at 2:42 p.m., the administrator acknowledged Former Resident #35 being sent to the hospital on 3/31/23 should have been included in a progress note.

A licensure complaint, prompted by #CO30644, #CO32505, #CO33013, #CO33378, was completed on 8/22/23. Deficiencies were cited.

Based on interview and record review, the residence failed to comply with all federal, state, and local laws concerning licensure and certification, affecting 63 current residents. (Cross-reference Q2130)Findings include:1. Residence policy and referencea. The residence's COVID-19 Isolation and Testing policy, dated 3/18/20, read in part, residents with close contact to COVID-19 exposure were required to test at least five full days after exposure. If the test was negative, residents should isolate if symptomatic for five days and wear a mask for 10 days.b. According to the Assisted Living and Group Homes for Persons with Intellectual and Developmental Disabilities Guidance, dated 7/24/23, read in part, residents with suspected or confirmed COVID-19 should follow Isolation and Precautions for People with COVID-19. Residents that were exposed to COVID-19 should follow Center for Disease Control's (CDC) What to do if you were Exposed to COVID-19. An outbreak was defined as one or more facility-acquired COVID-19 confirmed cases in a resident. Test all residents that had close contact immediately.c. According to the CDC, if a resident was exposed to COVID-19, wear a mask immediately for 10 full days. Test the resident at least five full days after their last exposure. CDC (8/24/22) What to do if you were Exposed, retrieved from: https://www.cdc.gov/coronavirus/2019-ncov/your-health/if-you-were-exposed.html 2. Resident Positive for COVID-19 A progress note for Resident #33, dated 8/12/23, read in part, the resident was sick with congestion and a stuffy nose. A hospital note for Resident #34, dated 8/13/23, read in part, the resident was symptomatic and positive for COVID-19. The resident experienced 105 degree fever. On 8/22/23, at 7:35 a.m., the legal representative for Resident #33 and #34 stated the two residents shared an apartment. She stated Resident #33 had a low grade fever, runny nose, a cough and lethargy on 8/12/23. She also stated she informed the residence staff and the director of nursing that the resident did not feel well on the evening of 8/12/23. Further, she stated Resident #34 had a 105 degree fever on the morning of 8/13/23, therefore, she contacted emergency services for an assessment. Additionally, the legal representative stated Resident #34 was sent to the emergency department on 8/13/23 and had not returned to the residence yet. She stated she returned Resident #33 back to the residence on the evening of 8/13/23 and informed Staff #15 that Resident #34 tested positive for COVID-19 on 8/13/23. However, she stated Resident #33 was not encouraged to wear a mask or isolate ever. On 8/22/23 at 12:34 p.m., a representative from the department stated Resident #33 should have been tested for COVID-19 immediately after he experienced symptoms. She also stated after Resident #34 tested positive for COVID-19 in the hospital, Resident #33 should have been encouraged to wear a mask for 10 days and isolated for five days (until 8/17/23). On 8/22/23 at 2:05 p.m., Staff #15 stated on 8/13/23 he was told by the legal representative of Residents #33 and #34 that Resident #34 had tested positive for COVID-19 at the hospital. However, he stated Resident #33 was not put in isolation or encouraged to wear a mask. On 8/22/23 at 2:13 p.m., the assisted living director stated Resident #34 tested positive for COVID-19 on 8/13/23. However, Resident #33 was not put in isolation or encouraged to wear a mask as required. On 8/22/23 at 12:56 p.m., the administrator stated Resident #33 was not tested for COVID-19 until 8/16/23. Although he also stated he was unable to provide evidence of said COVID-19 test. He further stated Resident #33 should have been tested immediately after Resident #34 tested positive on 8/13/23 at the hospital. He also stated Resident #33 was encouraged to isolate and wear a mask, however, the resident refused to do so. A second interview on 8/22/23 at 1:41 p.m., the legal representative for Residents #33 and #34stated she visited Resident #33 almost every day since 8/13/23 and the resident was never encouraged to wear a mask or isolate as required.

Based on interview and record review, the residence failed to contact the resident's primary practitioner when the resident experienced a significant change in baseline, affecting two of four sample residents (#33, #34). (Cross-reference Q2130)Findings include:1. Resident #33 was admitted to the residence on 3/10/22 with diagnoses including asthma. A progress note, dated 8/12/23, read in part, the resident was sick with congestion and a stuffy nose. On 8/22/23 at 7:35 a.m., the legal representative for Resident #33 stated on 8/12/23 the resident had a low grade fever, cough, and lethargy. She stated he was too tired to leave his room which was unusual behavior for him. Further, she stated she typically notified the practitioner if the resident was sick or had a significant change in baseline not the residence, however, she did not. The legal representative stated the residence staff was made aware the resident was sick on 8/12/23 because she discussed it with them and the director of nursing. She added, she was sure the residence staff did not notify the practitioner either because she was the main contact for the practitioner and the residence had a history of not notifying the practitioner. On 8/22/23 at 2:05 p.m., Staff #15 stated the practitioner should have been notified on 8/12/23 that Resident #33 was sick. He stated he was not aware that no staff notified the practitioner. On 8/22/23 at 2:13 p.m., the assisted living director stated the resident was independent with most care, therefore, staff was not aware the resident was sick. However, she confirmed the practitioner for Resident #33 should have been notified of the resident's symptoms on 8/12/23 by residence staff. 2. Resident #34 was admitted to the residence on 3/10/22. A care plan, dated 7/12/23, read in part, the resident required staff assistance to transfer. A progress note, dated 8/19/23, read in part, On 8/13/23 the resident's legal representative visited the resident and checked her temperature. The legal representative contacted emergency services because the resident had a temperature. On 8/22/23 at 7:35 a.m., the legal representative for Resident #34 stated on 8/12/23 the resident began to feel lethargic. She stated she was too tired to leave her room which was unusual behavior for her. Further, she stated she typically notified the practitioner if the resident was sick or had a significant change in baseline not the residence, however, she did not. The legal representative stated the residence staff was made aware the resident was sick on 8/12/23 because she discussed it with them and the director of nursing. She added, she was sure the residence staff did not notify the practitioner either because she was the main contact for the practitioner and the residence had a history of not notifying the practitioner. Additionally, she stated on the morning of 8/13/23 the resident's condition worsened to where the resident could not sit up on her own. She stated she contacted emergency medical services to assess the resident at approximately 11:30 a.m. on 8/13/23 because the residence staff did not. On 8/22/23 at 2:05 p.m., Staff #15 stated Resident #34 had a significant change in baseline condition on the morning of 8/13/23 because she was no longer able to sit up on her own. He stated staff should have notified the practitioner immediately. On 8/22/23 at 2:13 p.m., the assisted living director stated the resident had a significant change in baseline condition because she had become weak and could not sit up on her own. She stated staff should have notified the practitioner immediately, however, they did not. On 8/22/23 at 2:42 p.m., the administrator stated the practitioner for Residents #33 and #34 should have been notified on 8/12 and 8/13/23. He confirmed there was no documentation regarding if the practitioner was notified so he was not able to confirm if the practitioner was notified as required.

Based on observation, record review and interview, the residence failed to establish a fall management program that included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting two of two sample residents (#31 and #32). Specifically, Resident #32 was at risk of falling and had a fall without injury on 5/4/23. The residence failed to update the care plan to include individualized approaches necessary to address Resident #32's risk for falls. Subsequently, Resident #32 sustained a fall that resulted in a skin tear on 5/31/23. Additionally, Resident #32 sustained falls on 6/4/23, 6/21/23 and 6/30/23, one of which resulted in a bruise on her right eye. Findings include: 1. Residence Policy The residence's Fall Management policy, dated 7/12/22, read in part: "All communities must have a Fall Management Plan including fall prevention training for staff and individualized resident care plans addressing fall risk."2. Resident #32 was admitted to the residence on 7/3/22, with diagnoses that included repeated falls and hypertension. The residence's most recent care plan, dated 3/20/23, and updated 8/22/23 (the day of the onsite investigation), read that Resident #32 was a potential fall risk, staff were to check for appropriate lighting, clutter, spills in apartment, and encourage proper footwear, educate the resident to push her pendant as needed for assistance and mobility. Interventions read that Resident #32 was to use a walker at all times, receive reminders to keep feet on the ground, encourage fluids, and rounding three times daily. The care plan further read that Resident #32 was independent with mobility, did not require transfer assistance and utilized a walker. However, the care plan was updated the day of the onsite investigation and had not been updated to include individualized approaches necessary to address fall risks after Resident #32 fell on 5/4, 5/31, 6/4, 6/21, or 6/30/23. A progress note, dated 5/4/23, read Resident #32 had a witnessed fall. A progress note, dated 5/31/23, read Resident #32 was found on the floor after she had tripped on her walker. There was a small skin tear found on her left arm and wrist. A progress note, dated 6/4/23, read Resident #32 was found on the floor next to her walker and stated she had tripped on her walker. A progress note, dated 6/21/23, read Resident #32 fell in the dining room, emergency medical services was called and the resident was sent to the emergency room. A progress note, dated 6/22/23, read Resident #32 was sent to the emergency room after she fell on 6/21/23 and reported she felt dizzy. Resident #32 returned from the hospital with a diagnosis of a urinary tract infection (UTI). A progress note, dated 6/30/23, read Resident #32 slid out of her recliner to the floor with no injuries or pain. Bruising was observed around the right eye from a previous fall. On 8/22/23 at 1:59 p.m., Staff #10 stated Resident #32 used a walker. Staff #10 further stated Resident #32 also had a wheelchair; however, she did not use it. Staff #10 stated she was unaware of any other fall interventions. On 8/22/23 at 2:00 p.m., Staff #13 stated Resident #32 was in the hospital for four hours on 6/21/23. Staff #13 stated Resident #32 did not have an injury from her fall; however, was sent to the hospital because she felt dizzy. Staff #13 further stated Resident #32 was diagnosed with a UTI. Staff #13 stated Resident #32 had no other fall interventions besides her wheelchair. On 8/22/23 at 2:13 p.m., the assisted living director stated that care plans were updated by the director of nursing (DON) every time a resident fell, and was unsure why it had not been done for Resident #32. On 8/22/23 at 2:24 p.m., the family member for Resident #32 stated Resident #32 had a history of falls when she had lived in assisted living prior to moving to the secure environment. The family member for Resident #32 stated Resident #32 had lived at the residence for three years and did not recall being provided fall management education when Resident #32 was admitted. The family member stated Resident #32 was admitted to the hospital on 6/21/23 because there was concern she sustained a head injury. The family member stated Resident #32 was diagnosed with a UTI and not a head injury. Resident #32's family member stated that Resident #32 used a walker and refused to use her wheelchair. The family member stated they were unaware of any other fall interventions. On 8/22/23 at 2:42 p.m., the administrator stated Resident #32 was at risk for falls. He stated the DON updated resident care plans. The administrator stated that he was unaware what individual fall interventions were in place for Resident #32 and stated the DON updated care plans after every fall. He stated he was not sure why the care plan for Resident #32 had not been updated since March 2023. The administrator acknowledged that Resident #32's care plan should have been updated to reflect her current needs and interventions. On 8/22/23 at 3:05 p.m., the regional nurse stated she recieved a list of residents that had frequently fallen from the administrator. She stated she editted Resident #32's care plan to add interventions and confirmed the care plan was updated the day of the onsite visit. She confirmed prior to the onsite visit the care plan for Resident #32 had not been updated since March 2023. 3. Resident #31 was admitted to the residence on 7/26/23, with a diagnosis of Alzheimer's disease. The residence's most recent care plan for Resident #31, dated 7/4/23, read that Resident #31 was at risk for falls, staff were to check for appropriate lighting, clutter, spills in apartment and encourage proper footwear. Additionally, the care plan read Resident #31 was independent with ambulation, used a walker and pushed her pendant for assistance. However, Resident #31 used a wheelchair and not a walker, did not use a call pendant and was dependent on one staff member for transfer assistance. The care plan further read, to modify for individual fall interventions. However, the care plan had no modifications made. No individualized approaches necessary to address fall risk were updated unto the care plan, after Resident #31 fell on 8/1, 8/9 or 8/20/23. A progress note, dated 7/26/23, read on 7/22/23 Resident #31 was sent to the hospital after a change in condition, increased confusion, fever, and inability to ambulate on her own. The resident required one person for transfer assistance, utilized a wheelchair and was admitted to external hospice services. A progress note, dated 8/1/23, read Resident #31 screamed for help and was found on the floor. There was no pain or injuries noted. "The (resident) was stressed however."A progress note, dated 8/9/23, read Resident #31 had an unwitnessed fall and yelled for help. The resident expressed agitation and the resident's external hospice provider stated they would monitor the resident for a few days. A progress note, dated 8/20/23, read at 10:30 a.m., Staff #14 heard a scream from Resident #31's room. Resident #31 was found laying flat on the floor in front of her recliner. Staff #14 attempted to lift Resident #31 off the floor independently without success. Staff #14 called Staff #13 for help, and they were able to get her back in her recliner. On 8/22/23 at 2:02 p.m., the external hospice nurse for Resident #31 stated Resident #31 only had a wheelchair and a hospital bed as fall interventions. She stated the interventions were put in place by external hospice agency after Resident #31 was hospitalized at the end of July 2023. She stated she was not aware of any additional fall interventions implemented by the residence. On 8/22/23 at 2:09 p.m., Staff #13 stated that Resident #31 fell on 8/20/23 and hit her head. Staff #13 stated Resident #31 fell due to holding her rolling bedside table to stand by herself. Staff #13 stated Resident #31 had a wheelchairand required transfer assistance from one person. Staff #13 stated she was unaware of any other fall interventions put in place, and acknowledged there weren't any new interventions put in place after Resident #31's falls on 8/1, 8/9 and 8/20/23. On 8/22/23 at 2:13 p.m., the assisted living director stated that care plans were updated by the DON every time a resident fell, and was unsure why it had not been done for Resident #31. On 8/22/23 at 2:38 p.m., the family member for Resident #31 stated that Resident #31 had resided at the residence since 2021. The family member stated Resident #31 had a cognitive and physical change in condition on 7/22/23 that resulted in having been hospitalized. She stated Resident #31 was no longer able to ambulate independently. The family member for Resident #31 stated she removed Resident #31's walker from the residence on 7/26/23, since she was no longer able to use it and utilized a wheelchair. The family member further stated that Resident #31 had not had a call pendant since she was admitted to the residence and added she was not capable of using one. The family member for Resident #31 stated after Resident #31's falls on 8/1, 8/9 and 8/20/23 the residence had not implemented any fall interventions, there was only the wheelchair that external hospice implemented on 7/26/23. On 8/22/23 at 2:42 p.m., the administrator stated Resident #31 was at risk for falls. The administrator stated he was unaware what individual fall interventions were in place for Resident #31. He stated the DON updated care plans after every fall and he was not sure why it had not been updated for Resident #31. The administrator acknowledged that the care plan for Resident #31 should have been updated to reflect current interventions. The administrator stated it was the responsibility of the DON to update care plans; however, she was on vacation.

Based on interview and record review, the residence failed to ensure that each authorized practitioner's order for medication included the timing and/or frequency of administration, affecting one of three sample residents (#34). Findings include:1. Residence PolicyThe residence's Medication Assistance policy, dated 2123, read in part, the residence was responsible for ensuring signed orders included directions for administration. 2. Resident #34 was admitted to the residence on 3/10/23 with diagnoses including chronic kidney disease. A written practitioner's order, dated 5/5/23, directed the residence to administer amlodipine 5 mg. However, the order did not include the frequency of administration. The August 2023 electronic medication administration record (eMAR) read in part, the medication was administered twice daily from 8/1-8/12/23, for a total of 24 doses. A written practitioner's order, dated 5/5/23, directed the residence to administer carvediol 3.125 mg. However, the order did not include the frequency of administration. The August 2023 eMAR read the medication was administered twice daily from 8/1-8/12/23, for a total of 24 doses. A written practitioner's order, dated 5/5/23, directed the residence to administer calcitriol 0.25 mcg. However, the order did not include the frequency of administration. The August 2023 eMAR read the medication was administered once daily from 8/12-8/13/23, for a total of 13 doses. On 8/22/23 at 2:13 p.m., the assisted living director stated she was responsible for ensuring medication orders for Resident #34 included all required elements such as the frequency of administration. However, she stated the pharmacy must have received the correct order from the practitioner and the residence did not have access to the order. She stated she was unable to provide a practitioner order that included the frequency of administration for the aforementioned medications. On 8/22/23 at 2:42 p.m., the administrator stated he expected the practitioner orders to include the frequency of administration. However, he stated the pharmacy directly implemented the orders into the eMAR system and the residence had not received the correct orders from the practitioner. He confirmed the residence should have ensured the correct order was in the resident's record.

Based on observation, record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting one of three sample residents (#31). Findings include: 1. Residence PolicyThe residence's Medication Administration policy, dated 2/1/23, read in part: "All medications require a signed (practitioner's order) which includes ... the route of administration, directions of administration, quantity of medication and strength of medication ... assist one resident at a time based on the established procedure."2. Resident #31 was admitted to the residence on 7/26/23, with a diagnosis of Alzheimer's disease. AcetaminophenA written practitioner's order, dated 8/9/23, directed the residence to administer acetaminophen 500 mg two tablets three times daily at 6:00 a.m., 2:00 p.m., and 10:00 p.m. However, the August 2023 electronic medication administration record read acetaminophen was not administered on 8/11 in the evening and 8/12/23 in the morning due to waiting on the pharmacy to deliver, for a total of two missed doses. 3. InterviewsOn 8/22/23 at approximately 2:13 p.m., the assisted living director stated medications marked as unavailable or waiting on pharmacy, meant the medication was not administered. On 8/22/23 at 2:38 p.m., Resident #31's family member stated the residence was responsible for administering her medications. On 8/22/23 at approximately 3:00 p.m., the administrator stated that the residence should have followed practitioner's orders for Resident #31. The administrator stated the family member for Resident #31 might have administered the medication as well.

Based on interview and record review, the residence failed to ensure each qualified medication administration person (QMAP) shall accurately document each medication administration at the time the event was completed, affecting two of three sample residents whose medications were reviewed (#31, #33) and one former resident (#27). 1. Residence PolicyThe residence's Medication Administration policy, dated 2/1/23, read in part: "ensure documentation in the electronic medication administration record (eMAR) and the reason a medication was given."2. Resident #33 was admitted to the residence on 3/10/22 with diagnoses including asthma.a. Albuterol sulfateA written practitioner order, dated 7/3/23, directed the residence to administer albuterol sulfate inhalation 108 mcg two puffs every four hours. However, the August 2023 eMAR revealed no evidence of documentation at 4:00 a.m. on 8/11 and 8/12 and at 12:00 a.m. on 8/11/23.b. Advair DiskusA written practitioner order, dated 7/13/23, directed the residence to administer Advair diskus inhalation 250-50 mcg one puff twice daily. However, the August 2023 eMAR revealed no evidence of documentation on the evening of 8/15/23.c. FinasterideA written practitioner order, dated 5/10/23, directed the residence to administer finasteride 5 mg one daily. However, the August 2023 eMAR revealed no evidence of documentation on 8/15/23.d. TheophyllineA written practitioner order, dated 5/10/23, directed the residence to administer theophylline 300 mg twice daily. However, the August 2023 eMAR revealed no evidence of documentation on the evening of 8/15/23.3. Former Resident #27 was admitted to the residence on 8/15/22, with a diagnosis of rheumatoid arthritis. a. Diclofenac sodium gelA written practitioner's order, dated 9/1/22, directed the residence to administer diclofenac sodium twice daily. However, the August 2023 eMAR revealed no evidence of documentation the evening of 11/8/22.b. TrazodoneA written practitioner's order, dated 10/3/22, directed the residence to administer trazodone 0.5 mg at bedtime. However, the August 2023 eMAR revealed no evidence of documentation on 11/10/22. On 8/22/23 at 2:13 p.m., the ALD stated a blank space on the eMAR indicated the medication was administered; however, staff failed to document the administration. The ALD further stated staff should have documented the administration. On 8/22/23 at 2:42 p.m., the administrator stated he was not aware of what a blank space on the eMAR indicated. However, he confirmed that staff should have documented the administration of medication for Former Resident #27, accurately. 4. Resident #31 was admitted to the residence on 7/26/23, with a diagnosis of Alzheimer's disease. A written practitioner's order, dated 7/18/23, directed the residence to administer destin hypoallergenic cream 13% three times daily. However the August 2023 eMAR revealed no evidence of documentation the evening of 8/19/23. On 8/22/23 at 2:13 p.m., the assisted living director (ALD) stated a blank space on the eMAR indicated the medication was administered, however, staff failed to document the administration. She stated staff should have documented the administration. On 8/22/23 at 2:42 p.m., the administrator stated he was not aware of what a blank space on the eMAR indicated. However, he confirmed that staff should have documented the administration of medication accurately.

Based on record review and interview, the residence failed to ensure two individuals jointly counted all controlled substances at the end of each shift and signed documentation regarding the results of the count at the time it occurred, affecting one of three sample residents (#31). Findings include:Residence PolicyThe residence's Medication Assistance: Controlled Substances policy, dated 8/6/21, read in part, staff were required to verify the existing controlled substance count matched the number of doses left in the medication container or package. Resident #31 was admitted to the residence on 7/26/23, with a diagnosis of Alzheimer's disease. A written practitioner's order, dated 8/3/23, directed the residence to administer lorazepam 0.5 mg three times a day. A controlled substance count sheet read the controlled substance was not jointly counted three times during the first shift on 8/8, 8/14 and 8/17/23. On 8/22/23 at 7:37 a.m., Staff #10 stated staff were required to jointly count all controlled substances before and after their shift with another qualified medication administration person (QMAP). On 8/22/23 at 2:13 p.m., the assisted living director (ALD) stated staff should double count and double sign for controlled substances at the beginning and end of each shift. The ALD stated there were no issues with counts in the assisted living which she was responsible for. The ALD further stated the memory care director (MCD) was responsible for controlled substance count checks in the secure environment. On 8/22/23 at 2:42 p.m., the administrator stated staff were required to jointly count all controlled substances before and after their shift with another QMAP. He stated he was not sure why the controlled substance sheets would not be signed off as required, and acknowledged further education with his staff was required. On 8/22/23 at 3:21 p.m., the MCD stated she had been on vacation and was unsure why the count sheets were not jointly signed off on the above days. The MCD stated it should have been signed off and there was no excuse for staff not to document.

Based on interview and record review, the residence failed to ensure progress notes were included in the resident record, affecting three of four sample residents (#31, #33, #34) and one former resident (#35). (Cross-reference Q540, Q1130, and Q1180)Findings include:1. Resident #33 was admitted to the residence on 3/10/22. A progress note, dated 8/12/23, read in part the resident had symptoms for COVID-19. On 8/22/23 at 7:35 a.m., the legal representative for Resident #33 stated the resident experienced symptoms of COVID-19 on 8/12/23 and later tested for COVID-19 on 8/16/23. On 8/22/23 at 2:42 p.m., the administrator stated all staff were responsible for ensuring progress notes were documented. He confirmed all out of the ordinary events were required to be documented in a progress note. Further, he stated the resident getting tested for COVID-19 and the results of the test should have been documented in a progress note for the resident. 2. Resident #34 was admitted to the residence on 3/10/23. A hospital note for Resident #34, dated 8/13/23, read in part, the resident was symptomatic and positive for COVID-19. The resident experienced a 105 degree fever. A progress note, dated 8/19/23, read in part, on 8/13/23 the resident's legal representative visited the resident and checked her temperature. The legal representative contacted emergency medical services because the resident had a temperature. However, there was no progress note regarding the resident testing positive for COVID-19 or that she was admitted to the emergency department. Additionally, there was no progress note that the resident resided in a skilled nursing facility for physical therapy. On 8/22/23 at 7:35 a.m., the legal representative for Resident #34 stated the resident tested positive for COVID-19 after being admitted to the hospital on 8/13/23. She stated the resident resided at a skilled nursing facility for physical therapy, but would return to the assisted living residence in a few weeks. On 8/22/23 at 2:42 p.m., the administrator stated the residence staff should have written a progress note regarding the positive test result for Resident #34, that she was admitted to the emergency department and that she resided in a skilled nursing facility. He confirmed the aforementioned events were out of the ordinary and should have been in a progress note. 3. Resident #31 was admitted to the residence on 7/26/23, with a diagnosis of Alzheimer's disease. A progress note, dated 8/20/23, read that at 10:30 a.m., Staff #14 heard a scream from Resident #31's room, and she was found laying flat on the floor in front of her recliner. Staff #14 attempted to lift Resident #31 off the floor independently without success. Staff #14 called Staff #13 for help, and were able to get her back in her recliner. On 8/22/23 at 2:09 p.m., Staff #13 stated that she was on shift when Resident #31 fell on 8/20/23. Staff #13 stated Resident #31 fell due to holding on her rolling bedside table to stand by herself and stated she had hit her head. However, there was no progress note of Resident #31 having hit her head. On 8/22/23 at 2:13 p.m., the assisted living director (ALD) stated that it should have been included in progress notes that Resident #31 hit her head during a fall on 8/20/23. On 8/22/23 at 2:42 p.m., the administrator stated any out of the ordinary event which included Resident #31 having hit her head in a fall, should have been included in progress notes. 4. Former Resident #35 was admitted to the residence on 3/21/23 with a diagnosis of Alzheimer's Disease. A progress note, dated 3/31/23, read that Former Resident #35 had a fall when leaning out of his chair. The note read he hit his elbow and sustained a skin tear. Former Resident #35 was put on alert charting every two hours. A progress note, dated 4/3/23, read that the family member of Former Resident #35 was called for an update, and the family member stated "the goal is to bring my dad back to memory care." However, there was no progress note that read that Former Resident #35 had been sent to the hospital. On 8/22/23 at 7:48 a.m., Staff #10 stated Former Resident #35 was sent out to the hospital after a fall in March 2023, and never came back to the residence. On 8/22/23 at 11:22 a.m., the family member for Former Resident #35 stated that she was there when Former Resident #35 fell on 3/31/23 and stated he was sent to the hospital to be evaluated. On 8/22/23 at 2:16 p.m., the ALD stated that she was aware there was no progress note about Former Resident #35 being sent out to the hospital on 3/31/23, and stated there should have been a progress note. The ALD further stated the qualified medication administration person or caregiver who wrote the note failed to include that Former Resident #35 was sent out to the hospital. On 8/22/23 at 2:42 p.m., the administrator acknowledged Former Resident #35 being sent to the hospital on 3/31/23 should have been included in a progress note.