HILLCREST OF LOVELAND

An administrative relicensure survey was completed on 3/5/26. No deficiencies 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 revisit survey was completed on 4/17/25 for all previous deficiencies cited on 1/7/25. 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 change of ownership survey was completed on 9/12/24. No deficiencies were cited.

A relicensure survey with complaint #CO36039 was completed on 1/7/25. Deficiencies were cited.

12.2.2 Infection Control Officer (B) Each facility shall assign at least one (1) staff member responsible for the site management of the facility's Infection Prevention and Control Program and training. This individual shall be responsible for the following: (1) Completing an infection prevention and control training from a nationally recognized provider or the Department's training program within two (2) weeks of appointment/designation that meets the requirements based on facility type. Based on record review and interview, the residence failed to ensure that the assigned infection control officer completed infection prevention and control training from a nationally recognized provider or the Department ' s training program, affecting 24 current residents. (Cross-reference S1596) On 1/7/25, the residence could not provide the required certificate of the infection prevention and control program training for the staff designated as the infection control officer. On 1/7/25 at 10:09 a.m., the health and wellness director (HWD) stated she was in charge of infection control at the residence; however, she had not completed an infection prevention and control program training. She added that the administrator might have completed the training. On 1/7/25 at 2:04 p.m., the administrator stated she had not completed an infection prevention and control program training. She added that the HWD was the designated infection control officer at the residence, and she was unaware whether the HWD had completed it. She stated she was not aware of the requirement for the training.

Based on observation, record review, and interview, the residence failed to request, prior to staff hire, a name-based criminal history record check conducted by the Colorado Bureau of Investigation (CBI) for each prospective staff member for two staff (#1, #2), affecting 24 current residents. Findings include:On 1/7/25 from 7:00 a.m. to 3:00 p.m., Staff #1 and #2 worked directly with residents. The personnel files for Staff #1 and #2 read the following:Staff #1 was hired on 12/8/23. Staff #2 was hired on 6/15/23. The personnel files for Staff #1 and #2 did not contain evidence that the residence requested a criminal history record check conducted by the CBI.On 1/7/25, documentation of CBI criminal history record checks for Staff #1 and #2 were requested but not provided. A review of the December 2024 and January 2025 staff schedules revealed: Staff #1 worked the following dates: 12/30, 12/31/24, and 1/4-1/6/25 Staff #2 worked the following: 12/30/24-1/3/25 and 1/6/25. On 1/7/25 at 1:57 p.m., the business office manager stated that the residence used a background check service that did not include a CBI check for any staff, including Staff #1 and #2. She added she was not aware that a background check through CBI was a requirement. On 1/7/25 at 3:18 p.m., the administrator stated that she expected the residence to conduct criminal history background checks per the requirement prior to hiring the staff. She added she was unaware that the residence's background check service did not include the required check through the CBI.

Based on observation, record review, and interview, the residence failed to request, prior to staff hire, a check of the Colorado Adult Protective Services (CAPS) data system for each prospective staff member for two staff (#1, #2), affecting 24 current residents. Findings include:On 1/7/25 from 7:00 a.m. to 3:00 p.m., Staff #1 and Staff #2 worked at the residence directly with residents. The personnel file for Staff #1 and Staff #2 read the following:Staff #1 was hired on 12/8/2023. Staff #2 was hired on 6/15/2023. The personnel files for Staff #1 and #2 did not contain evidence that the residence requested a CAPS check. On 1/7/25 at 1:57 p.m., the business office manager stated that the residence did not request CAPS checks for Staff #1 and #2. On 1/7/25 at 3:18 p.m., the administrator stated that she expected the residence to conduct a CAPS check per the requirement. She added that since evidence of the CAPS check was not in the staff file, the residence would be unable to prove that they conducted a CAPS check for Staff #1 and #2.

Based on an interview and record review, the residence failed to ensure that at least one staff member was onsite with a current certification in first aid, affecting 24 current residents. (Cross-reference S0736)Findings include:On 1/7/25, from 9:13 a.m. to 10:43 a.m., the residence provided first aid certifications for the administrator, the business office manager (BOM), and Staff #1 and #2. On 1/7/25 at 4:55 p.m., the administrator sent an electronic message that contained a first aid certification for Staff #5. The January 2025 staff schedule read in part that Staff #1, #2, #5, the administrator, or the BOM did not work at the residence, and therefore, no first aid-certified staff worked on the following shifts:On 1/1-1/6/25 from 5:30 p.m. to 10:00 p.m. On 1/2, 1/3, and 1/6/25 from 10:00 p.m. to 6:00 a.m. On 1/7/25 at 11:12 a.m., the administrator affirmed that the residence was required to have one staff member onsite at all times who was certified in first aid. She added that several staff first aid certifications expired, and there had been staff turnover at the residence, which added to the residence not having a first aid certified staff on each shift. The administrator stated she and the BOM were certified; however, they typically worked Monday through Friday during business hours with some variation of earlier or later days; however, they had not worked at the residence from 5:30 p.m.-10:00 p.m. consistently, and they had not worked during the overnight shift from 10:00 p.m. until 6:00 a.m.

Based on interview and record review, the residence failed to ensure that at least one staff member onsite at all times was certified in cardiopulmonary resuscitation (CPR) and obstructed airway techniques from a nationally recognized organization and included a skills assessment observed and evaluated by an instructor, affecting 24 current residents. (Cross-reference S0736)Findings include:The residence's undated Service Agreement read in part that the residence had designated staff trained in CPR on each shift in the event that a resident required CPR. On 1/7/25, from 9:13 a.m. until 10:43 a.m., the residence provided CPR certifications for the administrator, the business office manager (BOM), and Staff #2-#4. On 1/7/25 at 4:55 p.m., the administrator sent an electronic message that contained an online CPR certification without the required skills check for Staff #5. Additionally, the administrator wrote that Staff #6 had a CPR certification; however, she did not attach the certification to the message. The January 2025 staff schedule read in part that Staff #1-#4, the administrator, and the BOM did not work at the residence, and therefore, no CPR-certified staff worked on the following shifts:On 1/1-1/6/25 from 5:30 p.m. to 10:00 p.m. On 1/1-1/6/25 from 10:00 p.m. to 6:00 a.m. A medical scope of treatment form (MOST) for Resident #4 read that the resident elected to have CPR.On 1/7/25 at 11:12 a.m., the administrator affirmed that the residence was required to have one staff member onsite at all times who was certified in CPR. She added that several staff CPR certifications expired, and there had been staff turnover at the residence; both reasons added to the residence not having a CPR-certified staff on each shift. The administrator stated she and the BOM were certified; however, they typically worked Monday through Friday during business hours with some variation of earlier or later days; however, they had not worked at the residence from 5:30 p.m. to 10:00 p.m. consistently, and they had not worked during the overnight shift from 10:00 p.m. to 6:00 a.m. The administrator affirmed that one resident elected to have CPR at the residence. She affirmed that it was essential to have CPR-certified staff in the event any resident required assistance with obstructed airway technique.

Based on observation and interview, the residence failed to place in a visible location a list of all staff who have current certification in first aid or cardiopulmonary resuscitation (CPR) so that the information is readily available to staff at all times, affecting 24 current residents. (Cross-reference S0732, S0734)During the onsite visit on 1/7/25, the residence had not placed a list of staff members with current certification in first aid and CPR in a visible location at the residence. On 1/7/25 at 2:04 p.m., the administrator stated that there was no list of all staff who have current certifications in first aid or CPR posted in a visible location at the residence. She added that she was not aware of the requirement. On 1/7/25 at 2:21 p.m., the health and wellness assistant stated there was no list of all staff who had current certification in first aid or CPR placed or posted at the residence.

Based on observation and interview, the residence failed to ensure that qualified medication administration persons (QMAPs) were trained in and applied nationally recognized protocols for basic infection control and prevention when preparing and administering medications, affecting nine of 11 sample residents (#1, #2, #5-#11) whose medications were administered. Findings include:On 1/7/25, from approximately 7:40 a.m. to 8:35 a.m., the following was observed: the residence had several residents in isolation in their rooms with personal protective equipment outside of their doors. During medication administration, Staff #1 failed to don a pair of gloves and did not perform hand hygiene prior to medication preparation or between the administration of medication to residents. Staff #1 touched the medication containers, medical cart drawers, keys, and doorknobs and operated a computer. Staff #1 then dispensed medications for Residents #2 and #9. At no time did Staff #1 apply hand sanitizer or wash their hands. On 1/7/25, the administrator provided training records dated 4/24/24 regarding the proper use of personal protective equipment (PPE), handwashing, and use of sanitizer. Staff #1 did not sign the attendance sheet. On 1/7/25 at approximately 7:15 a.m., Staff #2 stated that the assisted living residence floor of the residence was experiencing a COVID-19 outbreak. On 1/7/25 at approximately 7:35 a.m., the administrator stated that the assisted living residence floor of the residence was experiencing a COVID-19 outbreak. In a later interview, at 3:17 p.m., the administrator stated that she expected staff to sanitize or wash their hands after and before each medication administration to residents. The investigation revealed similar deficient practice with Residents #1, #5-#7, #10, and #11.

Based on record review and interview the residence failed to provide each staff member a minimum of six hours of general training and education on providing care and services for residents with dementia/cognitive impairment for two staff (#1, #2) affecting 10 current residents in the secure environment (SE). Findings include:On 1/7/25, from 7:00 a.m. to 3:00 p.m., Staff #1 and #2 worked directly with residents. The personnel file for Staff #1 and #2 read the following:Staff #1 was hired on 12/8/23. Staff #2 was hired on 6/15/23. The personnel files for Staff #1 and #2 did not contain evidence that the residence provided the required six hours of dementia training. On 1/7/25 at 3:18 p.m., the administrator stated that staff who worked in the SE had not completed the full six hours of dementia training within 60 days of hire, including Staff #1 and #2. She affirmed that both Staff #1 and #2 worked in the SE. She added that she was unaware of the requirement.

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 7.13.12 The assisted living residence shall develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin. 14.10 Unless otherwise allowed by statute, the assisted living residence shall not permit a qualified medication administration person to perform any of the following tasks: (H) Pre-pouring of medication; 14.11 Only medication that has been ordered by an authorized practitioner shall be prepared for or administered to residents. 14.23 For medication reminder boxes that the assisted living residence is responsible for, the assisted living residence shall ensure that the box contains: (A) No more than a 14 calendar day supply of medications at a time;(B) No PRN medications, including PRN controlled substances;(C) Only medication intended for oral ingestion; and(D) No medications that require administration within specific timeframes unless the medication reminder box.

A revisit survey was completed on 3/5/24 for all previous deficiencies cited on 11/6/23. The facility is in compliance with all deficiencies that were cited.

A licensure complaint, prompted by #CO32152, was completed on 11/6/23. Deficiencies were cited.

Based on record review and interviews, the residence failed to provide the required orientation, prior to providing any care or services to residents, for five of five sample staff (#1-#5), affecting nine current residents who resided in the secure environment . Findings include:1. References a. Chapter VII regulation governing assisted living residences, in part 7.8 A, requires residences to ensure each staff member receives orientation and training. The orientation is to include the following topics:The care and services provided by the assisted living residence. Assignment of duties and responsibilities, specific to the staff member or volunteer. Hand Hygiene and infection control. Emergency response policies and procedures, including:(a) Recognizing emergencies, (b) Relevant emergency contact numbers, (c) Fire response, including facility evacuation procedures (d) Basic first aid, (e) Automated external defibrillator (AED) use, if applicable, (f) Practitioner assessment, and (g) Serious illness, injury, and/or death of a resident. (5) Reporting requirements, including occurrence reporting procedures within the facility;(6) Resident rights; (7) House rules;(8) Where to immediately locate a resident's advance directive; and(9) An overview of the assisted living residence's policies and procedures and how to access them for reference.b. Chapter VII regulation governing assisted living residences, in part 7.12, requires each personnel file to include written documentation regarding orientation and training. 2. During the 11/1/23 onsite visit, the following was revealed:The review of personnel files for staff #1-#5 contained conflicting dates, in order to determine when each staff member began to work in the residence. At 11:44 a.m, the director of health services (DHS) stated that the onboarding date was not necessarily the date the staff started to work in the residence, and the only way to find that out would be to go through previous timecards. The DHS advised the surveyor to use the effective dates in the personnel records, although noting they may not be accurate. The effective dates for the five sample staff, as found in the personnel files, were as follows:Staff #1's effective date was 6/26/23. Staff #2's effective date was 4/20/23. Staff #3 and #5''s effective date was 5/23/23. Staff #4's effective date was 8/14/23. The personnel files of the above five sample staff did not contain evidence that they had received the required orientation noted above. At 1:00 p.m., Staff #1 stated she started to work at the residence on 6/30/23 and usually worked the 6:00 a.m. to 2:30 p.m. shift. She said "There was not much training," and said she shadowed a former LPN (licensed practical nurse) for one day and was working alone and independently the next day. Staff #1 also stated that "getting thrown into something was overwhelming" however, she was a fast learner. Staff #1 stated she had not received orientation. During an interview at 2:12 p.m, the DHS stated that she herself had not received a "robust training on the training" that was to be provided and was working on "figuring it out on my own." The DHS stated that by an external consulting group, she realized the residence needed to set up employees for success, which included a new and better orientation program. At 3:00 p.m, the administrator stated that her expectation was that new staff should have shadowed for three days. She noted that when Staff #1 was hired in June 2023, the residence was "in flux, and there was no nurse at the time. Everybody was doing parts of the training, in bits and pieces." The administrator stated that she knew the orientation needed improvement.

Based on record review and interviews, the residence failed to provide the required training, prior to a staff member working independently, for five of five sample staff (#1-#5), affecting nine current residents, residing in the secure environment. Findings include:1. References a. Chapter VII regulation governing assisted living residences, in part 7.8 B, requires residences to ensure each staff member receives training relevant to their specific duties and responsibilities, prior to that staff member working independently. The training is required to include the following topics:Overview of state regulatory oversight applicable to the assisted living residence. Person-centered care. The role of and communication with external service providers. Recognizing behavioral expression and management techniques, as appropriate for the population being served. How to effectively communicate with residents that have hearing loss, limited English proficiency, dementia, or other conditions that impair communication, as appropriate for the population being served. Training related to fall prevention and ways to monitor residents for signs of heightened fall potential such as deteriorating eyesight, unsteady gait, and increasing limitations that restrict mobilityHow to safely provide lift assistance, accompaniment, and transport of residents. Maintenance of a clean, safe and healthy environment including appropriate cleaning techniques. Food safety. Understanding the staff or volunteer's role in end of life care including hospice and palliative care.b. Chapter VII regulation governing assisted living residences, in part 7.12, requires each personnel file to include written documentation regarding orientation and training. 2. During the 11/1/23 onsite visit, the following was revealed:The review of personnel files for staff #1-#5 contained conflicting dates, in order to determine when each staff member began to work in the residence. At 11:44 a.m, the director of health services (DHS) stated that the onboarding date was not necessarily the date the staff started to work in the residence, and the only way to find that out would be to go through previous timecards. The DHS advised the surveyor to use the effective dates in the personnel records, although noting they may not be accurate. The effective dates for the five sample staff, as found in the personnel files, were as follows:Staff #1's effective date was 6/26/23Staff #2's effective date was 4/20/23Staff #3 and #5''s effective date was 5/23/23Staff #4's effective date was 8/14/23The personnel files of the above five sample staff did not contain evidence that they had received the required training noted above. At 1:00 p.m., Staff #1 stated she started to work in the facility on 6/30/23 and usually worked the 6:00 a.m. to 2:30 p.m. shift. She said "There was not much training," and said she shadowed a former LPN (licensed practical nurse) for one day and was working alone and independently the next day. Staff #1 also stated that "getting thrown into something was overwhelming" however, she was a fast learner. Staff #1 stated she had not received training. At 2:12 p.m, the DHS stated that she herself had not received a "robust training on the training" that was to be provided and was working on "figuring it out on my own." The DHS stated that by an external consulting group, she realized the residence needed to set up employees for success. The DHS further stated she wanted to build a caregiver foundation, and build from that. At 3:00 p.m, the administrator stated that her expectation was that new staff should have shadowed for three days. She noted that when Staff #1 was hired in June 2023, the residence was "in flux, and there was no nurse at the time. Everybody was doing parts of the training, in bits and pieces." The administrator stated that she knew the training needed improvement.

Based on record review and interview, the residence failed to ensure its written resident agreement specified the understanding between parties regarding the services not provided, affecting seven of seven sample residents (#1-#7). Findings include:The residence's written resident agreement did not specify the services the residence would not provide. (Cross-reference P1110). On 11/1/23 at approximately 3:00 p.m, the administrator reviewed the agreement and agreed it did not include what services the residence would not provide. The administrator stated the residence currently did not provide diabetic services and confirmed it was not included in the resident agreement.

Based upon observation, record review and interview, the residence failed to provide protective oversight and personal services, sufficient to meet the needs of six of seven sample residents (#1-#6). Findings include: 1. ReferencesChapter VII regulations governing assisted living residences, part 2.34 defines "Personal services" as those services that an assisted living residence and its staff provide for each resident including, but not limited to: Assistance with activities of daily living. Chapter VII regulations governing assisted living residences, part 2.3, defines "Activities of daily living (ADLs)" as those personal functional activities required by an individual for continued well-being, health and safety. As used in this Chapter 7, activities of daily living include, but are not limited to, accompaniment, eating, dressing, grooming, bathing, personal hygiene (hair care, nail care, mouth care, positioning, shaving, skin care), mobility (ambulation, positioning, transfer), elimination (using the toilet) and respiratory care. Chapter VII regulations governing assisted living residences, part 2.38, defines "Protective oversight"as guidance of a resident as required by the needs of the resident or as reasonably requested by the resident, including the following: (B) Monitoring the activities of the resident while on the premises to ensure the resident ' s health, safety and well-being, including monitoring the resident ' s needs and ensuring that the resident receives the services and care necessary to protect the resident ' s health, safety, and well-being. The residence's resident agreement, titled Assisted Living Residence and Service agreement, read the resident would be responsible for paying to Manager the following fees, as set forth on Exhibit A: Base monthly feeAssisted Living FeeAdditional ChargesCommunity FeeThe sum of the Base Monthly Fee, the Assisted Living Fee, and any Additional Charges shall be known as the "Total Monthly Fee." The agreement also read, under Assisted Living Service Fee:Level 1- 1-60 points $650Level 2- 61 to 100 points $1,050Level 3- 101-150 points $1,450Level 4- 151- 200 points $1,850Level 5- 201 -275 points $2,350Level 6- 276+ points $2,650* The community fee was $3500 and the current Base Monthly fee was blank, to be filled in. Under Assisted Living Services it read, "Assisted living Services are determined by the Assisted Living Service Level assessed for each resident. a. Monitoring of medicationsb. Transferring and bathroom assistancec. Escorting to meals and activitiesd. Daily monitoring of vital signse. Arranging appointments and transportationf. Personal laundryg. Assistance with bating, dressing or groomingh. Daily housekeepingi. Incontinence managementj. Behavior change monitoringk. Resident enrichment programi. 24- hour oversight by professional trained caregivers 2. During the 11/1/23 onsite visit, the following was revealed:Observations of the residence's secure environment were made from 7:11 a.m. until 10:00 a.m. During this time period, residents were noted not to receive personal services and care to ensure their health, safety and welfare, and as directed by their care plans/assessments, and rules governing assisted living residences. Upon arrival to the secure environment (SE) at 7:11 a.m., two of the nine residents residing in the unit were seated at a dining room table: Residents #3 and #7. The other seven residents were in their rooms. a. Resident #2: At 7:13 a.m., Resident #2 walked into the dining area. Her hair was unwashed, there was dandruff in her hair and on the front of her shirt. She was not wearing shoes and had on mismatched socks: one tan sock (right foot) and one blue sock (left foot). Resident #2 continued to wear mismatched socks throughout the onsite investigation. Staff #1 stated the resident was fully independent, was more confused lately and recently had an aortic dissection. Staff #1 stated the resident did her own oral care and when questioned of her unwashed hair, Staff #1 stated she did not like showers and external hospice services had just been started so she believed they would be taking over care services for the resident. Subsequent record review revealed Resident #2 was admitted to the residence on 2/7/23 with diagnoses including frailty, anemia, fibromyalgia, giant cell arteritis, dementia and anxiety. The most recent Resident Assessment was dated 10/23/23, and read the resident had received a score of 64 points and was a level 2. The assessment read that the resident required one person, total assistance with bathing twice per week. The resident was independent with grooming. The assessment read the resident required reminders to dress appropriately. The resident's most recent care plan, provided by the HSD read she was independent with grooming, was to be be clean daily, staff were to remind the resident to dress appropriately, be well groomed and staff were to "provide set up and cueing of personal hygiene supply for dental ... Hair brush or comb." b. Resident #3: During interview at 7:16 a.m., Staff #1 stated that Resident #3 was usually up early, and needed assistance with dressing and grooming. However, the resident appeared not to have received this service as her hair on the back of her head was parted and matted toward the sides, as if she had slept on her back the evening before. Subsequent record review revealed Resident #3 was admitted to the residence on 3/15/19 with diagnoses including dementia, cerebral ischemia, DM2, dysphagia, GERD. The most recent resident assessment was dated 7/29/23, and read the resident had received a score of 264 points and was a level 5. The assessment read the resident required one person total assistance with grooming. The resident's most recent care plan, provided by the HSD read the resident was to receive total assistance with grooming. c. Resident #6: At 7:25 a.m., Staff #2 went to the room of Resident #6 to see if she was "ready to get moving this morning." The resident stated she wanted to "wait for awhile" and Staff #2 stated she needed to eat breakfast in order to be ready for a hair appointment. At 7:37 a.m., Staff #2 went to the room of Resident #6 and encouraged her to put on a house dress, so she could attend breakfast. Staff #2 reminded the resident she had an appointment to get her hair done. The resident responded that she was 92 years old, "worn out a bit," and said her hair was a mess, but she was going to get it done today. Staff #2 assisted her with her house dress, and told the resident she would make her bed. The resident stated she needed to use the bathroom and did this independently. Staff #2 had left the room and did not provide any other care to the resident. The resident did not perform any oral care and applied lipstick, before going to the dining area. At 9:29 a.m, Resident #6 was in her room watching television and continued to ask about her hair appointment. Staff #2 reminded her of the appointment time and removed plastic cups to place in the trash. Resident #6 left the secure environment at 9:34 a.m. to go to her hair appointment. Subsequent record review revealed Resident #6 was admitted to the non-secured area of the residence on 11/27/22 and admitted to the secure environment on 6/19/23, with diagnoses including mild cognitive impairment, diverticulosis, osteoporosis. The most recent resident assessment was dated 5/31/23, and read the resident had received a score of 168 points and was a level 4. The assessment read the resident was independent with grooming. The resident's most recent care plan, provided by the HSD read the resident was to receive reminders to maintain proper hygiene, and "monitor condition of the resident's mouth, document and report irritation, bleeding gums, pain, tooth decay, etc" and, "assist resident with brushing hair and teeth in the morning and at night." However, these reminders were not provided to the resident. d. Resident #4: At 7:27 a.m, Resident #4 entered the dining area and had unwashed hair. Subsequent record review revealed Resident #4 was admitted to the residence on 8/17/23 with diagnoses including Alzheimer's disease, dementia and hypertension. The most recent resident assessment was dated 9/1/23, and read the resident had received a score of 53 points and was a level 1. The assessment read the resident was independent with grooming. The resident's most recent care plan, provided by the HSD read the resident was to be bathed once a week, on Wednesday evenings. The care plan read she was independent with grooming but a goal was to "maintain the client's personal hygiene and appearance." e. Resident #5: At 7:30 a.m., Staff #2 went to the room of Resident #5 and asked the resident what she was going to wear today, and brought her some socks. She asked the resident if she wanted coffee and subsequently reported to Staff #1 that she was almost ready for breakfast. At 7:49 a.m., Resident #5 left her room and was noted to have hair matted down on the back of her head. Staff #2 stated the resident was getting her hair done at 10:00 a.m. today. At 8:47 a.m, Resident #5 walked back to her room and was asked by the surveyor if she had brushed her teeth that morning and she said she had, although it was not observed by the surveyor. At 8:50 a.m, Staff #2 entered the resident's room to apply lotion and to administer an eye drop. No other additional care was provided. Subsequent record review revealed Resident #5 was admitted to the residence on 2/9/18 with diagnoses including Alzheimer's disease, vascular dementia with behavioral disturbance, hypertension, repeat falls, gait abnormality, foot drop, insomnia and weakness. The most recent resident assessment was dated 10/18/23, and read the resident had received a score of 250 points and was a level 5. The assessment read the resident required one person total assistance from grooming. The resident's most recent care plan, provided by the HSD, contained discrepant information and read under Grooming that she required "Total Assist" but read below that, "Cue as needed." Under "Hygiene/oral care" it read the resident was required to be reminded to perform oral hygiene twice daily, however, this did not take place the morning of the survey. f. Resident #1: At 8:24 Resident #1 left her room and entered the dining area. She was wearing mismatched socks: one with flowers and one with stripes. She was not wearing shoes and her purple pants were stained on two spots on the right leg and her turquoise top was stained in two places. Her hair had not been brushed. Resident #1 was not observed to receive care from staff. At 9:15 a.m, following breakfast, Staff #1 walked Resident #1 to her room and changed her incontinence product and clothes. Following this, Staff #1 exited the room with Resident #1 and she was wearing clean clothing and her hair had been brushed. She was still wearing mismatched socks and had a braid in the back of her hair. She had been dressed in gray slacks, black sweater and a clean shirt. Subsequent record review revealed Resident #1 was admitted to the residence on 9/1/23 with diagnoses including dementia. The most recent resident assessment was dated 9/6/23, and read the resident had received a score of 202 points and was a level 5. The assessment read the resident required one person total assistance with grooming, dressing and toileting. The resident's most recent care plan, provided by the HSD, read the resident required total assistance with dressing and grooming. Under transferring, it read staff were to ensure the use of proper footwear with nonslip soles and good support. During interview starting at 1:00 p.m, Staff #1 was asked why the resident was wearing soiled clothing that morning. Staff #1 stated those were the clothes she wore the day before and the night staff must not have changed her the evening before. Staff #1 did not explain the mismatched socks, but said the resident did not like to wear shoes. 3. During an interview at 2:12 p.m, the above observations were shared with the DHS. The DHS stated that she did her best to set expectations and hoped that staff would follow them. 4. During an interview at 3:30 p.m, the above observations were shared with the administrator. The administrator stated she was not aware that there was not good oral care in the secure environment. 5. During an interview on 11/7/23 at 2:56 p.m, the administrator stated the residence had not managed the care needs of residents in the secure environment as it should have.

Based on record review and interview, the residence failed to provide training on the care plans of each resident, before being allowed to work independently in the secure environment, for five of five sample staff (#1-#5), affecting nine current residents residing in the secure environment. Findings include:1. References: Chapter VII regulations governing assisted living residences, part 7.12, requires each personnel file to include written documentation regarding orientation and training. 2. During the 11/1/23 onsite visit, the following was revealed:The review of personnel files for Staff #1-#5 contained conflicting dates, in order to determine when each staff member began to work in the residence. At 11:44 a.m, the director of health services (DHS) stated that the onboarding date was not necessarily the date the staff started to work in the residence, and the only way to find that out would be to go through previous timecards. The DHS advised the surveyor to use the effective dates in the personnel records, although noting they may not be accurate. The effective dates for the five sample staff, as found in the personnel files, were as follows:Staff #1's effective date was 6/26/23. Staff #2's effective date was 4/20/23. Staff #3 and #5''s effective date was 5/23/23. Staff #4's effective date was 8/14/23. The personnel files of the above five sample staff did not contain evidence that they had received training on the care plans of each resident, prior to being allowed to work independently in the secure environment. During interview starting at approximately 1:00 p.m., Staff #1 stated she started to work in the facility on 6/30/23 and usually worked the 6:00 a.m. to 2:30 p.m. shift. When asked about her training she received at hire she said "There was not much training," and said she shadowed a former LPN (licensed practical nurse) for one day and was working alone and independently the next day. Staff #1 also stated that "getting thrown into something was overwhelming" however, she was a fast learner. Staff #1 stated she had not received training on the care plans of residents in the secure environment. During an interview at approximately 3:00 p.m, the administrator stated that when Staff #1 was hired in June 2023, the residence was "in flux, and there was no nurse at the time. Everybody was doing parts of the training, in bits and pieces." The administrator stated that she knew the training needed improvement.

Based on record review and interview, the residence failed to hold family council meetings, affecting nine residents currently residing in the secure environment of the residence. Findings include: The director of health services (DHS) and administrator were asked to provide the meeting minutes from the Family Council meetings. Subsequently, at 10:59 a.m, the DHS stated the residence did not hold organized, family council meetings and just met with family members on a one on one basis. Subsequently, the administrator stated multiple nurses had quit recently, and a plan had been made to hold a meeting on 12/5/23. The administrator stated it had been a year to a year and a half, since a family council meeting had been held.