ST ANDREWS VILLAGE

A licensure complaint, prompted by #CO36052 was completed on 2/24/25. No deficiencies were cited.

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 07.7.12 Personnel files for current employees and volunteers shall be readily available onsite for Department review. 12.15 The assisted living residence shall develop policies and procedures to establish a fall management program. The program shall include the following: (A) Providing fall management education and materials to residents and family members;(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; (C) Providing resident engagement activities to improve strength and balance as specified in Part 12.22(C); (D) Routinely inspecting and maintaining a safe exterior and interior environment as specified in Parts 21 and 22; and (E) Providing staff training related to fall prevention as specified in Part 7.8(B)(6). 13.1 The assisted living residence shall adopt, and place in a publicly visible location, a statement regarding the rights and responsibilities of its residents. The assisted living residence and staff shall observe these rights in the care, treatment, and oversight of the residents. The statement of rights shall include, at a minimum, the following items: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 2.2.10.5 The licensee shall provide, upon request, access to or copies of the following to the Department for the performance of its regulatory oversight responsibilities: (A) Individual client records. (B) Reports and information required by the Department including but not limited to, staffing reports, census data, statistical information, and other records, as determined by the Department. 4.1.2 The program shall be implemented in accordance with a quality management plan that is reviewed and approved annually by the governing body, or if the facility or agency is not required to have a governing body, by the administrator or the administrator's designee(s). The plan shall have the following elements:(A) Identification of quality management projects (1) For the client safety component of the program, the plan shall identify: (a) The types of service delivery errors and potential for error that will be monitored, which may shall be based, at minimum, on a review of negative client outcomes that are unanticipated, client grievances, deficiencies cited by regulatory agencies, occurrences and/or errors, and potential for errors reported by staff. (b) A process for staff to report service delivery error and potential for error within a prescribed period of time and a plan for how staff will be trained regarding such reporting. (c) The methods used to collect and analyze data in order to find patterns and trends. The plan shall also include how the governing body, if applicable, and the administrator will be informed of such patterns and trends. (d) The method(s) used to select quality management projects. (e) The method(s) for selecting the service delivery practice(s) that will be reviewed. (B) Implementation of improvement strategies (1) The plan shall include how improvement strategies will be developed. This may include identifying the personnel that will be involved in designing the intervention, opportunities for client input, and the administrative approvals needed to finalize the intervention design. (2) There shall be documentation for each improvement strategy that includes: (a) A description of the intervention design. For client safety improvements, this shall include how information about patterns and trends will be shared with staff and how the underlying systemic problem(s) that led to the pattern or trend will be addressed.(b) How staff will be allocated and/or trained to implement the strategy. (c) How the strategy will be evaluated for effectiveness. (d) Timelines for implementation and evaluation of the strategy and how the facility or agency is tracking the meeting of these milestones.

A complaint revisit was completed on 2/24/25 for the previous deficiencies cited on 2/9/23. The residence is in compliance with all regulations surveyed.

A relicensure survey with complaint #CO30780 was completed on 2/9/23. Deficiencies were cited.

Based on record review and interview, the residence failed to provide, upon request, residence documents, staff information and other records as requested by the department, affecting 58 current residents. Findings include: 1. Referencesa. Chapter VII regulations governing assisted living residences, part 6.8, requires that the administrator shall be responsible for the overall day-to-day operation of the assisted living residence, including, but not limited to:(I) Completing, maintaining, and submitting all reports and records required by the Department. 2. Record ReviewOn 2/9/23 at 7:50 a.m., the following documents were requested from the administrator:a. Current staff listb. Resident agreementc. The quality management programOn 2/9/23 at 11:45 a.m., the staff list and resident agreement were provided, four hours after they were requested. On 2/9/23 at 12:05 p.m., the quality management program was provided, four hours and 15 minutes after it was requested. 3. InterviewOn 2/9/23 at 1:14 p.m., the administrator stated it took so long to provide documents because it was her first time trying to print from the electronic system the residence used.

Based on record review and interview, the residence failed to ensure its quality management program (QMP) contained the required elements, affecting 58 current residents. Findings include:1. Referencesa. Chapter II regulations governing health facilities, part 4.1.2, requires a quality management plan to be reviewed and approved on an annual basis, by the administrator or the administrator's designee. b. Chapter II regulations governing health facilities, part 4.1.2A, requires the QMP to include the following elements:Identification of quality management projects For the client safety component of the program, the plan shall identify: a. The types of service delivery errors and potential for error that will be monitored, which shall be based, at minimum, on a review of negative resident outcomes that are unanticipated, resident grievances, deficiencies cited by regulatory agencies, occurrences and/or errors, and potential for errors reported by staff. b. A process for staff to report service delivery error and potential for error within a prescribed period of time and a plan for how staff will be trained regarding such reporting. c. The methods used to collect and analyze data in order to find patterns and trends. The plan shall also include how the administrator will be informed of such patterns and trends. d. The method(s) used to select quality management projects.e. The method(s) for selecting the service delivery practice(s) that will be reviewed. 2. QMP ReviewOn 2/9/23, the residence provided documentation. The documentation provided included data sheets which read resident information such as body weights. However, the QMP did not include:a. The types of service delivery errors and potential for error that will be monitored, which shall be based, at minimum, on a review of negative resident outcomes that are unanticipated, resident grievances, deficiencies cited by regulatory agencies, occurrences and/or errors, and potential for errors reported by staff. b. A process for staff to report service delivery error and potential for error within a prescribed period of time and a plan for how staff will be trained regarding such reporting. c. The methods used to collect and analyze data in order to find patterns and trends. The plan shall also include how the administrator will be informed of such patterns and trends. d. The method(s) used to select quality management projects.e. The method(s) for selecting the service delivery practice(s) that will be reviewed. 3. InterviewOn 2/9/23 at approximately 1:14 p.m., the administrator acknowledged that the quality management program provided contained only various resident data sheets and did not include the required elements.

Based on record review and interview, the residence failed to ensure its quality management program (QMP) implemented improvement strategies, affecting 58 current residents. Findings include:1. Referencesa. Chapter II regulations governing health facilities, part 4.1.2, requires a quality management plan to be reviewed and approved on an annual basis, by the administrator or the administrator's designee. b. Chapter II regulations governing health facilities, part 4.1.2B, requires the QMP to include the following elements:Implementation of improvement strategiesHow the improvement strategies would be developedDocumentation for each improvement strategy, to include: How information about patterns and trends will be shared with staff and how the underlying systemic problem(s) that led to the pattern or trend will be addressed. How staff will be allocated and/or trained to implement the strategy. How the strategy will be evaluated for effectiveness. Timelines for implementation and evaluation of the strategy and how the facility is tracking the meeting of these milestones. 2. QMP ReviewThe residence submitted documentation to the department on 2/9/23. The administrator reported the residence had chosen the following service delivery errors to implement improvements:Medication administrationResident body weightsResident fallsInfection control. However, there was no evidence provided to show the following was met for the above areas:Implementation of improvement strategiesHow the improvement strategies would be developedDocumentation for each improvement strategy, to include: How information about patterns and trends will be shared with staff and how the underlying systemic problem(s) that led to the pattern or trend will be addressed. How staff will be allocated and/or trained to implement the strategy. How the strategy will be evaluated for effectiveness. Timelines for implementation and evaluation of the strategy and how the facility is tracking the meeting of these milestones. 3. InterviewOn 2/9/23 at approximately 1:14 p.m., the administrator acknowledged the residence's quality management program did not include implementation of strategies.

Based on interview and record review, the residence failed to ensure personnel files for current employees shall be readily available onsite for department review for three of three sample staff (#1-#3), affecting 58 current residents. Findings include: Chapter VII regulations governing assisted living residences, part 2.45, defines "Staff" as employees and contracted individuals intended to substitute for or supplement employees who provide personal services. "Staff' does not include individuals providing external services, as defined herein. Chapter VII regulations governing assisted living residences, part 7.12, requires each personnel file shall include, but not be limited to, written documentation regarding the following items:(A) A description of the employee or volunteer duties; (B) Date of hire or acceptance of volunteer service and date duties commenced; (C) Orientation and training, including first aid and CPR certification, if applicable; (D) Verification from the Department of Regulatory Agencies, or other state agency, of an active license or certification, if applicable; (E) Results of background checks and follow up, as applicable; and(F) Tuberculin test results, if applicable. On 2/9/23 at approximately 10:45 a.m., the personnel files for Staff #1-#3 were requested. On 2/9/23 at 1:00 p.m. approximately two hours and 15 minutes after requested, the human resources director provided incomplete personnel files for Staff #1-#3. On 2/9/23 at approximately 1:14 p.m., the administrator confirmed she was unable to access all the personnel files as required. She acknowledged that the personnel files were not readily available onsite. She also stated the human resources director was unable to access the complete personnel files for Staff #1-#3 because the files were stored electronically and she was unable to access them.

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, affecting three of three sample residents (#1-#3). Specifically, Resident #1 was admitted to the residence on 1/14/23 with diagnoses including dementia. The resident had a fall in December 2022 which led to her admission to the assisted living residence on 1/14/23. Additionally, she had a fall on 2/5/23 that resulted in two skin tears to her left arm. However, the care plan, dated 1/31/23, did not include the individualized approach necessary to address fall risk. Further, staff were not aware the resident required two hour safety checks. Specifically, Resident #2 was admitted to the residence on 1/31/21 with diagnoses including dementia. The resident had a history of falls and on 12/22/22 had a fall that resulted in a skin tear to his right hand and elbow. However, the care plan, dated 9/29/22, did not include the individualized approach necessary to address fall risk. Specifically, Resident #3 was admitted to the residence on 11/22/20 with diagnoses including Parkinson's disease. The resident had a history of falls and on 1/28/23 had a fall that resulted in skin tears to his lower right arm and above his wrist. However, the care plan, dated 9/28/22, did not include the individualized approach necessary to address fall risk. Findings include:1. Residence policyThe residence's Fall Reduction Program, dated 3/23/2020, read in part, "Update care plan/service plan with new interventions appropriate for cognitive level and relative to the conditions involving the fall. A new intervention must be developed for each fall or a determination made that current interventions are appropriate and root cause analysis is performed to identify potential breakdowns that lead to the fall. Establish resident-specific interventions."2. Resident #1 was admitted to the residence on 1/14/23 with diagnoses including dementia. An undated pre-admission assessment, read in part, the resident had a history of falls and required a fall reduction program. A care plan, dated 1/31/23, read in part, staff were required to observe the resident for fall risk. However, the care plan did not detail the individualized approach necessary to address fall risk. A progress note, dated 2/6/23, read in part, the resident fell in her room on 2/5/23. The fall resulted in two skin tears to her left arm. Staff required to provide the resident with two hour safety checks until further notice. A task sheet, dated February 2023, revealed two hour checks were not completed on the following days:2/6/23 from 12:00 a.m. to 7:00 p.m. 2/7/23 from 12:56 a.m. to 4:19 a.m. and 8:00 a.m. to 12:00 p.m. 2/8/23 from 12:22 a.m. to 4:03 a.m., 4:04 a.m. to 1:32 p.m., 1:33 p.m. to 8:43 p.m., and 8:43 p.m. to 11:59 p.m. 2/9/22 from 12:55 a.m. to 4:03 a.m. On 2/9/23 at 7:42 a.m., Staff #1 stated he was not aware Resident #1 fell on 2/5/23 or had a history of falls. On 2/9/23 at 7:58 a.m., Staff #3 stated she was unaware that Resident #1 was at risk for falls. On 2/9/23 at 9:33 a.m., the legal representative for Resident #1 stated the resident was at risk for falls. She stated the resident had a fall in December 2022 which lead to her admission to the residence and she ensured that the residence knew the resident was at risk for falls during the pre-admission assessment. Further, she stated she was unaware of the individualized approach necessary to address fall risk. Additionally, the legal representative stated the resident fell on 2/5/23 which resulted in two skin tears on her left arm. On 2/9/23 at 10:00 a.m., Resident #1 stated she was at risk for falls and had a history of falls. She confirmed she had a fall in her room on 2/5/23 which resulted in two skin tears to her left arm. On 2/9/23 at 10:15 a.m., the director of nursing stated Resident #1 was at risk for falls and staff were required to provide the resident with two hour safety checks. She stated she was not aware the resident had a history of falls prior to moving in as documented in the pre-admission assessment. On 2/9/23 at 10:59 a.m., the private caregiver for Resident #1 stated she had provided care for the resident four days a week for the prior six months. She confirmed the resident was at risk for falls due to a history of falls. On 2/9/23 at 11:30 a.m., Staff #4 stated Resident #1 was a fall risk. She stated she did not know individualized approaches to address Resident #1's fall risk. On 2/9/23 at approximately 1:14 p.m., the administrator stated Resident #1 was at risk for falls and staff interventions included two hour safety checks. However, she confirmed that if the two hour check was not documented on the task sheet, then the two hour check was not completed. Further she stated that she and the director of nursing were responsible for ensuring care plans were updated after a resident fell with new staff interventions. She confirmed the care plan had not been updated after the resident fell on 2/5/23 as required. On 2/9/23 at approximately 10:00 a.m., Resident #1 had two skin tears near her left elbow. 3. Resident #2 was admitted to the residence on 1/31/21 with diagnoses including dementia. An assessment, dated 11/25/22, read in part, the resident had a history of falls and required a fall prevention program. A fall risk assessment, dated 12/23/22, read in part, the resident sustained multiple falls and was a high risk for falls. A care plan, dated 9/29/22, read in part, the resident had a history of falls and required a fall prevention program. However, the care plan did not detail the individualized approach necessary to address fall risk. A progress note, dated 11/30/22, read in part, the resident had an unwitnessed fall. A progress note, dated 12/22/22, read in part, the resident had an unwitnessed fall which resulted in a skin tear to his right hand and elbow. A progress note, dated 2/6/23, read in part, the resident reported he fell on 2/5/23. On 2/9/23 at 10:13 a.m., Resident #2 stated his last fall was recent. He added he was not sure what interventions the residence had in place to prevent future falls. On 2/9/23 at 11:30 a.m., Staff #4 stated that Resident #2 was a fall risk. She stated general interventions included encouraging call pendant use; however, she was not sure of individualized approaches necessary to address Resident #2's fall risk. On 2/9/22 at 11:35 a.m., Staff #2 stated Resident #2 was at risk for falls; however, he was not aware of staff interventions in place to mitigate falls. On 2/9/23 at approximately 1:14 p.m., the administrator stated that Resident #2 was a fall risk. She stated the resident was on a toileting schedule and assurance checks. She added that interventions should have been on his care plan. 4. Resident #3 was admitted to the residence on 11/22/20 with diagnoses including Parkinson's disease. A fall risk assessment, dated 1/28/23, read in part, the resident was at risk for falls and had a history of multiple falls. A care plan, dated 9/28/22, read in part, the resident had a history of falls and required a fall prevention program. However, the care plan did not detail the individualized approach necessary to address fall risk. A progress note, dated 1/19/23, read in part, the resident was found on the floor. An incident report, dated 1/20/23, read in part, the resident had a fall. A progress note, dated 1/21/23, read in part, the resident had a fall. A progress note, dated 1/28/23, read in part, the resident was found on the floor and sustained skin tears to his lower right arm and above his wrist. On 2/9/23 at 11:30 a.m., Staff #4 stated that Resident #3 was a fall risk. She stated general interventions included encouraging call pendant use; however, she was not sure the individualized approaches necessary to address Resident #3's fall risk. On 2/9/23 at 11:35 a.m., Staff #1 stated Resident #2 was at risk for falls and staff were required to check on the resident frequently. On 2/9/23 at approximately 1:14 p.m., the administrator stated that Resident #3 was a fall risk. She stated the resident was on a toileting schedule and assurance checks. She added that interventions should have been on his care plan.

Based on interview and record review, the residence failed to develop and implement a policy for investigation of injuries with unknown origin affecting one of three sample residents (#1). Findings include 1. Residence Policy and Referencea. Chapter VII regulations governing assisted living residences, requires in part 13.12, that the assisted living residence shall develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin. Such policies and procedures shall include, but not be limited to, the following requirements:(A) The assisted living residence shall identify and document resident injuries for which the origin of the injury was not observed by or otherwise known by staff, and either:(1) The resident cannot explain how the injury occurred; or(2) The resident can explain the source of the injury, but the source could be addressed to prevent future injuries.(B) The assisted living residence shall document the following:(1) The investigation and identification of any injury identified in (A), above.(2) The implementation and outcome of the following for injuries for which the investigation determines the source/origin:(a) Compliance with Part 13.11, when the source/origin of the injury is suspected to be abuse, neglect, or exploitation; or(b) The steps taken to prevent or mitigate future injuries of like nature for both the injured resident and other residents when the source/origin of the injury is not suspected abuse, neglect, or exploitation. Such steps may include, but not be limited to:(i) Staff or volunteer corrective action and/or additional training; or(ii) Modification of the assisted living residence's policies, procedures or physical environment.(3) When the source of the injury remains undetermined, the steps taken to monitor the resident in an effort identify and prevent similar injuries.(C) All documentation of the investigation, outcomes, and steps taken shall be retained by the assisted living residence, including, but not limited to, details of any interviews and/or records used in the investigation. Such documentation shall be made available for review at the Department's request.(1) Documentation on the investigation, outcomes, and steps taken may be maintained separately from the resident record, in which case a summary of the investigation and steps taken shall be included in the resident's care plan and progress notes.(D) The assisted living residence shall notify the resident's representative of the outcome of the investigation and steps taken.b. The residence's Abuse, Neglect, Injuries of unknown Origin, Misappropriation of Property and Exploitation, dated 4/14/21, read in part, physical injury of unknown origin shall be reported and investigated and all potential witnesses shall be interviewed. 2. Failure to investigate injuries of unknown originResident #1 was admitted to the residence on 1/14/23 with diagnoses including dementia. On 2/9/23 the legal representative for Resident #1 provided a photograph of a large bruise on the resident's left leg and ankle. The bruise was dark purple in color. On 2/9/23 at 9:33 a.m., the legal representative for Resident #1 stated she was informed of the bruise on Resident #1's ankle on approximately 1/31/23, the same day the photograph was taken. She stated the private caregiver told her about the bruise and the residence staff did not seem to be aware of the bruise. On 2/9/23 at 10:00 a.m., Resident #1 stated she did have a bruise on her left ankle a few weeks prior. However, she stated she was not aware where the bruise came from. On 2/9/23 at 10:59 a.m., the private caregiver for Resident #1 stated she found a bruise on the resident's left ankle on approximately 1/31/23 and informed the family immediately. On 2/9/23 at approximately 1:14 p.m., the administrator stated she was aware the resident had a bruise on her left ankle because the legal representative informed her. She stated shewas not sure how the resident got the bruise. She confirmed she did not conduct an investigation of injury of unknown origin after she was made aware of the bruise a few weeks prior and was not aware she was required to do so.