ALTAVITA MEMORY CARE CENTRE LLC

An administrative relicensure survey was completed on 7/1/26. No deficiencies were cited.

A licensure complaint, prompted by #CO39600 and #CO39801, was completed on 11/5/25. No deficiencies were cited.

A revisit survey was completed on 5/29/25 for all previous deficiencies cited on 2/19/25. The facility is in compliance with all deficiencies that were cited.

A relicensure and complaint revisit was completed on 2/19/25 for the previous deficiencies cited on 12/4/24. Deficiencies were cited. Tag S1528 (14.10) was not cited in the previous event; however, the deficiency was included in the previous event's informational 999 tag.

Based on interview and record review, the residence failed to ensure qualified medication administration persons (QMAPs) did not assess residents or make decisions regarding administering medications pro re nata (PRN), affecting one sample resident (#3) residing in the secure environment. Findings include:Resident #3 was admitted to the residence on 10/20/20 with diagnoses of Alzheimer's disease, anxiety disorder, and irritable bowel syndrome. A written practitioner order, dated 9/13/24, directed the residence to administer one disintegrating ondansetron 4 mg every six hours as needed for nausea and vomiting. The February 2025 medication administration record (MAR) revealed that the health and wellness assistant #1 (HWA1) administered the medication on 2/5/25. A written practitioner order, dated 9/13/24, directed the residence to administer one loperamide HCl 2 mg as needed for diarrhea: administer two tablets with the first loose stool, then one tablet after each subsequent loose stool. The February 2025 MAR revealed that Staff #5 administered one 2 mg tablet on 2/6/25. On 2/19/25 at 10:12 a.m., the health and wellness director (HWD) stated that Resident #3 was unable to request PRN medications by name. She added that she was a nurse and that the regulation required a nurse to make decisions regarding PRN medications. The HWD stated that these decisions were not within a QMAP's scope of practice. On 2/19/25 at 11:56 a.m., the HWA1 stated that she administered a PRN medication to Resident #3. She affirmed Resident #3 could not request the medication and stated that she and Staff #5 were QMAPs, not nurses. The HWA1 added she was unaware of the requirement that nurses must make the assessments and decisions regarding PRN medications. On 2/19/25 at 12:34 p.m., the administrator stated that the residence failed to ensure that QMAPs did not make decisions regarding the PRN medication.

Based on interview and record review, the residence failed to ensure resident records contained progress notes, which included documentation regarding any out-of-the-ordinary event or issue that affects a resident's physical, behavioral, cognitive and/or functional condition, along with the action taken by staff to address that resident's changing needs, affecting one sample resident (#6) residing in the secure environment. This deficiency was cited previously during a relicensure survey and complaint investigation on 12/4/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:Resident #6 was admitted to the residence on 12/19/23. Progress notes, dated 2/2/25 and 2/3/25, read in part that Resident #6 had pain; however, the note contained no documented action taken by the residence to meet the resident's needs. On 2/19/25 at 12:38 p.m., the administrator stated that the residence failed to document the staff actions in progress notes. On 2/19/25 at 12:44 p.m., the health and wellness director stated that on 2/3/25 she completed a full assessment on Resident #6; he was able to move comfortably, and she contacted the resident's power of attorney and practitioner. However, she stated she did not document her actions in the progress notes.

A relicensure survey with complaints #CO38180 and #CO38342 was completed on 12/4/24. Deficiencies were cited.

Based on interview and record review, the residence failed to ensure a resident had the right to be free from neglect, affecting one former resident (#5). (Cross-reference S2230)Specifically, the residence failed to provide, in a timely manner, medical care for Resident #5. Resident #5, in a period of eight days, reported pain frequently and was administered medication which was recorded as ineffective. Furthermore, Resident #5 had hallucinations and the residence failed to follow up with the practitioner or transport the resident to the emergency department. Additionally, the residence failed to provide details of the pain to the practitioner and, in turn, Resident #5 went without treatment for the pain for more than 24 hours and without treatment for a urinary tract infection (UTI) for approximately eight days. Findings include:1. Reference Chapter VII regulations governing assisted living residences, part 2.12, defines "Caretaker neglect" as neglect that occurs when adequate food, clothing, shelter, psychological care, physical care, medical care, habilitation, supervision or any other service necessary for the health or safety of an at-risk person is not secured for that person or is not provided by a caretaker in a timely manner and with the degree of care that a reasonable person in the same situation would exercise, or a caretaker knowingly uses harassment, undue influence or intimidation to create a hostile or fearful environment for an at-risk person. 2. Record ReviewResident #5 was admitted to the residence on 7/9/24 with a diagnosis of Alzheimer's disease. Progress notes, dated 10/2/24, read as follows:At approximately 3:00 a.m., Resident #5 was observed lying on his left side on his bedroom floor and no injuries were reported. At approximately 7:00 a.m., Resident #5 was observed lying on his bedroom floor and no injuries were reported. At approximately 8:00 a.m., Resident #5 "was complaining of pain." A shift report, dated 10/2/24, read in part that during the evening shift the resident "kept complaining of back pain," and his balance was worse than usual. Fax confirmations, dated 10/2/24, from the residence to the practitioner read as follows: At 11:10 a.m., the residence notified the practitioner that urinalysis test produced a negative result and that Resident #5 had expressed hallucinations of seeing ants. At 12:02 p.m., the residence notified the practitioner of a fall and did not include the resident's previous reports of pain. A progress note, dated 10/8/24, at approximately 10:30 p.m., read that Resident #5 was "screaming out in pain after putting him in bed."A progress note dated 10/9/24, at approximately 1:00 a.m., read that staff administered pain medication, that it had been ineffective, and that Resident #5 fell at midnight and was complaining of back pain. A fax confirmation, dated 10/9/24 at approximately 12:00 p.m. from the residence to the practitioner, read that Resident #5 was found on his knees holding onto the side of his bed and had been complaining of back pain. The fax confirmation read that staff administered another pain medication but it was ineffective; it read Resident #5 had also reported burning when attempting to urinate. Progress notes, dated 10/9/24, read as follows:At approximately 6:00 p.m.: "Resident #5 had back pain."At approximately 8:00 p.m.: Resident #5 had pain when urinating. A shift report, dated 10/9/24, read in part that the resident fell and had pain at 8:20 p.m., that the resident fell at 11:00 p.m., and that the resident "finally fell asleep around 5:20 a.m."A shift report, dated 10/10/24, read in part that the resident had two swollen feet and the resident had behavioral expressions of aggression. A progress note dated 10/10/24 at approximately 2:30 p.m., read that Resident #5 went to his practitioner ' s office for a scheduled visit and from there was transported to the emergency department (ED). A hospital note, dated 10/10/24, read in part that Resident #5 was admitted to the ED with a UTI, a differential diagnosis of sepsis, urinary retention greater than one liter, and effusion to the right knee. Resident #5 was borderline septic. A hospital note, dated 10/13/24, read that in addition to the right knee effusion, the resident had abrasions on his legs upon admission. 3. InterviewsOn 12/3/24 at approximately 3:00 p.m., the health and wellness assistant (HWA) #2 stated that she contacted the practitioner regarding Resident #5, with a fax and did not follow up until the next day at which time she left a message without informing the practitioner about the resident's pain, asking for a return phone call. On 12/3/24 at approximately 4:00 p.m., a family member of Resident #5 stated that she had been with Resident #5 at the practitioner's office for the scheduled visit on 10/10/24 and saw abrasions and bruising on Resident #5 ' s right leg and an open wound on Resident #5 ' s right knee. In a later interview, at 5:05 p.m., the family member stated that the residence's lack of response to the resident's pain and poor communication regarding the UTI was neglect, which resulted in the resident's uncontrolled pain and untreated UTI. On 12/4/24 at approximately 9:00 a.m., the health and wellness assistant (HWA) #1 stated that she sent the fax to the practitioner's office and that she could not recall when she followed up with the practitioner; she stated that it was between 10/2/24 and 10/9/24. She stated that when she did follow up, she did not talk with the practitioner and was told by his medical assistant that she would receive a return phone call. She stated that she did not ever receive a phone call from the practitioner. On 12/4/24 at approximately 10:00 a.m., the administrator stated that she expected staff to have communicated the Resident #5's pain in the faxes they sent to the practitioner. Furthermore, the administrator stated that she expected that staff would have Resident #5 transported to the ED when he screamed in pain. The administrator stated that according to regulations, she agreed that the residence neglected Resident #5. On 12/4/24 at approximately 10:30 a.m., the health and wellness director (HWD) stated that staff should have notified her or another staff who was on call regarding Resident #5's pain or that staff would have had Resident #5 transported to the ED.

Based on observation, interview, and record review, the residence failed to ensure that staff documented, before the end of their shift, any out-of-the-ordinary event or issue regarding a resident that they observed or was reported to them, along with the action taken by staff to address that resident's needs, affecting three of four sample residents (#1, #3, #4) and one former resident (#5). (Cross-reference S1324)Findings include:Resident #3 was admitted to the residence on 10/20/20 with a diagnosis of Alzheimer's disease. On 12/3/24 at 11:15 a.m., a soiled incontinence product was in the garbage can in the resident's room. An odor of urine was detectable from the hallway while the resident's door was closed. An external service provider (ESP) note, dated 10/22/24, read in part that the resident had a history of urinary tract infection (UTI) and that staff should monitor the resident's behavior, encourage fluids, and check urine as needed. An electronic message, dated 12/1/24 from a family member of the resident to the administrator, read in part that a family member of the resident visited on 11/27/24, and the resident expressed increased agitation, which led the family member to suspect that the resident had a UTI.Progress notes, dated 11/27/24-12/4/24, revealed that the residence failed to document behavioral expressions of agitation or the report of the suspected UTI.The residence provided no additional documentation that contained information regarding the resident's behavioral expressions or suspected UTI. On 12/3/24 at approximately 2:30 p.m., the health and wellness director (HWD) stated that she expected staff to document unusual events and staff actions regarding the concern. On 12/4/24 at approximately 9:50 a.m., the administrator said she expected staff to document actions they took when a resident experienced pain or a suspected UTI. She affirmed that urine odor detected at a distance may indicate a UTI. 3. Additionally, the residence demonstrated similar deficient practice for Residents #1, #4, and Former Resident #5.

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY.No response is necessary. The residence was advised it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.12.18 The assisted living residence's policy shall also require documentation of the action taken by staff and ongoing efforts to prevent a reoccurrence of the situation in the future. 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:(F) Decision making regarding PRN or "as needed" medication administration. 14.31 The administrator and the QMAP supervisor shall, on a quarterly basis, audit the accuracy and completeness of the medication administration records, controlled substance list, medication error reports, and medication disposal records. Any irregularities shall be investigated and resolved. The results of the audits shall be documented and routinely included as part of the assisted living residence's Quality Management Program assessment and review.