KEYSTONE PLACE AT LEGACY RIDGE ASSISTED LIVING

A certification complaint, prompted by #CO36959, was completed on 7/31/24. A deficiency was cited.

Based on observation, interview, and record review, the facility (residence) failed to identify and outline the participant's (resident's) needs and the services and supports to meet those meet those needs in the care plan affecting four of four sample residents (#5, #6, #9, #10) who used bed canes. Findings include: 1. Former Resident #10 was admitted to the residence on 7/16/18 with diagnoses including spinal stenosis and senile degeneration of brain.a. Record Review A verbal practitioner's order, dated 5/28/24, read that a bed cane was in use at the time of admission; however, the residence was unable to provide a written practitioner's order dated 7/16/18, the date of the resident's admission. The residence's documentation of the investigation of Resident #10's death, dated 7/29/24, read in part that the resident began using the bed cane in June 2021, contrary to the verbal practitioner's order. An external service provider (ESP) note, dated 5/7/24, read in part Resident #10 required a transfer pole to improve transfers and reduce fall risk. However, the ESP note failed to provide a therapist evaluation of the use of a bed cane. A comprehensive assessment for Resident #10, dated 6/7/24, read in part that Resident #10 "requires full assistance including physical and verbal assistance with walking needs. Requires hands-on assistance with helping stand up, helping use any walking devices, and helping sit down/lay down." However, the residence did not include the use of a bed cane in the resident ' s assessment. A care plan for for Resident #10, dated 7/1/24, read in part that Resident #10 required hands-on assistance with standing up, using walking devices and sitting down/lay down; however, the residence did not include the use of a bed cane in the resident ' s assessment. An external hospice provider (EHP) progress note, dated 7/1/24, read in part: Resident #10 was found in his bedroom at 5:30 a.m. Staff reported finding Resident #10 ' s body on the floor and his head stuck between the mattress and bed cane; however, no cause of death was established. None of the EHP notes demonstrated there was an evaluation for the resident ' s bed cane. Documentation of the residence ' s investigation of Former Resident #10's death, dated 7/29/24, read in pertinent part that Resident #10 ' s family member placed the bed cane on his bed in June 2021 and the residence did not include information about the bed cane in the care plan because he was independent with his transfers and safe, according to his physical therapist.b. Interviews On 7/31/24 at 1:22 p.m., the administrator stated that the residence did not ensure the practitioner or physical therapist evaluated the resident's use of a bed cane annually or when there was a change in the resident's baseline status to ensure the resident could properly use it, despite the care plan for Former Resident #10 reading that he required full assistance with transfers. She affirmed that neither a physical therapist or practitioner performed an assessment of Resident #10's use of a bed cane when he had a change in his baseline status on 6/7/24 when he broke his clavicle and had his arm in a sling which added to limiting his mobility. The administrator stated that the residence did not document Resident #10's use of a bed cane in the care plan. On 7/31/24 at 1:51 p.m., the health and wellness director (HWD) stated the residence did not ensure the practitioner or physical therapist evaluated the resident's use of bed cane annually or when the resident had a change in their baseline status to ensure the resident could properly use it. She stated that the residence did not address the use of a bed cane in the care plan but should have. The HWD added that Resident #10 ' s baseline status changed when his arm was in a sling approximately two months prior to his death, and the residence should have ensured that a practitioner or physical therapist evaluated his use of a bed cane and did not. 2. Additionalobservations, interviews, and record reviews revealed the residence failed to ensure devices that facilitate a resident's well-being or independence were used only when there was an order from a practitioner, a practitioner and therapist documented the benefits and hazards associated with the device and information on its appropriate use, the continued use of the device was re-evaluated by both therapist and practitioner at least annually or whenever the resident experienced a significant change in status, and that all of the documentation was retained in the resident ' s care plan for Residents #5, #6, #9.

A licensure complaint, prompted by #CO36958, was completed on 7/31/24. Deficiencies were cited.

Based on observation, record review, and interview, the residence failed to make available, either directly or indirectly through a resident agreement, personal services including on-going monitoring to meet the resident ' s needs affecting one sample residents (#8) and on former resident (#10). Findings include:1. Resident AgreementThe resident agreement, dated 7/15/23, read in part: "We will work with you, your representative and your health care provider to coordinate a care plan inclusive of your assisted living and personal care service needs (the "Care Plan") that takes into account information from you and your representative, the most recent assessment information and that promotes choice, mobility, independence and safety, details specific needs and preferences, staff tasks to meet those needs, identifies external service providers and care coordination arrangements and identifies formal planned and informal spontaneous engagement opportunities that match your personal choices and needs." 2. Former Resident #10A care plan, dated 7/1/24, read in part: "please physically enter apartment and check on resident's wellbeing and ensure that all needs are met, this is to be done routinely as scheduled and as needed. This resident is a high fall request (sic) and requires checks as scheduled to ensure safety." It also read, "[The) resident assistant will conduct (a) safety check once nightly between 10 p.m. and 6 a.m.- DO NOT WAKE RESIDENT daily at 5:00 a.m." A task sheet, dated 6/30/24, read in part that Staff #8 provided toilet assistance three times, provided assistance with and ensured that Resident #10 ' s sling was in place on his injured arm] at 12:23 a.m., and completed a night check at 4:26 a.m. 3. InterviewsOn 7/31/24 at 10:37 a.m., Staff #8 stated when her shift started at 10:30 p.m. on 6/30/24, she went to check on Resident #10 and found him sliding off of his recliner, which was slightly tilted. She stated that she assisted him with toileting then with laying in bed. Staff #8 stated she left his room at approximately 12:00 a.m. and checked on him at 3:00 a.m., adding that she ' peeked her head in ' because she could see him from the front room door. She said she did not want to wake him. Staff #8 said she checked in on Resident #10 again at 5:00 a.m. and found him with his neck caught between the mattress and the bed cane with his feet facing the bathroom. Staff #8 stated that Resident #10 ' s face was blue. Staff #10 stated that she called Staff #9 who informed the health and wellness director (HWD) and they then called the resident's external service provider and the coroner's office. On 7/31/24 at 1:32 p.m., the health and wellness director (HWD) stated that staff were to perform wellness checks every two hours and a night check for Resident #10. The HWD stated her expectation was for staff to physically go into the room and ensure the resident's wellbeing. She stated that Staff #8 could not have seen Resident #10 from the front door because his room had been re-arranged. The HWD also stated that the door from Resident #10 ' s bedroom had been removed for several months prior to this incident at a family member's request. 4. Additionally, the the residence failed to make available, either directly or indirectly through a resident agreement, personal services including on-going monitoring to meet the resident ' s needs for Resident #8.

Based on observation, interview, and record review, the residence failed to ensure devices that facilitate a resident's well-being or independence were used only when there was an order from a practitioner, a practitioner and therapist documented the benefits and hazards associated with the device and information on its appropriate use, the continued use of the device was re-evaluated by both therapist and practitioner at least annually or whenever the resident experiences a significant change in status, and that all of the documentation be retained in the resident ' s care plan affecting four of four sample residents (#5, #6, #9, #10) who used bed canes. (Cross-reference S1110)Findings include: 1. Former Resident #10 was admitted to the residence on 7/16/18 with diagnoses including spinal stenosis and senile degeneration of brain.a. Record Review A verbal practitioner's order, dated 5/28/24, read that a bed cane was in use at the time of admission; however, the residence was unable to provide a written practitioner's order dated 7/16/18, the date of the resident's admission. The residence's documentation of the investigation of Resident #10's death, dated 7/29/24, read in part that the resident began using the bed cane in June 2021, contrary to the verbal practitioner's order. An external service provider (ESP) note, dated 5/7/24, read in part Resident #10 required a transfer pole to improve transfers and reduce fall risk. However, the ESP note failed to provide a therapist evaluation of the use of a bed cane. A comprehensive assessment for Resident #10, dated 6/7/24, read in part that Resident #10 "requires full assistance including physical and verbal assistance with walking needs. Requires hands-on assistance with helping stand up, helping use any walking devices, and helping sit down/lay down." However, the residence did not include the use of a bed cane in the resident ' s assessment. A care plan for for Resident #10, dated 7/1/24, read in part that Resident #10 required hands-on assistance with standing up, using walking devices and sitting down/lay down; however, the residence did not include the use of a bed cane in the resident ' s assessment. An external hospice provider (EHP) progress note, dated 7/1/24, read in part: Resident #10 was found in his bedroom at 5:30 a.m. Staff reported finding Resident #10 ' s body on the floor and his head stuck between the mattress and bed cane; however, no cause of death was established. None of the EHP notes demonstrated there was an evaluation for the resident ' s bed cane. Documentation of the residence ' s investigation of Former Resident #10's death, dated 7/29/24, read in pertinent part that Resident #10 ' s family member placed the bed cane on his bed in June 2021 and the residence did not include information about the bed cane in the care plan because he was independent with his transfers and safe, according to his physical therapist.b. Interviews On 7/31/24 at 1:22 p.m., the administrator stated that the residence did not ensure the practitioner or physical therapist evaluated the resident's use of a bed cane annually or when there was a change in the resident's baseline status to ensure the resident could properly use it, despite the care plan for Former Resident #10 reading that he required full assistance with transfers. She affirmed that neither a physical therapist or practitioner performed an assessment of Resident #10's use of a bed cane when he had a change in his baseline status on 6/7/24 when he broke his clavicle and had his arm in a sling which added to limiting his mobility. The administrator stated that the residence did not document Resident #10's use of a bed cane in the care plan. On 7/31/24 at 1:51 p.m., the health and wellness director (HWD) stated the residence did not ensure the practitioner or physical therapist evaluated the resident's use of bed cane annually or when the resident had a change in their baseline status to ensure the resident could properly use it. She stated that the residence did not address the use of a bed cane in the care plan but should have. The HWD added that Resident #10 ' s baseline status changed when his arm was in a sling approximately two months prior to his death, and the residence should have ensured that a practitioner or physical therapist evaluated his use of a bed cane and did not. 2. Additional observations, interviews, and record reviews revealed the residence failed to ensure devices that facilitate a resident's well-being or independence were used only when there was an order from a practitioner, a practitioner and therapist documented the benefits and hazards associated with the device and information on its appropriate use, the continued use of the device was re-evaluated by both therapist and practitioner at least annually or whenever the resident experienced a significant change in status, and that all of the documentation was retained in the resident ' s care plan for Residents #5, #6, #9.

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 7.12.10 Each resident care plan shall:(A) Be developed with input from the resident and the resident's representative;(B) Reflect the most current assessment information;(C) Promote resident choice, mobility, independence and safety;(D) Detail specific personal service needs and preferences along with the staff tasks necessary to meet those needs;(E) Identify all external service providers, including essential caregivers for the purposes of the assisted living residence's visitation policy as required by Part 9.2, along with care coordination arrangements;(F) and Identify formal, planned, and informal spontaneous engagement opportunities that match the resident's personal choices and needs.

A certification complaint, prompted by #CO34441, was completed on 12/28/23. A deficiency was cited.

Based on observation, interview, and record review, the facility (residence) failed to document special health needs that support the participant (resident), affecting two of three sample residents (#2, #3) and one former resident (#4). Specifically, Former Resident #4 sustained five falls from 11/1-12/8/23. The falls sustained on 11/1, on 11/6 resulted in pain, the resident fell again on 11/22, 11/25, and on 12/8 resulted in pain and a fractured femur. The resident died on 12/9. The coroner ' s report read that the former resident ' s death was caused by a left hip fracture due to an unwitnessed fall. However, the residence failed to update the resident ' s care plan and task sheet, dated 10/24/23, with individualized approaches necessary to address fall risk after each of the falls sustained by the resident as required..Specifically, Resident #2 sustained four falls from 11/12-12/13/23. The fall sustained on 11/12 resulted in a skin tear, the resident fell again on 11/14 and 12/8 that resulted in pain and on 12/13 that resulted in a reopened skin tear. However, the residence failed to update the resident ' s care plan and task sheet, dated 10/24/23, with individualized approaches necessary to address fall risk after each of the falls sustained by the resident as required. Specifically, Resident #3 sustained five falls from 10/11-11/30/23. A fall sustained on 10/19 resulted in pain. The resident fell again on 11/11 that resulted in a skin tear, on 11/12, and on 11/30 that resulted in pain. However, the residence failed to update the resident ' s care plan and task sheet, dated 10/24/23, with individualized approaches necessary to address fall risk after each of the falls sustained by the resident as required. Findings include:1. Residence Policy and Resident AgreementThe residence ' s Fall Management and Lift Assistance Policy, dated 5/11/22, revealed that the policy contained no information that established a fall management policy. Further, the policy failed to contain the requirement that the residence detailed in each resident ' s care plan the individualized approach necessary to address fall risk related to deficits identified during the comprehensive resident assessment. The policy contained information regarding procedures for the residence providing lift assistance to residents and procedures immediately after a resident sustained a fall. The Residence and Services Agreement, dated 7/15/23, read in part that the residence completed an individualized and person-centered care plan that detailed specific needs and staff tasks to meet those needs. The care plan promoted safety and mobility. Further, the residence modified the care plan when the resident experienced a change in functional and cognitive status. 2. Former Resident #4 was admitted to the residence on 8/25/23 with diagnoses including major neurocognitive disorder due to unspecified dementia, gout, orthostatic hypotension, and osteoporosis. Residence observation notes dated 11/1/23-12/8/23, read in part:On 10/24/23, "Service Plan was updated for this resident. Resident Assessment and Care Plan has been filled out."On 11/1/23," This nurse was notified by RA (resident assistant) that resident fell off his bed. Upon assessment, resident was laying on the floor next to his bed with head between dresser and bed and pillows underneath his head. Residents (family member who resided at the residence) stated that she was assisting him with putting on his under shorts and resident slid off the edge of his bed. Resident was assisted up by this nurse and RA. RA assisted resident with the rest of dressing. Resident was very weak and unsteady and could hardly stand up to pull his pants up. Recommended resident use wheelchair for safety. Resident was a two person assist while pivoting from bed to wheelchair. Per RA, Resident could hardly lift his right leg up. Very small pupils noted. VS (Vital signs) taken- BP (blood pressure) 102/53. RA provided resident and (family member who resided at the residence) with cup of coffee from dining room. This nurse expressed her concerns to resident and (family member who resided at the residence) and resident agreed to be evaluated at the hospital. POA (Power of Attorney) notified and resident transported via Emergency Medical Services (EMS)."On 11/22/23, "This nurse was notified that resident had a fall earlier this morning. Resident states he does not remember having a fall and denies pain. No bruising or injuries noted. Resident steadier today and has more strength than yesterday. Called (Power of Attorney) with no answer. Text message sent notifying her of fall. VS WNL (Vital signs within normal limits). Will monitor."On 11/25/23, "Resident found laying on the floor next to his bed. This nurse asked the resident ' s (family member who resided at the residence) if she had seen him fall, (she) states that yes he slid out of the bed and did not hit his head. Resident c/o (complaint of) dizziness after RA and this nurse got him off the floor. VS taken and IR filled out. (Resident representative) notified via phone call and hospice has been notified as well. Reminded resident to call for assistance when needed. Able to make needs known. Will continue to monitor."On 12/8/23, "Resident had a fall this morning in the bathroom, was found on the floor. Hospice nurse came in to assess resident this morning states that she don ' t think he injured himself and if anything call hospice again. This nurse was notified was QMAP that resident is c/o complaint of pain in his leg and went in to assess but resident would not take his blankets off and states he is having pain in his leg but does not know which one. Morphine was administered by QMAP (qualified medication administration person). Hospice nurse notified and will be in later today to check on resident. One hour after morphine was given, resident still screaming in pain. Hospice nurse has been notified again and she is working on getting the dosage increased for pain medication. POA has been notified. Will continue to monitor."Residence incident reports dated 10/24/23-12/8/23 read in part:On 11/1/23, "Residents (family member who resided at the residence) was assisting him with putting undershorts on and resident slid out off the bed. RA found resident laying on his side with head between dresser and bed. When resident was assisted up, he was very weak and unsteady and could hardly pivot into wheelchair. Pupils very small." The report revealed no actions documented in the section titled Follow-Up Information. On 11/6/23 at 8:45 a.m., "RA found resident half way off the bed so they assisted them down to the floor. Resident c/o (complaint of) pain in left shoulder. (Family member who resided at the residence) states that he c/o pain off and on all over and she thinks it is a muscle and didn ' t think it was necessary for him to be evaluated at the hospital. The resident sustained injuries. Pain in left shoulder" The report revealed no actions documented in the section titled Follow-Up Information. On 11/6/23 at 5:12 p.m., "Resident fell onto living room floor. Walker was not nearby. The resident states he is not sure what happened. Denies pain. (Family member who resided at the residence) said she went out with niece who is visiting from out of town and came back and found resident on the floor. Resident reminded to use pendant when he needs assistance." The report revealed no actions documented in the section titled Follow-Up Information. On 11/25/23, Resident was found lying on the floor next to his bed. RA walked into the apartment and found resident there. Nurse came in and asked (resident family member who resided at the residence) if she had seen him fall, she states that resident slid out of bed and did not hit his head. Resident c/o feeling dizzy right after we got him off the floor. No c/o pain. Hospice notified via phone." The report revealed no actions documented in the section titled Follow-Up Information. On 12/8/23, "Resident was found on the ground on the bathroom floor. he is complaining/yelling/of pain. hospice nurse notified (at 6:18 a.m.) and will be here shortly. The supervisor (health and wellness director) contacted at 9:15 a.m. Pain Level 10. No injuries sustained." The report revealed no actions documented in the section titled Follow-Up Information. The external hospice provider (EHP) admission care plan, dated 11/17/23, read in part that the former resident ' s ambulation was functionally limited and that safety measures for the former resident included transfer and ambulation precautions. The resident required assistance with transfers and toileting. Further, an ongoing assessment of fall risk and injury was required. EHP notes dated 12/8-12/10/23, read in part:On 12/8/23, the residence contacted EHP at 9:10 a.m. and reported that Former Resident #4 was in significant pain and inquired about morphine administration. Further, the residence-administered practitioner ordered morphine. The residence contacted EHP at 10:10 a.m. and reported that the resident was in severe pain. Further, the resident ' s family member wanted the resident transported to the emergency department as the family member suspected a fractured hip. EHP contacted the practitioner for an increased dose. A family member had already arranged for the resident to be transported to the emergency department. Further, the note revealed no documented contact from the residence prior to 9:10 a.m. On 12/10/23, read in part that the in-patient hospice facility that Former Resident #4 was transported to after he went to the emergency department contacted the EHP to report that the resident passed away on 12/9/23 at 2:30 a.m. An emergency medical services (EMS) report, dated 12/8/23 at 10:38 a.m., read in part: "Find patient lying supine in bed at (the residence)—patients (family member who resided at the residence) and (other family member) on scene. The patient apparently had an unwitnessed fall out of bed, resulting in left thigh pain."External hospital radiology report, dated 12/8/23, read in part that at 12:06 p.m., Former Resident #4 sustained a fall with pain, the findings read: "There is a comminuted, imparted, displaced, angulated intertrochanteric proximal left femur fracture with varus angulation of the distal fracture fragment. Diffuse osteopenia, No idiopathic foreign body or soft tissue gas. Arteriosclerosis calcification of the arteries of the left lower extremity. Small tibia tubercle, patellar and achilles enthesophytes."A residence assessment, dated 10/24/23, read in part that the former resident was independent with toileting, and walking and required no assistance despite the option of fall risk availability on the assessment tool. A residence care plan and care plan task sheet, dated 10/24/23, read in part that the care plan task read that the resident could ambulate independently with a walker. The care plan contained no individualized approach necessary to address fall risk. An external coroner ' s report, dated 12/28/23, read that the manner of death for Former Resident #4 was certified as an accident with the cause of death being left hip fracture due to an unwitnessed fall. 3. Interviews On 12/13/23 at approximately 7:00 a.m., Staff #6 stated that several residents had frequent falls, including two sample residents and Former Resident #4. On 12/13/23 at approximately 7:15 a.m., Staff #4 stated that Former Resident #4 had a few falls; however, she was unaware of the circumstances of the falls. On 12/13/23 at 7:55 a.m., Staff #6 stated that Former Resident #4 had several falls; however, she was unaware of any specific approaches staff were to take to address falls. On 12/13/23 at 10:48 a.m., a family member of Former Resident #4 stated that the resident had several falls in the prior three months. She added that the residence put no safety measures in place; however, the family member had independently attempted to mitigate the fall risk for the former resident by lowering his bed. She stated that the residence had not discussed approaches to address falls for the former resident. On 12/13/23 at 12:20 p.m., Staff #1 stated that she was unaware of the circumstances of prior falls for Former Resident #4 and that the residence had not communicated with her any approaches to address falls for the former resident. On 12/13/23 at 3:08 p.m., the health and wellness director (HWD) stated that the residence was required to assess residents after a fall and that completing an assessment populated the resident ' s care plan. She added that the residence had not completed the assessment using the assessment tool. Therefore, the care plan was not updated with interventions to address falls for two sample residents and Former Resident #4. On 12/13/23 at 4:31 p.m., the administrator stated that the residence assessed a resident after the resident experienced a fall and attempted to find approaches to mitigate falls. She added an example of an approach was increased safety checks. She added that the approach must be specific to the resident and should have been included in the resident's care plan. She added that the HWD and the wellness staff were responsible for updating the care plan for the residents. 4. Additionally, the investigation revealed evidence that the residence failed to establish a fall management program that included updating the care plans for Residents #2 and #3 with individualized approaches necessary to reduce fall risk, and each resident experienced subsequent falls, some of which were with injury. Further, during the onsite visit, Resident #3 was found on the floor of his room.

A licensure complaint, prompted by #CO34440, was completed on 12/28/23. Deficiencies were cited.

Based on observation, interview, and record review, the residence failed to detail the individualized approach necessary to address fall risk in each resident's care plan, affecting two of three sample residents (#2, #3) and one former resident (#4). (Cross-reference Q1192) Specifically, Former Resident #4 sustained five falls from 11/1-12/8/23. The falls sustained on 11/1 and 11/6 resulted in pain, the resident fell again on 11/22, 11/25, and on 12/8 another fall resulted in pain and a fractured femur. The resident died on 12/9. The coroner's report read that the former resident's death was caused by a left hip fracture due to an unwitnessed fall. However, the residence failed to update the resident's care plan and task sheet, dated 10/24/23, with individualized approaches necessary to address fall risk after each of the falls sustained by the resident as required. Specifically, Resident #2 sustained four falls from 11/12-12/13/23. The fall sustained on 11/12 resulted in a skin tear, the resident fell again on 11/14 and 12/8 that resulted in pain and on 12/13 that resulted in a reopened skin tear. However, the residence failed to update the resident's care plan and task sheet, dated 10/24/23, with individualized approaches necessary to address fall risk after each of the falls sustained by the resident as required. Specifically, Resident #3 sustained five falls from 10/11-11/30/23. A fall sustained on 10/19 resulted in pain. The resident fell again on 11/11 that resulted in a skin tear, on 11/12, and on 11/30 that resulted in pain. However, the residence failed to update the resident's care plan and task sheet, dated 10/24/23, with individualized approaches necessary to address fall risk after each of the falls sustained by the resident as required. Findings include:1. Residence Policy and Resident AgreementThe residence's Fall Management and Lift Assistance Policy, dated 5/11/22, revealed that the policy contained no information that established a fall management policy. Further, the policy failed to contain the requirement that the residence detailed in each resident's care plan the individualized approach necessary to address fall risk related to deficits identified during the comprehensive resident assessment. The policy contained information regarding procedures for the residence providing lift assistance to residents and procedures immediately after a resident sustained a fall. The Residence and Services Agreement, dated 7/15/23, read in part that the residence completed an individualized and person-centered care plan that detailed specific needs and staff tasks to meet those needs. The care plan promoted safety and mobility. Further, the residence modified the care plan when the resident experienced a change in functional and cognitive status. 2. Former Resident #4 was admitted to the residence on 8/25/23 with diagnoses including major neurocognitive disorder due to unspecified dementia, gout, orthostatic hypotension, and osteoporosis. Residence observation notes dated 11/1/23-12/8/23, read in part:On 10/24/23, "Service Plan was updated for this resident. Resident Assessment and Care Plan has been filled out."On 11/1/23," This nurse was notified by RA (resident assistant) that resident fell off his bed. Upon assessment, resident was laying on the floor next to his bed with head between dresser and bed and pillows underneath his head. Residents (family member who resided at the residence) stated that she was assisting him with putting on his under shorts and resident slid off the edge of his bed. Resident was assisted up by this nurse and RA. RA assisted resident with the rest of dressing. Resident was very weak and unsteady and could hardly stand up to pull his pants up. Recommended resident use wheelchair for safety. Resident was a two person assist while pivoting from bed to wheelchair. Per RA, Resident could hardly lift his right leg up. Very small pupils noted. VS (Vital signs) taken- BP (blood pressure) 102/53. RA provided resident and (family member who resided at the residence) with cup of coffee from dining room. This nurse expressed her concerns to resident and (family member who resided at the residence) and resident agreed to be evaluated at the hospital. POA (Power of Attorney) notified and resident transported via Emergency Medical Services (EMS)."On 11/22/23, "This nurse was notified that resident had a fall earlier this morning. Resident states he does not remember having a fall and denies pain. No bruising or injuries noted. Resident steadier today and has more strength than yesterday. Called (Power of Attorney) with no answer. Text message sent notifying her of fall. VS WNL (Vital signs within normal limits). Will monitor."On 11/25/23, "Resident found laying on the floor next to his bed. This nurse asked the resident ' s (family member who resided at the residence) if she had seen him fall, (she) states that yes he slid out of the bed and did not hit his head. Resident c/o (complaint of) dizziness after RA and this nurse got him off the floor. VS taken and IR filled out. (Resident representative) notified via phone call and hospice has been notified as well. Reminded resident to call for assistance when needed. Able to make needs known. Will continue to monitor."On 12/8/23, "Resident had a fall this morning in the bathroom, was found on the floor. Hospice nurse came in to assess resident this morning states that she don ' t think he injured himself and if anything call hospice again. This nurse was notified was QMAP that resident is c/o complaint of pain in his leg and went in to assess but resident would not take his blankets off and states he is having pain in his leg but does not know which one. Morphine was administered by QMAP (qualified medication administration person). Hospice nurse notified and will be in later today to check on resident. One hour after morphine was given, resident still screaming in pain. Hospice nurse has been notified again and she is working on getting the dosage increased for pain medication. POA has been notified. Will continue to monitor."Residence incident reports dated 10/24/23-12/8/23 read in part:On 11/1/23, "Residents (family member who resided at the residence) was assisting him with putting undershorts on and resident slid out off the bed. RA found resident laying on his side with head between dresser and bed. When resident was assisted up, he was very weak and unsteady and could hardly pivot into wheelchair. Pupils very small." The report revealed no actions documented in the section titled Follow-Up Information. On 11/6/23 at 8:45 a.m., "RA found resident half way off the bed so they assisted them down to the floor. Resident c/o (complaint of) pain in left shoulder. (Family member who resided at the residence) states that he c/o pain off and on all over and she thinks it is a muscle and didn ' t think it was necessary for him to be evaluated at the hospital. The resident sustained injuries. Pain in left shoulder" The report revealed no actions documented in the section titled Follow-Up Information. On 11/6/23 at 5:12 p.m., "Resident fell onto living room floor. Walker was not nearby. The resident states he is not sure what happened. Denies pain. (Family member who resided at the residence) said she went out with niece who is visiting from out of town and came back and found resident on the floor. Resident reminded to use pendant when he needs assistance." The report revealed no actions documented in the section titled Follow-Up Information. On 11/25/23, Resident was found lying on the floor next to his bed. RA walked into the apartment and found resident there. Nurse came in and asked (resident family member who resided at the residence) if she had seen him fall, she states that resident slid out of bed and did not hit his head. Resident c/o feeling dizzy right after we got him off the floor. No c/o pain. Hospice notified via phone." The report revealed no actions documentedin the section titled Follow-Up Information. On 12/8/23, "Resident was found on the ground on the bathroom floor. he is complaining/yelling/of pain. hospice nurse notified (at 6:18 a.m.) and will be here shortly. The supervisor (health and wellness director) contacted at 9:15 a.m. Pain Level 10. No injuries sustained." The report revealed no actions documented in the section titled Follow-Up Information. The external hospice provider (EHP) admission care plan, dated 11/17/23, read in part that the former resident ' s ambulation was functionally limited and that safety measures for the former resident included transfer and ambulation precautions. The resident required assistance with transfers and toileting. Further, an ongoing assessment of fall risk and injury was required. EHP notes dated 12/8-12/10/23, read in part:On 12/8/23, the residence contacted EHP at 9:10 a.m. and reported that Former Resident #4 was in significant pain and inquired about morphine administration. Further, the residence-administered practitioner ordered morphine. The residence contacted EHP at 10:10 a.m. and reported that the resident was in severe pain. Further, the resident ' s family member wanted the resident transported to the emergency department as the family member suspected a fractured hip. EHP contacted the practitioner for an increased dose. A family member had already arranged for the resident to be transported to the emergency department. Further, the note revealed no documented contact from the residence prior to 9:10 a.m. On 12/10/23, read in part that the in-patient hospice facility that Former Resident #4 was transported to after he went to the emergency department contacted the EHP to report that the resident passed away on 12/9/23 at 2:30 a.m. An emergency medical services (EMS) report, dated 12/8/23 at 10:38 a.m., read in part: "Find patient lying supine in bed at (the residence)-patients (family member who resided at the residence) and (other family member) on scene. The patient apparently had an unwitnessed fall out of bed, resulting in left thigh pain."External hospital radiology report, dated 12/8/23, read in part that at 12:06 p.m., Former Resident #4 sustained a fall with pain, the findings read: "There is a comminuted, imparted, displaced, angulated intertrochanteric proximal left femur fracture with varus angulation of the distal fracture fragment. Diffuse osteopenia, No idiopathic foreign body or soft tissue gas. Arteriosclerosis calcification of the arteries of the left lower extremity. Small tibia tubercle, patellar and achilles enthesophytes."A residence assessment, dated 10/24/23, read in part that the former resident was independent with toileting, and walking and required no assistance despite the option of fall risk availability on the assessment tool. A residence care plan and care plan task sheet, dated 10/24/23, read in part that the care plan task read that the resident could ambulate independently with a walker. The care plan contained no individualized approach necessary to address fall risk. An external coroner ' s report, dated 12/28/23, read that the manner of death for Former Resident #4 was certified as an accident with the cause of death being left hip fracture due to an unwitnessed fall. 3. Interviews On 12/13/23 at approximately 7:00 a.m., Staff #6 stated that several residents had frequent falls, including two sample residents and Former Resident #4. On 12/13/23 at approximately 7:15 a.m., Staff #4 stated that Former Resident #4 had a few falls; however, she was unaware of the circumstances of the falls. On 12/13/23 at 7:55 a.m., Staff #6 stated that Former Resident #4 had several falls; however, she was unaware of any specific approaches staff were to take to address falls. On 12/13/23 at 10:48 a.m., a family member of Former Resident #4 stated that the resident had several falls in the prior three months. She added that the residence put no safety measures in place; however, the family member had independently attempted to mitigate the fall risk for the former resident by lowering his bed. She stated that the residence had not discussed approaches to address falls for the former resident. On 12/13/23 at 12:20 p.m., Staff #1 stated that she was unaware of the circumstances of prior falls for Former Resident #4 and that the residence had not communicated with her any approaches to address falls for the former resident. On 12/13/23 at 3:08 p.m., the health and wellness director (HWD) stated that the residence was required to assess residents after a fall and that completing an assessment populated the resident's care plan. She added that the residence had not completed the assessment using the assessment tool. Therefore, the care plan was not updated with interventions to address falls for two sample residents and Former Resident #4. On 12/13/23 at 4:31 p.m., the administrator stated that the residence assessed a resident after the resident experienced a fall and attempted to find approaches to mitigate falls. She added an example of an approach was increased safety checks. She added that the approach must be specific to the resident and should have been included in the resident's care plan. She added that the HWD and the wellness staff were responsible for updating the care plan for the residents. 4. Additionally, the investigation revealed evidence that the residence failed to establish a fall management program that included updating the care plans for Residents #2 and #3 with individualized approaches necessary to reduce fall risk, and each resident experienced subsequent falls, some of which were with injury. Further, during the onsite visit, Resident #3 was found on the floor of his room.

Based on record review and interview, the residence failed to ensure trained staff were available to evaluate residents who had fallen to determine if the resident could be assisted in a safe manner, such as when the resident had no pain and/or there was no change from baseline, affecting one former resident (#4). (Cross reference Q1180, Q2140)Specifically, Former Resident #4 sustained a fall on 12/8/23. According to residence documentation and external provider notes, the former resident reported significant pain. Despite the former resident's pain, the residence staff lifted the resident. The former resident was later transported to the emergency department after a family member contacted emergency medical services (EMS), and the hospital radiology report read that the resident sustained a fractured femur. Findings include: 1. Reference and Residence Policy Chapter VII regulations governing assisted living residences, part 7.8 (B), requires that the assisted living residence shall provide each staff member or volunteer with training relevant to their specific duties and responsibilities prior to that staff member or volunteer working independently. This training may be provided through formal instruction, self-study courses, or on-the-job training and shall include, but is not limited to, the following topic:(7) How to safely provide lift assistance, accompaniment, and transport of residents;According to the Mayo Clinic, "Many patients with dementia are left with only basic expressions of pain presented through negative behaviors. These include screaming, cursing or striking out, particularly at caregivers." Winegarden, Mayo Clinic Palliative (1/26/23) Dementia-related pain: What caregivers need to know, retrieved from: https://www.mayoclinichealthsystem.org/hometown-health/speaking-of-health/dementia-related-pain-and-caregiversThe residence Fall Management and Lift Assistance policy, dated 5/11/22, read in part that when a resident fell, the residence required residence staff to telephone a residence nurse if one was not present onsite. When a residence nurse was onsite, the nurse evaluated the resident. When a resident utilized an external hospice provider (EHP), the residence required staff to contact the EHP provider immediately after the resident sustained a fall and follow the direction of the EHP. The residence staff were not to move the resident until the residence staff observed the resident for injury. When a residence nurse was on duty (8:00 a.m. until 5:00 p.m.), the nurse assessed for signs of trauma and pain. The residence required staff to lift the resident off of the floor if the resident had no evidence of trauma or pain. If a residence nurse was not onsite (from 5:00 p.m. until 8:00 a.m.) the staff were to consider the general condition of the resident, contact the on-call nurse for further instruction, or call 911 to arrange for transport to the emergency department. Further, the policy read that if residence staff were in doubt about the appropriate means of transportation, they were required to contact EMS.2. Record Reviewa. Former Resident #4 was admitted to the residence on 8/25/23 with diagnoses including major neurocognitive disorder due to unspecified dementia, gout, orthostatic hypotension, and osteoporosis. The residence pendant response time, dated 12/7-12/8/23, read that the staff was contacted at 5:45 a.m. by the pendant associated with the Former Resident #4 room number. An observation note, dated 12/8/23, read: "Resident had a fall this morning in the bathroom, was found on the floor. Hospice nurse came in to assess resident this morning states that she doesn't think he injured himself and if anything call hospice again. This nurse was notified was QMAP (qualified medication administration person) that resident is c/o (complaining of) pain in his leg and went in to assess but resident would not take his blankets off and states he is having pain in his leg but does not know which one. Morphine was administered by QMAP. Hospice nurse notified and will be in later today to check on resident. One hour after morphine was given, the resident was still screaming in pain. Hospice nurse has been notified again and she is working on getting the dosage increased for pain medication. POA (power of attorney) has been notified. Will continue to monitor."An incident report, dated 12/8/23, read: "Resident was found on the ground on the bathroom floor. he is complaining/yelling/of pain. hospice nurse notified (at 6:18 a.m.) and will be here shortly. Supervisor (health and wellness director) contacted at 9:15 a.m. Pain Level 10. No injuries sustained." The report revealed no actions documented in the section titled Follow-Up Information. An external emergency medical services (EMS) report, dated 12/8/23 at 10:38 a.m., read in part: "Find patient lying supine in bed at the residence-patients (family member who resided at the residence) and (other family member) on scene. The patient apparently had an unwitnessed fall out of bed, resulting in left thigh pain. Patient is on hospice for kidney failure. An unknown dose of morphine was administered by staff prior to arrival. No staff members present to clarify dose. Staff apparently assisted the patient to his bed and called 911. Non ambulatory. Acute pain due to trauma (complaint). Extremity-Lower (location)."External Hospice Provider (EHP) notes dated 12/8-12/10/23, read in part:On 12/8/23, the residence contacted EHP at 9:10 a.m. and reported that Former Resident #4 was in significant pain and inquired about morphine administration. Further, the residence administered practitioner ordered morphine. The residence contacted EHP at 10:10 a.m. and reported that the resident was in severe pain. Further, the resident ' s family member wanted the resident transported to the emergency department as the family member suspected a fractured hip. EHP contacted the practitioner for increased dose. A family member had already arranged for the resident to be transported to the emergency department. Further, the note revealed no documented contact from the residence prior to 9:10 a.m. An external hospital radiology report, dated 12/8/23, read in part that at 12:06 p.m., Former Resident #4 sustained a fall with pain; the findings read: "There is a comminuted, imparted, displaced, angulated intertrochanteric proximal left femur fracture with varus angulation of the distal fracture fragment. Diffuse osteopenia, No idiopathic foreign body or soft tissue gas. Atherscelorotic calcification of the arteries of the left lower extremity. Small tibia tubercle, patellar and Achilles enthesophytes."An external coroner ' s report, dated 12/28/23, read that the he manner of death for Former Resident #4 was certified as an accident with the cause of death being left hip fracture due to an unwitnessed fall.b. Personnel RecordsThe residence staff schedule, dated 12/7-12/8/23 from 10:30 p.m. until 7:00 a.m., read that Staff #1 and Staff #2 worked at the residence. The personnel record for Staff #1 read she was hired on 10/6/20 with a separation date of 10/9/20 and was re-hired on 3/17/21. Further, the personnel record contained no evidence that the residence trained the staff member on the procedures to provide lift assistance to a resident safely. 3. InterviewsOn 12/13/23 at 8:45 a.m., the EHP clinical director stated that the residence contacted the EHP on-call nurse at 6:18 a.m., and the on-call nurse arrived at the residence at approximately 7:08 a.m. She stated that the on-call nurse assessed Former Resident #4; however, she could not provide details of the assessment. She added that the family member who resided at the residence of Former Resident #4, who lived with the former resident at the residence, reported that the former resident had been in significant pain prior to the on-call nurse ' s arrival. She stated that the former resident ' s family member who resided at the residence reported that the former resident ' s pain was typical for the resident. She added that the former resident fell asleep while the on-call nurse was at the residence. She stated that the EHP on-call nurse left the residence. Contrary to the EHP note that read the residence contacted the EHP, she stated that the on-call nurse contacted the residence to check on the resident at 9:00 a.m. and directed them to administer morphine. On 12/13/23 at 10:54 a.m., a family member of Former Resident #4 stated the family member who resided at the residence of Former Resident #4 lived with him at the residence and reported that she contacted staff for assistance when the former resident fell. She added that the former resident ' s family member who resided at the residence did not want to be interviewed as she was traumatized after she witnessed the former resident ' s fall, staff lifting the resident while he was in pain, and his significant continued pain. She added the family member who resided at the residence of the former resident was further traumatized after the former resident ' s death less than 24 hours after he sustained the fall. She stated that the former resident ' s family member who resided at the residence reported that after she called residence staff, one unidentified staff member entered and stated she had to get another staff member to assist. She added that the family member who resided at the residence reported that the former resident was yelling for help and was in pain. When the staff member returned with an unidentified staff member, they failed to take the resident ' s vitals, and then they lifted him and had him stand despite his vocalization of pain. She stated the family member who resided at the residence reported that the former resident was in constant pain and yelled and screamed. She added the family member who resided at the residence of the former resident chose not to call staff again while the former resident was in pain and instead sat at his bedside despite his uncontrolled pain upsetting her. The family member stated that the residence contacted her after 10:00 a.m., several hours after the fall occurred. She added that the EHP reportedly assessed the former resident; however, she had not received a call from the EHP regarding the assessment. Further, she stated at about 10:15 a.m., another Former Resident #4 family member arrived at the residence; the former resident continued to moan and call out for help, and the other family member contacted EMS to transport the former resident to the emergency department. On 12/13/23 at 11:22 a.m., Staff #2 stated that he worked the overnight shift at the residence from 12/7 to 12/8/23. He stated that after 5:00 a.m. Staff #1 requested his assistance with a resident who had fallen. He stated that he went with Staff #1 to assist Former Resident #4 and found him on the bathroom floor. He added the resident was yelling, "ow, ow, ow." He stated that the resident continued to yell in pain and indicated that his leg was hurting. He stated that the former resident ' s pants were down, and it was essential to get the resident off the floor because of this; however, when he and Staff #2 lifted the former resident, he became rigid and began to fight with the staff members. He stated that they transferred the former resident onto his walker, and he continued to resist the transfer. He added himself and Staff #1, could transfer the former resident into his bed from his walker. He stated that after he lifted the resident into bed, the former resident stopped yelling. He stated he left the room; however, the family member who resided at the residence of the former resident remained with the former resident. He stated that the residence had not trained him to avoid lifting a resident when the resident was reporting or demonstrating pain only when the resident experienced an injury. On 12/13/23 at 12:20 p.m., Staff #1 stated she worked at the residence from 12/7 to 12/8/23. She stated she received a request for assistance from the pendant associated with the room of Former Resident #4 and his family member who resided at the residence at approximately 5:50 a.m. She added she checked on them at approximately 5:30 a.m., and they were both asleep. She stated that she entered the apartment and found the former resident on the bathroom floor with his pants down. She added she requested the assistance of Staff #2 to lift the resident as the former resident stated, "he was okay and had reported he was just in a lot of pain." She stated that she thought the former resident fractured a bone. She added that the former resident was grabbing at his hip and thigh. She stated that she and Staff #2 sat the resident up, and he appeared okay. She stated they lifted the former resident to a standing position and then had him sit on his walker. She stated she then asked the former resident where he was feeling pain, and the former resident pointed at his hip. She added she and Staff #2 transferred him to his bed and asked his family member who resided at the residence to notify staff if the former resident needed any additional assistance and that she was going to contact the EHP to ask about administering medications for pain. She stated she then left the room and contacted the EHP and reported that the resident had vocalized pain and pointed at his hip. She added that the EHP directed her to administer acetaminophen, which she reported to the QMAP at shift change at the end of her shift at 6:30 a.m. She stated that the residence trained her to contact the EHP when a resident received hospice services and fell, which she did after she and Staff #2 lifted the former resident and the resident was in bed. She added she had not contacted before the lift as he seemed uncomfortable on the floor. She stated that she had not been trained not to move a resident when they reported pain; however, she had been trained not to move a resident when the resident sustained an injury. On 12/13/23 at approximately 12:45 p.m., another family member of Former Resident #4 stated that she visited the residence at 10:45 a.m. after she was contacted by a family member of Former Resident #4 and learned that he fell. She stated that the former resident was screaming for help and experienced severe pain when she arrived. She added she asked him where he hurt, and he pointed to his left hip. She stated she believed his hip was broken at that time and contacted EMS for assistance. She stated that the family member who resided at the residence of the former resident reported that one staff member requested another staff member ' s assistance, and they lifted the resident to a standing position. She added that there was no protocol for lifting when a resident was injured. She stated that the former resident ' s family member who resided at the residence reported that there was no increase in wellness checks by the residence after the fall other than to administer medication two or three hours after they lifted the former resident. She stated that when EMS arrived, the former resident was yelling in pain. On 12/13/23 at 2:03 p.m., an EMS representative stated that when he arrived at the residence, Former Resident #4 was in excruciating pain. He added that the residence staff should not have moved him while he was in pain. On 12/13/23 at 2:41 p.m., the administrator stated that she could not locate the initial training for Staff #1 regarding lift assistance; however, she believed the staff member was training. She added that when a resident fell and was on hospice, she expected the staff member to contact hospice and lift the resident per their direction, and only if the resident was not injured or in pain. She stated that if Staff #1 stated that the residence permitted lift assistance when a resident was in pain, then that was not the residence ' s policy and that the missing initial training was more than a documentation oversight. She stated she was aware that the resident fell as she received an email from the electronic documentation system and that when she arrived at the residence, she saw the family member who resided at the residence and a family member of the former resident leaving the premises. She added she asked the family member where she and the family member who resided at the residence were heading and then learned the former resident was heading to the hospital, and they planned to meet him. On 12/13/23 at 2:53 p.m., the licensed practical nurse (LPN)1 stated that she worked at the residence on 12/8/23 and arrived at 7:00 a.m. She added that she learned that Former Resident #4 fell when she arrived. She stated that the EHP nurse was leaving the residence when LPN1 arrived, and the EHP nurse reported she believed that the resident had not sustained a fracture. She stated that approximately two hours after she arrived at work at the residence, Staff #3 reported the former resident was in pain. She stated that she assessed the former resident then, and he reported pain in his hip but could not identify which hip. She stated that when a resident sustained a fall, the residence staff contacted the residence nurse by telephone to seek direction from the nurse when there was no nurse onsite to assess. She added that the residence staff had not telephoned prior to lifting the former resident; however, she believed they had contacted the EHP. She stated that Staff #1 and #2 should not have lifted the former resident without contacting a nurse and should not have lifted the former resident if he was vocalizing pain. On 12/13/23 at 3:08 p.m., the health and wellness director (HWD) stated that the residence ' s policy regarding lift assistance was to contact a nurse to assess if there was no nurse onsite. She added that the staff were to take direction from the residence nurse or EHP nurse. She added that the residence staff were trained not to lift a resident when reporting pain or injury. She added she was unaware that Staff #1 and #2 lifted Former Resident #4 while he reported pain.

Based on record review and interview, the residence failed to ensure resident face sheet, care plan, and medication administration record for the current month were transferred with a resident if the resident's care was transferred to another health care facility, affecting one former resident (#4). (Cross reference Q1192)Findings include:1. Residence PolicyThe residence's Emergency Transfer policy, dated 11/6/22, read in part that the residence's nurse sent the resident's face sheet, medication list, vital signs, and advance directive to the hospital when the resident was transported to the emergency department. 2. Former Resident #4 was admitted to the residence on 8/25/23 with diagnoses including major neurocognitive disorder due to unspecified dementia, gout, orthostatic hypotension, and osteoporosis. An incident report, dated 12/8/23, completed by Staff #1, read: "Resident was found on the ground on the bathroom floor. he is complaining/yelling/of pain. hospice nurse notified (at 6:18 a.m.) and will be here shortly." An external hospice provider (EHP) note, dated 12/8/23, read in part that the residence contacted EHP at 10:10 a.m. and reported that the former resident was in severe pain. Further, the resident ' s family member wanted the resident transported to the emergency department as the family member suspected a fractured hip. EHP contacted the practitioner for an increased dose of pain medication. However, a family member of the former resident had already arranged for the resident to be transported to the emergency department. Further, the note revealed no documented contact from the residence prior to 9:10 a.m. An external emergency medical services (EMS) report, dated 12/8/23 at 10:38 a.m., read in part: "Find patient lying supine in bed at (the residence)-patients (family member who resided at the residence) and (other family member) on scene. The patient apparently had an unwitnessed fall out of bed, resulting in left thigh pain. Patient is on hospice for kidney failure. An unknown dose of morphine was administered by staff prior to arrival. No staff members present to clarify dose. Staff apparently assisted the patient to his bed and called 911. Non ambulatory. Acute pain due to trauma (complaint). Extremity-Lower (location)."3. Interviews On 12/13/23 at approximately 12:45 p.m., a family member stated that she contacted EMS to transport the former resident as she believed the resident fractured his hip. On 12/13/23 at approximately 1:00 p.m., Staff #4 stated she was at the residence on 12/8/23 when EMS arrived. She stated that she believed the staff received a telephone call from the concierge; however, they were unaware of which room EMS went to and, therefore, failed to meet them at the room of Former Resident #4. On 12/13/23 at 2:03 p.m., an EMS representative stated that when he arrived at the residence, he did not see any staff, received no face sheet or medication list, and could not verify the medications the former resident administered. He added that the residence preferred EMS to enter through the back or side doors, and had they entered through the front door at that time; they would have passed the concierge desk. On 12/13/23 at 2:37 p.m., the concierge stated she was not working on 12/8/23; however, the concierge shift would have begun prior to the time EMS entered the residence and the concierge would witnessed EMS entering the building and notified wellness staff. On 12/13/23 at 2:53 p.m., the licensed practical nurse (LPN)1 stated that she worked at the residence on 12/8/23 and that she was initially unaware of Former Resident #4 leaving the residence via EMS; however, she contacted the EHP as they stated they would follow up with the hospital. On 12/13/23 at 3:08 p.m., the health and wellness director (HWD) stated that she was unaware if LPN1 sent paperwork to the emergency department after she became aware of the residence transfer. She added that LPN1 should have sent the face sheet and medication list for the former resident if she had not. On 12/13/23 at 2:41 p.m., the administrator stated that the expectation was for the residence to send a resident ' s face sheet and medication list with the resident when transferred to the emergency department. She added that the residence became aware of the Former Resident #4 transfer when she witnessed the (family member who resided at the residence) and a family member leaving the residence and asked where they were heading. Later, she stated that she became aware of one unidentified staff member who was aware of the transfer and did not notify the appropriate staff to gather documents and send them with the former resident and EMS.

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 7.12.9 The comprehensive assessment shall be updated for each resident at least annually and whenever the resident ' s condition changes from baseline status.

A revisit survey was completed on 7/18/23 for all previous deficiencies cited on 1/11/23. 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 recertification survey was completed on 1/11/23. No deficiencies were cited.

A relicensure survey was completed on 1/11/23. Deficiencies were cited.

Based on record review and interview, the residence failed to ensure its quality management program (QMP) contained the required elements, affecting 81 current residents. Findings include: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. Review of the residence's quality management program revealed that the last quality management project was 1/2019, and read in part: "training and incident reports for falls." Furthermore, no updates to the quality management program had been made, and the program had not been reviewed since. On 1/11/23 at 12:30 p.m., the administrator stated she was responsible for reviewing and developing the QMP, and stated that she had last reviewed and updated the QMP in 2022. However, she stated she failed to update the QMP binder since October of 2019.

Based on interviews and record review, the residence failed to ensure there was a readily available roster that included emergency contact information and a residence diagram showing room locations, affecting 81 current residents. Findings include:On 1/11/23 at approximately 8:10 a.m., a copy of the current resident roster was requested. However, the resident roster provided did not include resident's emergency contact information or a diagram that showed the room locations. On 1/11/23 at approximately 2:10 p.m., the administrator confirmed the resident roster provided did not include emergency contact information or a diagram that showed room locations. She stated she was not aware of the elements required to be included in the resident roster.

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 7.14.21 The assisted living residence shall be responsible for complying with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers. 14.33 The assisted living residence shall ensure that the resident's authorized practitioner and resident's legal representative are promptly notified of:(A) A decline from a resident's baseline status;(B) A resident's pattern of refusal;