GOOD SAMARITAN SOCIETY ESTES PARK VILLAGE

A relicensure survey was completed on 1/7/25. 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 7.9.2 The assisted living residence shall have written policies and procedures regarding the visitation rights detailed in Section 25-3-125(3)(a), C.R.S. Such policies and procedures shall: (A) Set forth the visitation rights of the resident, consistent with 42 CFR 482.13(h); 42 U.S.C. 1396r(c)(3)(C); 42 U.S.C. 1395i(c)(3)(C); 42 CFR483.10(a), (b), and (f); and Section 2527-104, C.R.S., as applicable to the facility type; (B) Describe any restriction or limitation necessary to ensure the health and safety of residents, staff, or visitors and the reasons for such restriction or limitation; (C) Be available for inspection at the request of the Department;(D) Be provided to residents and/or family members upon request; and (E) Include the right of each resident of an assisted living residence to have at least one visitor of the resident ' s choosing during their stay at the residence, unless restrictions or limitations under federal law or regulation, other state statute, or state or local public health order apply. This visitation right shall be exercised in accordance with the following: (1) A visitor to provide a compassionate care visit to alleviate the resident's physical or mental distress. (2) For a resident with a disability:(a) A visitor or support person, designated by the resident, orally or in writing, to support the resident during the course of their residency. The support person may visit the resident and may exercise the resident ' s visitation rights even when the resident is incapacitated or otherwise unable to communicate. (b) When the resident has not otherwise designated a support person and the resident is incapacitated or otherwise unable to communicate their wishes, an individual may provide an advance medical directive designating the individual as the resident ' s support person or another term indicating that the individual is authorized to exercise visitation rights on behalf of the resident. Pursuant to Section 15-18.7-102(2), C.R.S., "(2) ' Advance medical directive ' means a written instruction concerning medical treatment decisions to be made on behalf of the adult who provided the instruction in the event that he or she becomes incapacitated. An advance medical directive includes, but need not be limited to: (a) A medical durable power of attorney executed pursuant to Section 15-14-506; (b) A declaration executed pursuant to the "Colorado Medical Treatment Decision Act", article 18 of this title; (c) A power of attorney granting medical treatment authority executed prior to July 1, 1992, pursuant to Section 15-14-501, as it existed prior to that date; or (d) A CPR directive or declaration executed pursuant to article 18.6 of this title." (3) For a resident who is under eighteen years of age, the parent, legal guardian, or person standing in loco parentis to the resident is allowed to exercise these visitation rights pursuant to any limitations described in Parts 9.2(F) and (G). (F) The policies and procedures may impose limitations on visitation rights. During a period when the risk of transmission of a communicable disease is heightened, an assisted living residence may: (1) Require visitors to enter the residence through a single, designated entrance;(2) Deny entrance to a visitor who has known symptoms of the communicable disease;(3) Require visitors to use medical masks, face-coverings, or other personal protective equipment while on the assisted living residence premises or in specific areas of the residence; (4) Require visitors to sign a document acknowledging: (a) The risks of entering the residence while the risk of transmission of a communicable disease is heightened; and (b) That menacing and physical assaults on health-care workers and other employees of the residence will not be tolerated; (5) Require all visitors, before entering the residence, to be screened for symptoms of the communicable disease and deny entrance to any visitor who has symptoms of the communicable disease; (6) Require all visitors to the residence to be tested for the communicable disease and deny entry for those who have a positive test result; and (7) Restrict the movement of visitors within the residence, including restricting access to where immunocompromised or otherwise vulnerable populations are at greater risk of being harmed by a communicable disease. (8) If an assisted living residence requires that a visitor use a medical mask, face covering, or other personal protective equipment or to take a test for a communicable disease in order to visit a resident at the assisted living residence, nothing in these regulations: (a) Requires the residence allow a visitor to enter, if the required equipment or test is not available due to lack of supply; (b) Requires the residence to supply the required equipment or test to the visitor, or bear the cost of the equipment for the visitor; or (c) Precludes the health-care residence from supplying the required equipment or test to the visitor.(G) The policies and procedures may impose additional limitations for the visitors of a resident with a communicable disease who is isolated. In this case, the residence may impose additional restrictions including: (1) Limiting visitation to essential caregivers who are helping to provide care to the resident; (2) Limiting visitation to one caregiver at a time per resident with a communicable disease; (3) Scheduling visitors to allow for adequate time for screening, education, and training of visitors and to comply with any limits on the number of visitors permitted in the isolated area at the time; and(4) Prohibiting the presence of visitors during aerosol-generating procedures or during collection of respiratory specimens. (H) Any limitations imposed shall be consistent with applicable federal law and regulation and other state statute. 9.3 The assisted living residence shall have an involuntary discharge grievance policy that complies with Section 25-27-104.3, C.R.S., and includes, at a minimum: (A) The individual designated by the assisted living residence to receive involuntary discharge grievances. (B) The ability for any of the persons the assisted living residence is required to notify in accordance with Part 11.16 to file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (A), above, within 14 calendar days after written notice of the involuntary discharge is provided by the assisted living residence. (C) The ability for the resident, or other person allowed to file a grievance to receive assistance in preparing and filing a grievance without interference from the assisted living residence. (D) A requirement that grievances related to involuntary discharge be submitted to the individual designated by the facility in accordance with subpart (A) as follows(1) In writing, or (2) Orally submitted to the individual designated in accordance with subpart (A), above. In the case of an oral submission, the assisted living residence shall ensure the individual submitting the grievance retains proof of the oral submission through a witness or other evidence. (a) If the grievance is orally submitted and witnessed, the assisted living residence shall ensure that the resident or other person filing the grievance has the witness ' s name and contact information, and shall keep that information as part of the grievance documentation. (E) A requirement that no later than 5 business days after the submission of a grievance in accordance with subpart (D), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall provide a response to the grievance as follows: (1) A written response shall be provided to the individuals required to receive notice in Part 11.16, the state long-term care ombudsman, and the designated local ombudsman.(2) An oral explanation of the written response shall be provided to the resident and/or person filing the grievance, as appropriate. (3) The written response shall include the following statement regarding the filing of an appeal:"If the resident, or other person that submitted this grievance is dissatisfied with this response, they may file an appeal to the executive director of the Colorado Department of Public Health and Environment within 5 business days after receiving this written response. The appeal must include the original grievance, the original notice of involuntary discharge and supporting documentation given to the resident as part of that notification, and any additional information or documentation." (F) Acknowledgement that if the resident, the individual filing the grievance, or the assisted living residence is dissatisfied with the findings and recommendations of the Department related to an appeal, they may request a hearing conducted by the Department pursuant to Section 24-4-105, C.R.S. (G) A requirement that the assisted living residence not take any punitive or retaliatory action against a resident due to the resident filing a grievance or appeal pursuant to this Part. (H) A requirement that the assisted living residence continue to assist with planning a discharge or transfer of the resident while the grievance or appeal to the Department is pending. (I) A requirement that the resident be allowed to return to the assisted living residence if all of the following apply: (1) The stated reason for the involuntary discharge in the notice of involuntary discharge provided in accordance with Part 11.17 is nonpayment of monthly services or room and board, (2) The assisted living residence discharged the resident on or after the 31st day after the written notice of involuntary discharge was provided to the resident, and (3) The resident substantially complied with payments due to the residence, as determined through the grievance and appeal process. 10.6 Each assisted living residence ' s emergency policies shall address, at a minimum, all of the following items: (A) Written instructions for each identified risk that includes persons to be notified and steps to be taken. The instructions shall be readily available 24 hours a day in more than one location with all staff aware of the locations; (B) A schematic plan of the building or portions thereof placed visibly in a central location and throughout the building, as needed, showing evacuation routes, smoke stop and fire doors, exit doors, and the location of fire extinguishers and fire alarm boxes; (C) When to evacuate the premises and the procedure for doing so; (D) A pre-determined means of communicating with residents, families, staff and other providers; (E) A plan that ensures the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids; (F) Storage and preservation of medications; (G) Assignment of specific tasks and responsibilities to the staff members on each shift including use of a triage system to assess the needs of the most vulnerable residents first; (H) Protection and transfer of health information as needed to meet the care needs of residents; and (I) In the event relocation of residents becomes necessary, written agreements with other health facilities and/or community agencies. 14.39 Controlled substances shall be kept in double lock storage.(A) Two individuals who are either qualified medication administration persons, nurses, or practitioners shall jointly count all controlled substances at the end of each shift and sign documentation regarding the results of the count at the time it occurs. Any discrepancy in the controlled substance count shall be immediately reported to the administrator. 22.32 The assisted living residence shall ensure that oxygen tanks are secured upright at all times in a manner that prevents tanks from falling over, being dropped, or striking each other.

A revisit survey was completed on 7/10/24 for all previous deficiencies cited on 4/23/24. The facility is in compliance with all deficiencies that were cited.

A licensure complaint, prompted by #CO35399, was completed on 4/23/24. Deficiencies were cited.

Based on interview and record review, the residence failed to prepare and administer only medications ordered by an authorized practitioner to residents, affecting one of three sample residents whose medications were reviewed (#1). Findings include:1. Reference Chapter VII regulations governing assisted living residences, part 14.17, requires the assisted living residence shall ensure that each authorized practitioner's order for medication includes ... the signature of the practitioner. 2. Resident #1 was admitted to the residence on 10/1/22.a. Doxycycline hyclate The April 2024 medication administration record (MAR) read Resident #1 was administered doxycycline hyclate 100 mg twice daily for ten days, on 4/11-4/20/24, for a total of 20 doses. However, the residence was unable to provide a signed practitioner's order for the medication. b. Hydrocodone-acetaminophenThe April 2024 MAR read Resident #1 was administered hydrocodone acetaminophen 5 mg-325 mg one tablet on 4/11/24 at 8:00 p.m for a total of one dose. However, the signed practitioner's order for hydrocodone acetaminophen 5 mg-325 mg one tablet three times daily at 8:00 a.m., 2:00 p.m. and 8:00 p.m., was dated 4/12/24. 3. InterviewsOn 4/23/24 at 11:28 a.m., the executive manager (EM) stated Resident #1's doxycycline was listed on a discharge summary from the practitioner's office from 4/11/24; however, there were no signed practitioner's orders for the medication. The EM stated Staff #1, who administered Resident #1's hydrocodone acetaminophen at 8:00 p.m., likely had given a dose of Resident #1's medication on 4/11/24 based off of a medication list, without having the signed practitioner's order in hand, which was dated 4/12/24. On 4/23/24 at approximately 12:51 p.m., the EM stated she was aware of the requirement for there to be signed practitioner's orders prior to administering medications, and she expected staff to ensure that this occurred.

Based on record review and interview the residence failed to comply with authorized practitioner orders associated with medication administration affecting one of three sample residents whose medications were reviewed (#2). Findings include:1. Resident #2 was admitted to the residence on 10/16/23. A written practitioner's order dated 4/13/24 directed the residence to administer doxycycline hyclate 100 mg twice daily for seven days. However, the April 2024 medication administration record revealed that staff did not administer the medication on the morning of 4/20/24 to complete the course, for a total of one missed dose. A medication error communication report sent from the residence to Resident #2's practitioner, dated 4/22/24, read Resident #2 was prescribed a seven day course of doxycycline hyclate, and the last dose was missed. On 4/23/24 at approximately 12:51 p.m., the executive manager stated she would expect the residence to comply with practitioner's orders and would have expected Resident #2 to have been administered his full course of doxycycline.

Based on interview and record review, the residence failed to ensure that each qualified medication administration person documented accurate information in the medication administration record (MAR), including any medication omissions; the residence additionally failed to ensure that, as part of the MAR, the residence maintained a legible list of the names of the persons utilizing the MAR, along with their signatures and initials, affecting three of three sample residents whose medications were reviewed (#1-#3). Findings include:1. Residence PolicyThe residence's medication errors policy, dated 12/6/23, read in part that the qualified medication administration persons (QMAP) or licensed nurse would document all medications at the time of occurrence, to include what occurred and whether a medication was administered or omitted, along with any resident responses. 2. Legible list of qualified medication administration person (QMAP) names on MARsA review of the March and April 2024 MARs for Resident #1-#3 revealed the residence failed to maintain a legible list of the names of the persons utilizing the MARs along with their initials. 3. Resident #1 was admitted to the residence on 10/1/22.a. AspirinA written practitioner's order, dated 3/3/24, directed the residence to administer aspirin 81 mg once daily. The April 2024 MAR contained circled QMAP initials on 4/15 and 4/22/24 without corresponding documentation as to the reason. However, there was documentation on the back of the April 2024 MAR that read the resident was "out of the facility" on 4/14 and 4/21/24, and there were no circled QMAP initials to correspond. b. AtenololA written practitioner's order, dated 11/1/23, directed the residence to administer atenolol 25 mg one 0.5 tablet daily. The April 2024 MAR contained circled QMAP initials on 4/15 and 4/22/24 without corresponding documentation as to the reason. However, there was documentation on the back of the April 2024 MAR that read the resident was "out of the facility" on 4/14 and 4/21/24, and there were no circled QMAP initials to correspond. c. Calcium-Vitamin D3A written practitioner's order, dated 11/1/23, directed the residence to administer calcium-vitamin D3 600 mg daily. The April 2024 MAR contained circled QMAP initials on 4/15 and 4/22/24 without corresponding documentation as to the reason. However, there was documentation on the back of the April 2024 MAR that read the resident was "out of the facility" on 4/14 and 4/21/24, and there were no circled QMAP initials to correspond. d. ModafinalA written practitioner's order, dated 11/1/23, directed the residence to administer modafinil 200 mg twice daily. However, the March 2024 MAR contained circled QMAP initials on 3/18/23, without a reason provided as to why the medication was circled. Additionally, the April 2024 MAR contained circled QMAP initials on 4/15 and 4/22/24 without corresponding documentation as to the reason. However, there was documentation on the back of the April 2024 MAR that read the resident was "out of the facility" on 4/14 and 4/21/24, and there were no circled QMAP initials to correspond. e. OmeprazoleA written practitioner's order, dated 1/31/24, directed the residence to administer omeprazole 20 mg once in the morning. The April 2024 MAR contained circled QMAP initials on 4/15 and 4/22/24 without corresponding documentation as to the reason. However, there was documentation on the back of the April 2024 MAR that read the resident was "out of the facility" on 4/14 and 4/21/24, and there were no circled QMAP initials to correspond.f. ValsartanA written practitioner's order, dated 11/1/23, directed the residence to administer valsartan 80 mg daily. The April 2024 MAR contained circled QMAP initials on 4/15 and 4/22/24 without corresponding documentation as to the reason. However, there was documentation on the back of the April 2024 MAR that read the resident was "out of the facility" on 4/14 and 4/21/24, and there were no circled QMAPinitials to correspond.g. Vitamin B12A written practitioner's order, dated 11/1/23, directed the residence to administer vitamin B12 1000 mcg daily. The April 2024 MAR contained circled QMAP initials on 4/15 and 4/22/24 without corresponding documentation as to the reason. However, there was documentation on the back of the April 2024 MAR that read the resident was "out of the facility" on 4/14 and 4/21/24, and there were no circled QMAP initials to correspond. 4. Evidence obtained during the onsite investigation, revealed the residence additionally failed to accurately document medication events on the MAR at the time of administration for Residents #2 and #3. 5. InterviewOn 4/23/24 at approximately 12:51 p.m., the executive manager (EM) stated a circled medication meant a medication refusal or "some other type of medication omission." The EM stated she would expect there to be corresponding documentation with circled medications and the notes on the back of the MAR to accurately correspond with each circled medication. The EM stated "blank spaces" on the MAR meant staff did not document whether the medication was administered or omitted, and she would have expected staff to have documented in the blank spaces with their initials at the time of administration. The EM further stated she was aware of the requirement for the MAR to include a legible list of names of those utilizing the MAR as well as their signature and initials and would have expected staff to have done so.

A revisit survey was completed on 5/4/23 for all previous deficiencies cited on 6/1/22. No deficiencies were cited.

A revisit survey was completed on 5/4/23 for all previous deficiencies cited on 6/1/22. No deficiencies were cited.

Citation coded "0000" or "9999" are initial and final comments of an inspection for informational purposes, this field may also have been left blank intentionally