PINE GROVE CROSSING — Colorado Facility Report

Inspections

Deficiencies

Actual Harm or Above

Occurrences

April 21, 2026

Last Inspection

S/S A/B/C Minimal potentialS/S D/E Potential for harm

The most recent inspection of PINE GROVE CROSSING on record is dated April 21, 2026. Across 37 published inspections, state surveyors cited 91 deficiencies, none of which reached the actual-harm level.

Colorado publishes inspections on a rolling window, so older surveys may no longer appear. Citation codes 0000 and 9999 are the surveyor's opening and closing comments, not deficiencies, and are excluded from the counts above. Where the state required one, the facility's own plan of correction is shown beneath the finding it answers.

Provider Information

Status

Active

Facility Type

Assisted Living Residence (Licensed Only)

Administrator

Backes, Kimberley

Owner

MSLA PARKER OPERATING LLC

Phone

(714) 305-3841

Payor Source

Private Pay

City

PARKER

ZIP

80138

Inspections & Citations

37 inspections · 91 deficiencies

4/21/2026General Inspection · ID JUDL21No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint survey prompted by #CO41949 was completed on 4/21/2026. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

3/24/2026Revisit: Licensure Complaint · ID E5XG12No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 3/26/26 for the previous deficiencies cited on 10/21/25. No deficiences were cited.

Plan of correction

The state did not require a plan of correction for this citation.

3/24/2026Licensure Complaint · ID LFW0115 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO41835, #CO41868 and #CO41883, was completed on 3/26/26. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

1110Res Care Srvs-Min Srvs Res AgrS/S C▼

Findings

Based on interview and record review, the residence failed to provide protective oversight when confronted with an unanticipated situation, affecting one of nine sample residents (#27). Specifically, on 3/21/26 at 3:14 p.m., Resident #27 was found unresponsive on a bench in the outdoor area of the assisted living. Her blood pressure was 137/120 and her pulse was 127 beats per minute. Residence staff stated when they found her she was "burning up, twitching, she would not open her eyes" and had vomited on herself. An external emergency medical services (EMS) report, dated 3/21/26 read Resident #27 was outside in direct sunlight for approximately three hours prior to having been evaluated by staff. When EMS evaluated her, Resident #27's oxygen saturation was at 84% and her body temperature was 104.7 degrees fahrenheit (F). The report further read that Resident #27 was unconscious, "extremely hot to the touch" and suspected to have suffered a heat stroke. Findings include:1. ReferenceAccording to Weather Underground, on 3/21/26 from approximately 11:53 a.m. to 3:53 p.m., the temperature outside ranged between 79 degrees F to 85 degrees F. Weather Underground (2026) Centennial, CO Weather History, retrieved from: https://www.wunderground.com/history/daily/us/co/centennial/KAPA/date/2026-3-21 2. Resident #27 was admitted to the residence on 11/24/24 with diagnoses including a personal history urinary tract infections. A care plan for Resident #27, dated 5/16/25 revealed Resident #27 was a fall risk and required regular safety checks. However, the care plan did not indicate how often safety checks were to be performed. Progress notes in Resident #27's record for March 2026 revealed the following:On 3/16/26 at 6:58 p.m., Resident #27's family member said Resident #27 was more confused than normal and he brought her to urgent care. On 3/21/26 at approximately 3:14 p.m., Resident #27 was found outside asleep and staff tried to wake her up but she was nonresponsive. A practitioner's order in Resident #27's record, dated 3/19/26, directed the residence to administer linezolid 600 mg every 12 hours for seven days for an acute urinary tract infection. An incident report in Resident #27's record, dated 3/21/26 at 3:14 p.m., read Resident #27 was seated outside in the courtyard asleep. A staff member tried to wake her up but she was unresponsive. Resident #27 threw up on herself. Resident #27's blood pressure was 137/120 and her pulse was 127. "(Resident #27's) body was burning up, twitching, would not open her eyes."A Task Administration Record for March 2026 for Resident #27 read Resident #27 required dressing assistance with her stockings in the morning and evening and reminders for hydration at 11:00 a.m, 3:00 p.m., and 8:00 p.m. An EMS report, signed by an authorized practitioner and dated 3/21/26, read the assessment and plan clinical impressions on Resident #27 were heat stroke; initial encounter, encephalopathy (altered brain function), aspiration pneumonia of the right lower lobe due to regurgitated food, hypoxic and severe sepsis. The physical exam read Resident #27 was in acute distress and hot to the touch. The report read, "it was reported by the staff that the patient (resident) had been in direct sunlight for approximately three hours." The report further read that (Resident #27) presented to the emergency department for evaluation of encephalopathy. "Differential includes sepsis and CNS (central nervous system) abnormality and heat stroke. On arrival, the resident presented with a significantly elevated temperature of 104.7 degrees F and an oxygen saturation of 84%. According to patient's history she was normal and then was outside in the heat for four hours and became altered leading me (the EMS evaluator) to believe this is more likely a heat stroke."3. InterviewsOn 3/24/26 at 1:20 p.m., Staff #7 said as she was walking back inside the residence from her break she observed Resident #27 seated outside in direct sunlight and her body was visibly red. She added Resident #27 was not moving and requested assistance from staff. Staff #7 said if staff took residents out into the courtyard they would then check on them otherwise she was not directed to check residents if they went outside on their own. Staff #7 said she was unsure if Resident #27 was a fall risk and if she required regular checks. On 3/24/26 at 1:34 p.m., Staff #8 said she arrived to work late at approximately 2:30 p.m. and entered the building through the courtyard and that is when she saw Resident #27 outside on the bench wearing a green beanie cap. She added she saw her twitch and thought she was asleep so she went inside to clock in for her shift. Staff #8 said at approximately 3:14 p.m., Staff #7 said Resident #27 was outside unconscious. Staff #8 said she went outside where Resident #27 was hot to the touch and would not wake up so staff contacted emergency medical services. Staff #8 said she was not on regular checks and the next time she was required to provide assistance with care was in the evening to help remove her stockings. Staff #8 said she spoke with Staff #10 who said she allegedly saw Resident #27 last at 1:05 p.m. heading outside to the courtyard. Staff #8 said the day prior Resident #27 was diagnosed with a urinary tract infection. On 3/24/26 at 2:06 p.m., Resident #27's family member said Resident #27 liked to eat lunch and go outside to sit on the patio. He added she typically wore a lot of warm clothes. The family member said he received a phone call from the residence on 3/21/26 and was told said staff found her outside unconscious so he met her up at the emergency department where he was told Resident #27's body temperature was 105 degrees F. He added the practitioners were able to stabilize her and she was doing fine until the a day prior on 3/23/26 when Resident #27 started to decline. The family member added he was trying to find out what had happened and how come the outdoor area was not monitored by staff. On 3/24/26 at approximately 3:45 p.m., the administrator said a family member of Resident #27 reached out to her on Sunday 3/22/26 and requested a care conference on Monday 3/23/26. She added at the conference a family member told her that a staff member found Resident #27 unresponsive outside in the courtyard and requested emergency medical service. The administrator acknowledged that staff did not notify her (the administrator) when the incident occurred on 3/21/26 and was first notified by Resident #27's family member. The administrator said she expected to be notified by staff when the incident happened on 3/21/26. On 3/25/26 at approximately 8:30 a.m., Staff #2 said Resident #27 often went outside to sit after lunch and either wore a scarf or beanie because she was always cold. She added, it was unusual for Resident #27 to fall asleep outside. On 3/25/26 at 8:40 a.m., Staff #11 said Resident #27 often wore a scarf or a beanie on her head because she was cold. He added, it was not normal for her to fall asleep outside. On 3/25/26 at 8:50 a.m., Staff #12 said Resident #27 was always dressed in warm clothing. She added, prior to this incident staff were not directed on how to monitor residents in the courtyard.

Plan of correction · submitted by the facility

Inservice provided to staff on 3/24/26 and 3/25/26 about heat and dangers in the elderly. Education and training to wellness staff will be provided by Regional Health Services Director/Wellness Director no later than 5/8/2026 regarding protective oversight and our responsibilities. This documentation will be placed in state prep binder for review. All staff will be monitoring residents in the courtyard and recommending they come in to the building, move to the shade and offering drinks.

1146Res Care Srvs-Comp Res Asmnt Annl/Chng BslnS/S B▼

Findings

Based on interviews and record review, the residence failed to complete a reassessment whenever the resident had a change from baseline status, affecting three of three residents (#4, #14, #24), who had changes in baseline status,Findings include:1. Resident #4 was admitted to the residence on 2/1/24 with diagnoses including venous insufficiency and edema. An external service provider note, dated 1/23/26, revealed Resident #4 required wound care three times per week for wounds on her right and left lower extremities. An assessment and care plan for Resident #4, dated 1/21/26, revealed no indication of any wound care services or how staff were required to provide personal care services while Resident #4 was receiving wound care treatment on her lower extremities. On 3/24/26 at 3:45 p.m., the administrator said she expected the wellness team to have initiated a change in baseline assessment and indicated that wound care was provided for Resident #4. On 3/25/26 at 8:30 a.m., Staff #2 said she was not provided any direction about how to provide care and services related to the wounds on Resident #4's lower extremities. She added Resident #4 would frequently remove her bandages. On 3/25/26 at 8:40 a.m., Staff #12 said she was not provided any direction by management in how to provide care and services while Resident #4 was being treated for wound care on her lower extremities. 2. Similar deficient practice was found for Residents #14 and #24.

Plan of correction · submitted by the facility

The Executive Director will ensure training is provided by Wellness Director as residents are onboarded for wound care. The Wellness Director/Regional Health Services Director will also update the service plan to reflect appropriate measures to be taken by care staff to assist in the healing process. These trainings and service plan updates will be documented and provided at monthly QA for verification of trainings for a period of no less than 90 days. Our Regional Health Services Director will be on site weekly to audit resident files and skin check documentation to ensure proper documentation and follow through of any concerns, including additional services and adjustment to care plans, as needed, for a period of no less than 90 days. These audits will be documented and reviewed at monthly QA. The Wellness Director will be responsible for ensuring documentation, additional care services, and care planning on all changes ongoing.

1190ReRes Care Srvs-Lift As P/P Av EMRS/S B▼

Findings

Based on record review and interviews, the residence failed to direct staff to assist residents who had fallen, rather than rely on emergency medical responders (EMR), affecting 101 current residents. Findings include:1. Residence PolicyA Falls policy, dated February of 2024, read in part: For residents who are cognitively impaired, prescribed blood thinners, known to have hit their head or if the fall is unwitnessed, the resident will be transported for a medical evaluation. 2. Record reviewResident #4 was admitted to the residence on 2/1/24 with a diagnosis of atrial fibrillation (A-fib). A progress note, dated 2/16/26, read that Resident #4 was found on the floor by a wound care nurse. No pain or injury. Called (EMR) to pick her up. On 3/24/26 at 7:30 a.m, a request for a lift assistance policy was made. At 10:00 a.m., the administrator said the residence did not have a policy on lift assistance and provided a Fall policy that contained guidance for when a resident would be transported for medical evaluation. An undated document, titled "On the Spot Training: Resident falls, slips, trips, etc" read in part: "If a resident slips out of their wheelchair, out of their bed, falls on the floor we [residence staff] are not, under any circumstances, to lift them up. If they are unable to get up on their own, we are to call the paramedics immediately." 3. InterviewsOn 3/24/26 at 8:14 a.m., Staff #1 said that up until two weeks prior to the onsite visit staff were directed by regional director clinical services to call EMR for any and all falls. Staff #1 was not aware of why the direction had changed. On 3/24/26 at 10:10 a.m., the administrator said staff were directed by the regional director of clinical services to call "911" unless a resident can get up on their own without any staff assistance. The administrator said she knew the regulations, and that the residence was not following the regulations, however, she [administrator] was unable to make those changes without approval from a corporate-level staff.

Plan of correction · submitted by the facility

Lift assist policy has been created by Meridian Senior Living and placed in policy binder, as well as state prep binder. Staff has been trained as of 4/30/2026 to new policy that they will assist residents up if they have fallen and have no signs or symptoms of injury, or have hit their head and are on blood thinners. If either of these occur, staff of Meridian Senior Living will follow fall policy and send out for evaluation. LIFT ASSIST WHEN NO INJURIES ARE APPARENT policy updated 4/1/2026PURPOSE:Colorado regulations (6 CCR 1011-1 Chapter 7) require assisted living residences to train staff to evaluate and perform non-emergency lift assists for fallen residents, avoiding 911 when safe. Staff must call 911 if the resident is injured, in pain, or has altered mental status. POLICY:The community will ensure all staff are trained to provide lift assistance to residents that have fallen, that have no apparent injuries, their mental status has not changed, and they did not hit their head. PROCEDURE:All QMAPs are to observe the resident for any obvious signs of pain, ask the resident what happened and watch for signs of impaired mental status. If the resident declares they are not hurting, and they did not hit their head, staff will assist the resident in getting up. If during this process, there are signs/symptoms of pain, or if their baseline changes, a call will then be placed to 911. Staff will document the process and notify the Wellness Director for physician evaluation at the next available time.

1412Res Rts-Inv Ab/Neg Alleg or Inj Unk Org IUOS/S B▼

Findings

Based on record review and interview, the residence failed to have policies and procedures meeting all components for the investigation of injuries of unknown origin, affecting two of two sample residents (#4 and #25) who sustained injuries of unknown origin. Findings include:1. Residence PolicyThe residence policy titled Incident Reporting, dated 3/2024, read in part: The executive director [administrator] and wellness director (regional director of clinical services) were responsible for ensuring an incident report was completed within twenty-four hours after an incident. Incidents may include, but are not limited to the following: skin tear, laceration, abrasion, bruise (including known or unknown cause of origin). However, the policy failed to include information from sections A-D of regulation 13.12. 2. Record review Resident #25 was admitted to the residence on 10/25/25, with a diagnosis of anemia. A progress note, dated 1/27/26 read that Resident #25 had a bruise on his hip and an unknown nurse was notified. A progress note, dated 2/3/26 read that Resident #25 had a bruise on the left side of his lower back and on his right arm near the elbow. On 3/25/26 at 8:11 a.m., a request was made for documentation of the investigation for injury of unknown origin. The administrator said she could not provide these investigations because they had not been done. 3. InterviewsOn 3/25/26 at 11:00 a.m., the administrator stated the residence's policy for injuries of unknown origin was titled Incident Reporting. She further said injuries of known and unknown origin were considered incidents and the policy reflected how said incidents were investigated. On 3/25/26 at 2:11 p.m., the administrator said she was aware of what components were missing in the residence policy for investigating injuries of unknown origin, however, she [administrator] was unable to revise the policy because policy revisions were done at a corporate level. The administrator said she was not aware of the bruises documented in the progress for Resident #25 prior to the onsite investigation. The administrator said it was the responsibility of herself or the regional director of clinical services to investigate injuries of unknown origin. The administrator said if staff did not communicate injuries of unknown injuries or it was not seen in a progress note by herself or the regional director of clinical services then it would go unknown. The administrator said there was not a system in place to ensure injuries of unknown origin did not go uninvestigated. 4. Similar deficient practice was found for Resident #4.

Plan of correction · submitted by the facility

Policy, below, has been updated to include language and procedures required by the State of Colorado. New verbiage highlighted in green, current verbiage in yellow. The Executive Director will ensure the Wellness Director and/or designee will have all required documentation on incident reporting. This process will be monitored monthly at QA with random request of 7 incident reports, documentation on QA reporting tool and for no less than a period of 90 days. PURPOSE:To ensure that unusual incidents involving Residents, Staff and Visitors are reported and investigated promptly to promote a safe environment. POLICY:All Incidents or unusual occurrences will be reported promptly to Community Management and documented on the Community’s Incident Reporting form within twenty-four (24) hours of the incident unless circumstances prevent the ability to do so (floods, fire, incidents where relocation is required). An incident or unusual occurrence is any situation which presents or may present an immediate or future risk to the health, safety, or well-being of a Resident, Staff member, or other individuals in the Community. The Community will take action in handling the incident or occurrence. Incident Reporting is part of the Meridian Senior Living Quality Assurance/Risk Management program. Incident Reports are internal documents of this program which are confidential and maintained secure. Incident reports are not released without the approval of Meridian Senior Living Management or Legal Office unless State Law and Regulations mandates release. The Executive Director will ensure the Incident Reporting procedure is in place. PROCEDURES:Staff will ensure a resident, staff, visitor, or other individual involved in an accident or incident receives prompt intervention and/or emergency treatment, as necessary. Staff will ensure an incident or change in condition is reported to the Executive Director, and Wellness Director if appropriate or designee promptly. If neither can be reached, staff will report to the Regional Director of Operations. The Executive Director, Wellness Director or designee will notify the Regional Director of Operation (RDO) who will report to the Vice President of Operations (VPO) and Resident Directors of Care Services staff (RDCS) if appropriate. The VPO will notify other Meridian Management as designated. The Executive Director, Wellness Director or designee will ensure reporting to the Medical Provider and authorized Responsible Party is completed and documented promptly. The Executive Director and Wellness Director are responsible to ensure an Incident report and insurance report if risk related is completed within twenty-four (24) hours after an incident. The reports should be complete, accurate, legible, and signed by the author and Executive Director. If signatures are not legible, the name should be printed under the signature. If the incident is risk related or a State Reportable Incident, the Executive Director will ensure notice and the report is sent for review prior to filing to: Meridian Management to include, the Regional Director of Operation, (RDO), who will report to the Vice President of Operations, (VPO), Risk Manager and other Meridian Senior Living Management as designated. The Executive Director is responsible for ensuring an incident is reported and sent to the State Agency on the appropriate form and within the required time required. Other Incidents may include, but are not limited to the following:Abuse, neglect or exploitation of a ResidentAggressive act by a Resident toward self or others (Staff, another Resident, visitor, family member, volunteer)Breach of confidentialityContagious disease outbreakElopement or missing residentEvent requiring evacuationFall with injuryFire, gas leak, flooding, equipment failure, damage resulting from a serious weather event or any other compromise of the buildingIngestion of toxic substanceMedication errorQuarantinesSkin tear, laceration, abrasion, bruise (including known or unknown cause of origin)Suicide, HomicideTheftUnexpected death of a ResidentViolation of Resident RightsVisitor requiring first aid or medical interventionWorkplace violenceOr any other incident of concernIf the results of the hospital evaluation are known, these shall be documented in the Resident’srecord, on the clinical incident report and on the insurance incident report. Documentation on the incident will also include;When the source of the injury remains undetermined, the steps taken to monitor the resident in an effort identify and prevent similar injuries. All documentation of the investigation, outcomes, and steps taken shall be retained by the assisted living residence, including, but not limited to, details of any interviews and/or records used in the investigation. Such documentation shall be made available for review at the Department's request. All of this information will be included in residents’ progress notes and steps taken will be updated in the service plan. If the incident involves more than one Resident or another individual, separate Incident Reports will be completed for each individual. To identify a second Resident or individual on an Incident Report, an identifying number should be used in place of the name. Documentation of the incident in a Resident’s chart will be completed by the Wellness Director (or designee). Incident Reports will be filed and maintained confidential. An Incident Log will be maintained. The Executive Director is responsible for ensuring the Incident Log is accurate and maintained secure. Staff Training includes:• Completing the Incident Report accurately and completely• Different types and reporting procedure for incidents including time limitsfor reporting of: employee incident reports, insurance reportingInternal clinical Incident Reports, State Reportable Incident reports, visitor incident reports, • Documenting emergency and first aid interventions• How to complete insurance report• How to correct an error on the Incident Report• Identifying critical/at-risk incidents• Incidents which require a report• Notifications required• Quality Assurance process for incident review

2230HIR-Cntnt IncldS/S B▼

Findings

Plan of correction · submitted by the facility

Processes have been discussed with outside provider, specifically Bloom Healthcare and Resilient PCP, to provide community with progress notes post visit which was the previous process of these providers. Bloom HC did not provide an official date this would begin so until that process happens the Wellness Director will be responsible for going into the portal and uploading post visit notes for each resident seen by provider. The Executive Director/ Regional Health Services Director will follow up weekly to ensure that this process has been completed so community does not fall behind. The process will be completed and in place no later than 6/30/2026 and weekly documentation will occur for a period no less than 90 days and verified at monthly QA.

3/24/2026Revisit: Licensure Complaint · ID PZP9125 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 3/26/26 for the previous deficiencies cited on 11/25/25. Deficiencies were cited. Tag U1412 was not cited in the previous event; however, the deficiency was included in the previous event's informational 999 tag.

Plan of correction

The state did not require a plan of correction for this citation.

0540Admin-Dts RespS/S B▼

Findings

Based on record review and interview, the residence failed to ensure the administrator managed day-to-day delivery of services to ensure residents receive the care that is described in the resident agreement, comprehensive assessments were updated after a change in condition, out of the ordinary events were documented, along with actions taken, prior to end of shifts, documentation of external services were included in the residents' records and ensure staff had access to electronic charting system, affecting 101 current residents. (Cross-reference U1146, U1412 and U1568)This deficiency was cited previously during a state licensure survey on 11/25/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Record Review A review of Resident #4's resident record identified wound care was needed three times a week, however, a change of condition assessment was not conducted nor was the care plan updated to reflect the care needs and who was to provide what care needs. On 3/25/26 a request was made for investigations for injuries of unknown origin regarding Resident #25's resident record that read on two occasions (1/27/26 and 2/3/26) bruises were identified by staff. However, the administrator was not able to provide these because none had been conducted. A review of Resident #23 ' s medication administration record (MAR) for February and March revealed, Resident #23 was not given Pradaxa (blood thinner) on 2/5 through 2/6; 2/12 through 2/14 and the evening of 3/22/26 through 3/25/26. It was noted on Resident #23 February and March MARS that the reason Pradaxa was not given was because the medication was unavailable. 2. InterviewsOn 3/25/26 at 9:42 a.m., Staff #2 said she was unable to chart in the electronic charting system because she had not received access yet. Staff #2 said she was on leave for two months and returned working at the residence in February of 2025, but her access had not been reactivated as of yet. Staff #2 said she had informed the wellness coordinator of the issue. On 3/25/26 at 10:00 a.m., the wellness coordinator (WC) said she was aware Staff #2 had not had access to the electronic charting system and had informed the regional director of clinical services. On 3/25/26 at 10:10 a.m., Staff #9 said she was unable to chart in the electronic charting system because she had not received access yet. Staff #9 said her first shift was six days prior to 3/25/26. On 3/25/26 at 11:00 a.m, the administrator said was not aware of Staff #2 and #9 not having access to the electronic charting system. On 3/25/26 at 1:18 p.m., the administrator said there was not a system in place for her [administrator] to ensure change of condition assessments were being completed, new employees had access to charting systems, injuries of unknown origin were investigated, progress notes and external provider notes were being added to resident records and that staff were following practitioner orders. The administrator said she had no control over updating residence policies to align with regulations. The administrator said she could not answer why the deficiency was being recited.

Plan of correction · submitted by the facility

There will be a weekly meeting with the Wellness Director/Regional Health Services Director that will include all incident reports from the week, and concerns from staff, to ensure Executive Director is made aware of incidents and can follow up on reports, care plans and progress notes. A note will be placed in the progress notes by the Executive Director that these items were reviewed weekly, and staff concerns will be documented in the grievance log with a follow up. Documentation review will occur monthly with 10 incidents and placed in monthly QA for a period of no less than 90 days.

0910Em Pr-Pol/Proc Res RstrS/S B▼

Findings

Based on observation, record review, and interviews, the residence failed to have a readily available roster of current residents showing their room assignments and a facility diagram showing room locations, affecting 101 current residents. This deficiency was cited previously during a state licensure survey on 11/25/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. 1. ObservationAt approximately 7:00 a.m. on 3/24/26, the residence's roster for emergency preparedness was requested in accordance with Chapter 7 regulations governing assisted living residences, Part 10.1. At approximately 7:45 a.m. on 3/24/26, the administrator arrived at the residence and provided an "evacuation emergency notebook," dated 3/2/26, which was their roster for emergency preparedness 2. Record ReviewOn 3/24/26 at approximately 7:50 a.m. the residence's "Evacuation Emergency Notebook" was reviewed and contained the following documents:Instructions for staff to account for and triage residents prior to exiting the building. Instructions for QMAP ' s and wellness staff to secure medications carts, computers and chargers. Instructions for care and maintenance staff to ensure oxygen is ready to go with staff in evacuation. Instructions for care staff to ensure residents' "go bags" are taken prior to evacuation. Instructions for Executive Director and or designee to reach out to State and resident responsible parties to inform them of the emergency. Diagrams of evacuation routes showing the location of all stairways located in the building. A separate list of all residents, their room numbers and responsible parties. However, the residence ' s "Evacuation Emergency Notebook," which was used as their roster, was incomplete, as it did not include resident room assignments or a facility diagram showing where each resident ' s room was located. 3. InterviewsOn 3/24/26 at approximately 7:00 a.m., the wellness coordinator stated she did not know where the residence's roster for emergency preparedness binder was located and would have to wait until the administrator arrived to provide it to the surveyors. On 3/24/26 at approximately 7:45 a.m., the administrator stated their residence's "evacuation emergency notebook" was their roster for emergency preparedness. She stated it was kept at the front desk and confirmed that it would be provided to emergency responders in the event of an evacuation or other emergency. On 3/25/26 at approximately 2:00 p.m., the administrator stated that she was not aware that the residence's current roster for emergency preparedness must include resident room numbers on the facility diagram and thought the deficiency had been corrected. The administrator agreed that emergency responders would not readily know where to locate residents who would require additional assistance to ensure timely evacuation, affecting all 101 residents.

Plan of correction · submitted by the facility

The roster that resides in the Emergency notebook does, in fact, contain room numbers. A facility diagram will be created with apartment numbers and a designation of evacuation assistance. This book will be updated as necessary by the concierge with oversight by the Facilities Manager. The Executive Director will audit monthly at QA for a period of no less than 90 days to ensure compliance. Staff training conducted 4/29/26, notices posted, for location of emergency notebooks in all areas of the community. The notebook will be complete no later than June 30, 2026.

1146Res Care Srvs-Comp Res Asmnt Annl/Chng BslnS/S B▼

Findings

Based on interviews and record review, the residence failed to complete a reassessment whenever the resident had a change from baseline status, affecting three of three residents (#4, #14, #24), who had changes in baseline status. (Cross-reference U0540)This deficiency was cited previously during a state licensure survey on 11/25/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #4 was admitted to the residence on 2/1/24 with diagnoses including venous insufficiency and edema. An external service provider note, dated 1/23/26, revealed Resident #4 required wound care three times per week for wounds on her right and left lower extremities. An assessment and care plan for Resident #4, dated 1/21/26, revealed no indication of any wound care services or how staff were required to provide personal care services while Resident #4 was receiving wound care treatment on her lower extremities. On 3/24/26 at 3:45 p.m., the administrator said she expected the wellness team to have initiated a change in baseline assessment and indicated that wound care was provided for Resident #4. On 3/25/26 at 8:30 a.m., Staff #2 said she was not provided any direction about how to provide care and services related to the wounds on Resident #4's lower extremities. She added Resident #4 would frequently remove her bandages. On 3/25/26 at 8:40 a.m., Staff #12 said she was not provided any direction by management in how to provide care and services while Resident #4 was being treated for wound care on her lower extremities. 2. Similar deficient practice was found for Residents #14 and #24.

Plan of correction · submitted by the facility

The Executive Director will ensure training is provided by Wellness Director/Regional Health Services Director as residents are onboarded for wound care. The Wellness Director/Regional Health Services Director will also update the service plan to reflect appropriate measures to be taken by care staff to assist in the healing process. These trainings and service plan updates will be documented and provided at monthly QA for verification of trainings for a period of no less than 90 days. There will be a weekly meeting with the Wellness Director/Regional Health Services Director that will include all incident reports from the week, and concerns from staff, to ensure Executive Director is made aware of incidents and can follow up on reports, care plans and progress notes. A note will be placed in the progress notes by the Executive Director/Regional Health Services Director that these items were reviewed weekly, and staff concerns will be documented in the grievance log with a follow up. Documentation review will occur monthly with 10 incidents and placed in monthly QA for a period of no less than 90 days.

1412Res Rts-Inv Ab/Neg Alleg or Inj Unk Org IUOS/S B▼

Findings

Based on record review and interview, the residence failed to have policies and procedures meeting all components for the investigation of injuries of unknown origin, affecting two of two sample residents (#4 and #25) who sustained injuries of unknown origin. (Cross-reference U0540). Findings include:1. Residence PolicyThe residence policy titled Incident Reporting, dated 3/2024, read in part: The executive director [administrator] and wellness director (regional director of clinical services) were responsible for ensuring an incident report was completed within twenty-four hours after an incident. Incidents may include, but are not limited to the following: skin tear, laceration, abrasion, bruise (including known or unknown cause of origin). However, the policy failed to include information from sections A-D of regulation 13.12. 2. Record review Resident #25 was admitted to the residence on 10/25/25, with a diagnosis of anemia. A progress note, dated 1/27/26 read that Resident #25 had a bruise on his hip and an unknown nurse was notified. A progress note, dated 2/3/26 read that Resident #25 had a bruise on the left side of his lower back and on his right arm near the elbow. On 3/25/26 at 8:11 a.m., a request was made for documentation of the investigation for injury of unknown origin. The administrator said she could not provide these investigations because they had not been done. 3. InterviewsOn 3/25/26 at 11:00 a.m., the administrator stated the residence's policy for injuries of unknown origin was titled Incident Reporting. She further said injuries of known and unknown origin were considered incidents and the policy reflected how said incidents were investigated. On 3/25/26 at 2:11 p.m., the administrator said she was aware of what components were missing in the residence policy for investigating injuries of unknown origin, however, she [administrator] was unable to revise the policy because policy revisions were done at a corporate level. The administrator said she was not aware of the bruises documented in the progress for Resident #25 prior to the onsite investigation. The administrator said it was the responsibility of herself or the regional director of clinical services to investigate injuries of unknown origin. The administrator said if staff did not communicate injuries of unknown injuries or it was not seen in a progress note by herself or the regional director of clinical services then it would go unknown. The administrator said there was not a system in place to ensure injuries of unknown origin did not go uninvestigated. 4. Similar deficient practice was found for Resident #4.

Plan of correction · submitted by the facility

Policy below has been updated to include language and procedures required by the State of Colorado. New verbiage highlighted in green, current verbiage in yellow. The Executive Director will ensure the Wellness Director and/or designee will have all required documentation on incident reporting. This process will be monitored monthly at QA with random request of 7 incident reports, documentation on QA reporting tool and for no less than a period of 90 days. PURPOSE:To ensure that unusual incidents involving Residents, Staff and Visitors are reported and investigated promptly to promote a safe environment. POLICY:All Incidents or unusual occurrences will be reported promptly to Community Management and documented on the Community’s Incident Reporting form within twenty-four (24) hours of the incident unless circumstances prevent the ability to do so (floods, fire, incidents where relocation is required). An incident or unusual occurrence is any situation which presents or may present an immediate or future risk to the health, safety, or well-being of a Resident, Staff member, or other individuals in the Community. The Community will take action in handling the incident or occurrence. Incident Reporting is part of the Meridian Senior Living Quality Assurance/Risk Management program. Incident Reports are internal documents of this program which are confidential and maintained secure. Incident reports are not released without the approval of Meridian Senior Living Management or Legal Office unless State Law and Regulations mandates release. The Executive Director will ensure the Incident Reporting procedure is in place. PROCEDURES:Staff will ensure a resident, staff, visitor, or other individual involved in an accident or incident receives prompt intervention and/or emergency treatment, as necessary. Staff will ensure an incident or change in condition is reported to the Executive Director, and Wellness Director if appropriate or designee promptly. If neither can be reached, staff will report to the Regional Director of Operations. The Executive Director, Wellness Director or designee will notify the Regional Director of Operation (RDO) who will report to the Vice President of Operations (VPO) and Resident Directors of Care Services staff (RDCS) if appropriate. The VPO will notify other Meridian Management as designated. The Executive Director, Wellness Director or designee will ensure reporting to the Medical Provider and authorized Responsible Party is completed and documented promptly. The Executive Director and Wellness Director are responsible to ensure an Incident report and insurance report if risk related is completed within twenty-four (24) hours after an incident. The reports should be complete, accurate, legible, and signed by the author and Executive Director. If signatures are not legible, the name should be printed under the signature. If the incident is risk related or a State Reportable Incident, the Executive Director will ensure notice and the report is sent for review prior to filing to: Meridian Management to include, the Regional Director of Operation, (RDO), who will report to the Vice President of Operations, (VPO), Risk Manager and other Meridian Senior Living Management as designated. The Executive Director is responsible for ensuring an incident is reported and sent to the State Agency on the appropriate form and within the required time required. Other Incidents may include, but are not limited to the following:Abuse, neglect or exploitation of a ResidentAggressive act by a Resident toward self or others (Staff, another Resident, visitor, family member, volunteer)Breach of confidentialityContagious disease outbreakElopement or missing residentEvent requiring evacuationFall with injuryFire, gas leak, flooding, equipment failure, damage resulting from a serious weather event or any other compromise of the buildingIngestion of toxic substanceMedication errorQuarantinesSkin tear, laceration, abrasion, bruise (including known or unknown cause of origin)Suicide, HomicideTheftUnexpected death of a ResidentViolation of Resident RightsVisitor requiring first aid or medical interventionWorkplace violenceOr any other incident of concernIf the results of the hospital evaluation are known, these shall be documented in the Resident’srecord, on the clinical incident report and on the insurance incident report. Documentation on the incident will also include; When the source of the injury remains undetermined, the steps taken to monitor the resident in an effort identify and prevent similar injuries. All documentation of the investigation, outcomes, and steps taken shall be retained by the assisted living residence, including, but not limited to, details of any interviews and/or records used in the investigation. Such documentation shall be made available for review at the Department's request. All of this information will be included in residents’ progress notes and steps taken will be updated in the service plan. If the incident involves more than one Resident or another individual, separate Incident Reports will be completed for each individual. To identify a second Resident or individual on an Incident Report, an identifying number should be used in place of the name. Documentation of the incident in a Resident’s chart will be completed by the Wellness Director (or designee). Incident Reports will be filed and maintained confidential. An Incident Log will be maintained. The Executive Director is responsible for ensuring the Incident Log is accurate and maintained secure. Staff Training includes:• Completing the Incident Report accurately and completely• Different types and reporting procedure for incidents including time limitsfor reporting of: employee incident reports, insurance reportingInternal clinical Incident Reports, State Reportable Incident reports, visitor incident reports, • Documenting emergency and first aid interventions• How to complete insurance report• How to correct an error on the Incident Report• Identifying critical/at-risk incidents• Incidents which require a report• Notifications required• Quality Assurance process for incident review

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼

Findings

Based on record review and interviews, the residence failed to comply with authorized practitioner's orders associated with medication administration, affecting six of nine sample residents (#13, #14, #15, #19, #23, and #27). (Cross-reference U0540) This deficiency was cited previously during a state licensure survey on 11/25/25. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Record ReviewResident #23 was admitted to the residence on 4/30/25 with diagnoses including obesity, parkinsonism, hypertension, vitamin B-12 deficiency and atrial fibrillation. Resident #23 was prescribed medications including Pradaxa. The 1/6/26 practitioner's order for Pradaxa specifically read "Take 1 capsule by mouth every 12 hours to prevent blood clots and strokes."Resident #23 care plan dated 12/22/25 reads in part, "Resident is on blood thinner. Staff are to monitor the resident for shortness of breath, increased fatigue, increased heart palpitations and dizziness." A review of Resident #23's February and March 2026 medication administration records (MARS), revealed that Resident #23 was not given Pradaxa (blood thinner) on 2/5 through 2/6; 2/12 through 2/14 and the evening of 3/22/26 through 3/25/26, for a total of 9 missed doses. It was noted on Resident #23 February and March MARS that the reason Pradaxa was not given was because the medication was unavailable. A progress note dated 3/14/26, written by Staff #13 read in part: (she) spoke with Resident #23 ' s new practitioner to obtain necessary medication refill authorizations and was informed that a clinical re-evaluation is required prior to the issuance of new prescriptions for Schedule II controlled medications. The progress note further read that Resident #23 ' s family will arrange the appointment and staff will follow up. 2. InterviewsOn 3/24/26 at 3:00 p.m., Staff #13 stated that several calls, including one that morning, were placed to Resident #23's new practitioner to request new medication orders. Staff #13 further stated her calls to the practitioner had not been returned for several days. On 3/24/26 at approximately 3:30 p.m., Resident #23's family member stated Resident #23 had an appointment with their new practitioner the day prior and was not aware Resident #23 had run out of their blood thinner medication. Resident #23 ' s family member further stated that had she known Resident #23 was out of this medication, she would have gotten it refilled that day. On 3/24/26 at 3:53 p.m., the administrator stated she would expect orders to be followed; however, was unsure what had occurred with Resident #23's practitioner. On 3/25/26, at approximately 4:45 p.m., an interview was conducted with Resident #23's practitioner who stated "missing dosages of his (Resident #23) blood thinner may lead to adverse reactions, so he would recommend the resident recieve the med as ordered. 3. Similar deficient practice was found for sampled residents #13, #14, #15, #19 and #27.

Plan of correction · submitted by the facility

Per previous plan of correction that was accepted, we stated "For any missing medications there will be documented follow up and these reports will be reviewed weekly for a period of no less than 90 days." This process was followed and documentation was present for all missing medications. The Executive Director and the Wellness Director/Regional Health Services Director are responsible for pulling the missed medication report daily to ensure all medications are being documented when completing a medication pass. For any missing medications there will be documented follow up and these reports will be reviewed weekly for a period of no less than 90 days. MAR to cart audits will be completed monthly by Executive Director and Wellness Director to ensure proper stock of all medications and these audits will be documented and available at monthly QA for a period of no less than 90 days. All QMAPs were trained on the 11/11/25 and 11/13/25 to ensure documentation is available in the chart stating why medication is missing, as well as WD documentation as to why medication is missing and what we have done about it. Our Regional Nurse will be on site every weeks to audit resident files and documentation to ensure proper documentation and follow through of any concerns or missing medications for a period of no less than 90 days. These audits will be documented and reviewed at monthly QA.

3/24/2026Revisit: Licensure Complaint · ID 8UVP13No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 3/26/26 for the previous deficiency cited on 10/21/25. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

11/24/2025Licensure Complaint · ID PZP91113 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO41137, #CO41138, #CO41145 and #CO41156, was completed on 11/25/25. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0540Admin-Dts RespS/S B▼

Findings

Based on record review, observations and interviews, the residence failed to ensure the administrator managed the day-to-day delivery of services, conducted medication audits, followed practitioners ' orders, ensured comprehensive assessments were updated after a change in condition and accurate medication administration record (MAR), affecting 108 current residents. (Cross-reference U1568 and U1604)Findings Include:1. References and Resident AgreementChapter VII regulations governing assisted living residences, part 2.2, defines "Administrator" as a person who is responsible for the overall operation, daily administration, management, and maintenance of the assisted living residence. 2. Record ReviewOn 11/25/25 at approximately 8:00 a.m., quarterly medication audits were requested however not provided. On 11/25/25 a review of Resident #19 ' s record was conducted. Resident #19 presented with a small wound on the left heel which was observed on 11/9/25 and progressed to a larger wound that had noticeable drainage and a cut on 11/15/25. Resident #19 ' s assessment had not been updated after a change in condition. 3. InterviewsOn 11/25/25 at 4:20 p.m., the administrator stated she had not participated in medication audits, she expected the residence to follow the practitioner orders and for all assessments to be updated after a change in condition. The administrator acknowledged that she had not overseen the day to day operations of the residence.

Plan of correction · submitted by the facility

(Cross-reference to POCD for Tag U1568 and U1604)The administrator has documented trainings with WD to ensure proper communication with ED so that proper procedures can be followed. Executive Director will ensure monthly audits are completed with the Wellness Director with doctors orders and MAR for accuracy. A sample of 10 residents will be pulled for monthly QA for a period of no less than 90 days. The ED will be responsible for ensuring assessments are completed timely and thoroughly at admission, at change of condition, and annually. A random sample of 10 residents will be checked monthly for a period of no less than 90 days to ensure proper documentation and procedures are being followed.

0910Em Pr-Pol/Proc Res RstrS/S B▼

Findings

Based on records review, observations, and interviews, the residence failed to maintain and provide a complete and accurate resident roster, room assignment list, and emergency contact information, affecting 108 current residents. (Cross-reference U0540)Findings Include:On 11/24/25 at 7:44 a.m., a resident roster with room numbers and emergency contact information was requested from the administrator via electronic communication. At approximately 8:40 a.m., the administrator provided a census report lacking resident emergency contact information. At approximately 9:00 a.m., a packet of resident face sheets was provided. At 1:55 p.m., the packet failed to include all current residents; specifically, Resident #2 was missing despite being listed on the census. Additional review of room assignments revealed that Resident #17 was residing in a room other than the room listed on the census and face sheets. At approximately 11:15 a.m., observation of Resident #17's room revealed she did not reside in the room, as no personal effects were in the room. At 12:45 p.m., the business office manager (BOM) stated Resident #2 had been marked as discharged early in the electronic record to prevent overbilling. At 1:54 p.m., the health and wellness director (HWD) stated Resident #17 lived in another resident ' s room in the secure environment with family approval. At 4:23 p.m., the administrator agreed that the census and packet of face sheets were inaccurate and did not meet requirements for a readily available resident roster.

Plan of correction · submitted by the facility

(Cross-reference U0540)The correct roster was given to surveyors with emergency contact information in a short amount of time after the original census was provided, unfortunately, it was not sent electronically to document this and I was questioned at the time about the emergency census being provided originally, which it was not, but it was provided. Upon discussion with MMIT Director, Resident #17 has never had many personal belongings, she even has purchased her slippers so she had something to wear on her feet. It is my understanding the families are aware of a personal relationship between #17 and another resident that was ongoing prior to hospitalization. Since return, #17 has not remembered this resident and is sleeping in her own apartment. The administrator has documented trainings with WD to ensure proper communication and procedures can be followed. These audits will be documented and reviewed at monthly QA.

1030Res Ad/D/C-Res Agr Wrt AgrS/S B▼

Findings

Based on records review and interviews, the residence failed to ensure residency agreements were signed, dated, and complete at the time of move-in for two of 14 sample residents (#2, #23). (Cross-reference U0540, U1034, U1326)Findings Include:Resident #23 ' s record contained three conflicting admission dates: 4/30/25, 5/6/25, and 5/10/25. The residency agreement for Resident #23 was incomplete; "Exhibit A - Total Monthly Fee" (Exhibit A), listing the monthly charges, was blank and unsigned by both parties. Similar deficient practice occurred for Resident #2, whose residency agreement was also incomplete. On 11/24/25 at approximately 9:00 a.m., Resident #2 stated that the residence's billing practices lacked transparency and were confusing. He explained that because of the "Care Level" system it is unclear what you are paying for and why. On 11/25/25 at 11:57 a.m., the administrator stated she was unaware the agreements were incomplete and agreed this failed to meet regulatory requirements.

Plan of correction · submitted by the facility

(Cross-reference to POCD for Tags U0540, U1034, U1326)The residency agreements are being reviewed. The two in question were prior to current administrators tenure at the community. Current practice includes an electronic version of the residency agreement that is being sent to the resident and/or A/R guarantor for review and signature prior to move in. All residency agreements are being renewed for anyone that has been here a year or longer and will be completed no later than January 30, 2026. Ongoing, procedure will be documented with a random sample of agreements at our monthly QA for a period of no less than 90 days. The Executive Director is responsible for ensuring all pages on the residency agreement are signed by necessary parties and renewed annually.

1034Res Ad/D/C-Res Agr Anul Rvw/CHOWS/S B▼

Findings

Based on records review and interviews, the residence failed to conduct annual reviews of residency agreements for eight of 14 sample residents (#11, #13–#19). (Cross-reference U0540, U1030)Findings Include:A review of residency agreements for Residents #11 and #13–#19 revealed each agreement was older than one year from its execution date and had not been reviewed or amended. On 11/25/25 at 11:58 a.m., the administrator stated she was aware of the annual review requirement and agreed the agreements were out of date and not compliant.

Plan of correction · submitted by the facility

(Cross-reference U0540, U1030)The residency agreements are being investigated. The two in question were prior to current administrators tenure at the community. Current practice includes an electronic version of the residency agreement that is being sent to the resident and/or A/R guarantor for review and signature prior to move in, and annually at anniversary date. All residency agreements are being renewed for anyone that has been here a year or longer and will be completed no later than January 30 2026. Ongoing, this procedure will be documented with a random sample of agreements at our monthly QA for a period of no less than 90 days. The Executive Director is responsible for ensuring all pages on the residency agreement are signed by necessary parties and renewed annually.

1146Res Care Srvs-Comp Res Asmnt Annl/Chng BslnS/S B▼

Findings

Based on interviews and record review, the residence failed to update a comprehensive assessment whenever a resident's condition changed from baseline status, affecting two of two residents sample residents who experienced a change from their baseline. (#19 and #21) Findings Include:The residence ' s change of condition policy dated 3/2024 read in pertinent part, any change in the residents condition shall be reported to the wellness director. The wellness director will revise the residents assessment to reflect the corresponding condition changes. Resident #x was admitted to the residence on 3/1/23 with a diagnosis of arthritis, Chronic Pain, Depression, and amputation of the right foot. A progress note dated 11/9/25, read in part Resident #19 ' s left heel is cracking, and there is an open sore. A progress note dated 11/15/25, read in part Resident #19 had drainage noted on the sock she was wearing last night and in her shoe as well. Care staff member on the floor at this time informed me that the wound had gotten much larger from the first time the caregiver had noticed it. States it was about the size of a dime with a split/cut in the middle but was not bleeding or draining at that time. Dressing was applied to the area as precaution. The resident's daughter took the resident to the ER.An inpatient podiatry note dated 11/16/25 read in part, Resident #19 presented to the hospital with a wound to her left heel, present for approximately 4 weeks without treatment. On 11/25/25 p.m., the administrator stated she was not aware of Resident #19 ' s wound and had expected the wound to have been noted on the residents assessment for the initiation of a new care plan.

Plan of correction · submitted by the facility

Staff did report to the Wellness Coordinator on 11/9/2025, and WC followed up, however, did not document. At the time we did not have an appointed WD and ED should have been notified. Process was discussed and documented with newly appointed WD that upon discovery of the cracked skin given the residents' history, home health should have been notified to return as they were providing wound care on same resident up until the 3rd week of October for a LLL wound. Once home health was on board, the care plan should have been updated to reflect new services. Meeting was had with home health agency ensuring our expectations are being followed while they are providing services in our community. While we have been having the care staff complete skin checks, which is how this was originally discovered. Our Regional Nurse will be on site every two weeks to audit resident files and skin check documentation to ensure proper documentation and follow through of any concerns, including additional services and adjustment to care plans, as needed, for a period of no less than 90 days. These audits will be documented and reviewed at monthly QA. The Wellness Director will be responsible for ensuring documentation, additional care services, and care planning on all changes ongoing.

1324Res Rghts Rts/Rspn-Civ/Rel-NeglectS/S C▼

Findings

Based on observation, record review and interview, the residence failed to ensure the residents were free from neglect affecting one sample resident (#19). (Cross-reference U0540 & U1146)Specifically, Resident #19 presented with a small wound on the left heel which was observed on 11/9/25 and progressed to a larger wound that had noticeable drainage and a cut on 11/15/25. Resident #19 ' s care plan and assessment had not been updated and the progressing wound had not been addressed until Resident #19's family member took the resident to the emergency room and was inpatient for approximately 10 days. An inpatient podiatry note stated the wound had progressed and had not been treated for four weeks. Findings Include:1. Record reviewThe residence ' s change of condition policy dated 3/2024 read in pertinent part, any change in the residents condition shall be reported to the wellness director. The wellness director will revise the residents assessment to reflect the corresponding condition changes. Resident #x was admitted to the residence on 3/1/23 with a diagnosis of arthritis, Chronic Pain, Depression, and amputation of the right foot. A progress note dated 11/9/25, read in part Resident #19 ' s left heel was cracking, and there was an open sore. A progress note dated 11/15/25, read in part Resident #19 had drainage noted on the sock she was wearing last night and in her shoe as well. A care staff member on the floor at this time informed me that the wound had gotten much larger from the first time the caregiver had noticed it. States it was about the size of a dime with a split/cut in the middle but was not bleeding or draining at that time. Dressing was applied to the area as precaution. The resident's daughter took the resident to the ER.An inpatient podiatry note dated 11/16/25 read in part, Resident #19 presented to the hospital with a wound to her left heel, present for approximately 4 weeks without treatment. 2. InterviewsOn 11/25/25 p.m., the administrator stated she was not aware of Resident #19 ' s wound and had expected the wound to have been noted on the residents assessment for the initiation of a new care plan. The administrator agreed Resident #19 ' s wound had been neglected and progressed due to the lack of care.

Plan of correction · submitted by the facility

(Cross-reference U0540 & U1146)Staff did report to the Wellness Coordinator on 11/9/2025, and WC followed up, however, did not document. At the time we did not have an appointed WD and ED should have been notified. Process was discussed and documented with newly appointed WD that upon discovery of the cracked skin given the residents' history, home health should have been notified to return as they were providing wound care on same resident up until the 3rd week of October for a LLL wound. Once home health was on board, the care plan should have been updated to reflect new services. Meeting was had with home health agency ensuring our expectations are being followed while they are providing services in our community. We have been having the care staff complete skin checks, which is how this was originally discovered. Our Regional Nurse will be on site every two weeks audit resident files and skin check documentation to ensure proper documentation and follow through of any concerns, including additional services and adjustment to care plans, as needed, for a period of no less than 90 days. These audits will be documented and reviewed at monthly QA. The Wellness Director will be responsible for ensuring documentation, additional care services, and care planning on all changes ongoing.

1326Res Rghts Rts/Rspn-Civ/Rel-ExpltS/S B▼

Findings

Based on records review and interviews, the residence failed to protect the resident ' s right to live free from financial exploitation by charging fees and service rates that were not assessed or agreed to in the residency agreement, resulting in six months of unauthorized charges for one of 14 sample residents (#23). (Cross-reference U0540, U1030, U1400)Findings Include:Resident #23 ' s record contained three conflicting admission dates: 4/30/25, 5/6/25, and 5/10/25. The residency agreement was incomplete; "Exhibit A - Total Monthly Fee" (Exhibit A), listing the monthly charges, was blank and unsigned by both parties. The agreement stated that the "Community Fee" costs must be assessed and listed on Exhibit A; however, no such documentation was provided. Additionally, "Exhibit G - Care Level Pricing" indicated "Care Level 2" requires an assessment of 501–1,000 points A review of the assessments provided for Resident #23, including the "Pre-move-in assessment" (4/28/25), the "30-day assessment" (6/11/25), and the "Change in Condition: Re-assessment" (9/8/25), all indicate a score lower than 100 points. No evidence was provided to support the need for "Care Level 2" services. No documentation or signed acknowledgement was provided to justify the billed care level. A review of the billing statements from June 1, 2025, to December 1, 2025, sent to the financially responsible party of Resident #23 revealed a "Community Fee" of $3,150, a one-time charge made on April 30, 2025. Additionally, a $609.68 "Care Level 2" pro-rated monthly charge from 5/5/25 to 5/30/25 and a $700 "Care Level 2" monthly charge from 6/1/25 to 11/30/25. The 12/1/25 invoice reflected the September "Change in Condition: Re-assessment" of "Care Level 0" while still charging $23.33 in "Care Level 2" for the period of 9/1/25 to 9/2/25. On 11/25/25 at 8:25 p.m., the administrator provided email communications between the financially responsible representative for Resident #23 (FRRR#23). These email communications occurred from 6/5/25 to 11/12/25 and included the administrator, the current and former business office manager (BOM), the former health and wellness director (HWD), as well as the regional operations specialist (ROS), divisional vice president of operations (DVPO), and regional director of clinical services (RDCS) from the corporate owner of the residence. On 11/25/25 at 12:00 p.m., the administrator acknowledged that Exhibit A was incomplete and that no documentation supported the "Community Fee". She agreed that no documentation supported the "Care Level 2" charges, and Resident #23 ' s assessments did not support the billed care level. The administrator agreed that the residence agreed to reimburse for overcharges, and she agreed that the invoices provided did not show any reimbursement. The administrator stated she did not believe the situation constituted financial exploitation because "I'm saying no because it will be refunded 100%".

Plan of correction · submitted by the facility

(Cross-reference U0540, U1030, U1400)Admission assessment was 812.50 points for care level 2, 30 day was 812.5 points for care level 2. Resident then subsequently had 2 falls in the period of time daughter was requesting decreased supervision. Wellness did not communicate at that time that we would not decrease due to this issue. Resident should have then been reassessed mid to late July for change as he did go 30 days without incident. Upon contact to the ED immediately set up care conference and changes to the assessment and care plan were documented on 9/8/25 which point assessed were now 15.00. At the time of the reassessment we did not have a business office manager in house, the position was being handled remotely, and a new business office manager was onboarded 9/29/25. This business office manager has since been discharged given the lack of urgency in the department. The correct care level, as discussed was updated and a full refund has been issued dating back to 6/1/2025. Moving forward, we will follow our policy and the WD and ED will determine when a change of condition assessment is needed based on staff communication, incident reports. We will ensure communication to family members is thorough and documented in progress notes as part of the chart. Weekly, a meeting will be had with the business office manager, interim or permanent, and this meeting will be documented for a period of no less than 90 days to ensure changes and correct charges are appropriated in our billing. The executive director will be responsible for accurate charges monthly.

1400Res Rghts-Intrnl Griev/Compl Res PrS/S B▼

Findings

Based on records review and interviews, the residence failed to promptly address a complaint filed by the financially responsible representative of Resident #23, affecting one of 14 sample residents. (Cross-reference U0540, U1326)Findings include:On 11/25/25 at 8:25 p.m., the administrator provided email communications between the financially responsible representative and the administrative staff of the residence and executives from the corporate owner from 6/5/25 to 11/12/25. The communications showed the facility became aware of the disputed charges in June 2025, but no billing changes occurred until September 2025. The facility agreed to reimburse Care Level 2 charges assessed from June through September; however, a review of billing invoices from 6/1/25 to 12/1/25 did not show any documented reimbursement. On 11/25/25 at 12:02 p.m., the administrator stated that prior administrative staff did not implement the internal grievance process effectively and agreed that the response was not prompt.

Plan of correction · submitted by the facility

(Cross-reference to POCDs for Tags U0540, U1326)Staff was trained and it was documented on our grievance procedure dated 11/5/2025 this included all department leaders. The WD in this situation is no longer employed with our company. Any grievance, compliment or concern is to be documented in our grievance log by the Executive Director with a follow up, by whom, and check for documentation in the residents chart. The grievance log will be checked monthly at QA for a period of no less than 90 days

1530Med/Med Adm-Gen Rq Pract OrdrS/S A▼

Findings

Based on record review and interview, the residence failed to prepare and administer medication that had been ordered by an authorized practitioner, affecting one of 14 sample residents (#13). (Cross-reference U0540, U1568, U1600, & U1604) 1. Resident #13 was admitted to the residence on 3/1/23 with diagnoses including congestive heart failure. On 11/24/25, at 9:46 a.m., Resident #13 ' s practitioner ' s order was requested from the residence and not provided. On 11/25/25, at 8:16 a.m., Resident #13 ' s practitioner ' s order was requested from the residence again and not provided. The November 2025 medication administration directed the residence to administer four grams of diclofenac gel 1% four times daily, 5mg of eliquis twice daily, 20mg of furosemide once daily, 100mg of losartan once daily, 1000mg of metformin twice daily, 200mg of extended-release metoprolol succinate, 8.6mg of senna every other day, 25mg of spironolactone once daily, 0.4mg of tamsulosin once daily, and 50mcg of vitamin D3 once daily to Resident #13. On 12/1/25, at approximately 1:35 p.m., practitioner ' s orders for Resident #13 was requested from the administrator again and not provided. The residence was informed by the survey team that not having written, signed, and dated practitioners' orders for all medications administered to Resident #13 was non-complaint with Chapter 7, 14.11.

Plan of correction · submitted by the facility

(Cross-reference POCD text to tags U0540, U1568, U1600, & U1604)This resident received services from the VA Hospital in Aurora. We are changing this resident to an in house provider to be more able to obtain the information we need to ensure proper care is being given. Daily Medication Administration reports are also completed by the Executive Director and Wellness Director and counseling of staff when there are issues. Our Regional Nurse will be on site every two weeks to audit resident files, including all physician orders, to ensure proper documentation and follow through of any concerns, for a period of no less than 90 days. These audits will be documented and reviewed at monthly QA.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼

Findings

Based on record review and interviews, the residence failed to comply with authorized practitioner ' s orders associated with medication administration, affecting four of 14 sample residents (#13, #14, #15, #19). (Cross-reference U0540, U1530, U1600, & U1604)Findings include:1. Record ReviewResident #19 was admitted to the residence on 3/1/23 with a diagnosis including arthritis and chronic pain.a. Oxycontin 30mg ERA written practitioner's order, dated 7/17/25, directed the residence to administer oxycontin 30mg ER tablet by mouth twice a day for chronic pain. The November 2025 Medication Administration Record (MAR) displayed an "11 code" that indicated the medication was missing and not administered to Resident #19 on 11/5/25 for the scheduled evening dose, and on 11/7/25 for the scheduled morning dose.b. Hydromorphone 2mgA written practitioner ' s order dated 8/25/25 directed the residence to administer hydromorphone 2mg tablet by mouth three times a day. The November 2025 MAR displayed an "11 code" that indicated the medication was missing and not administered to Resident #19 on 11/5/25 for the scheduled evening dose, 11/6/25 for the scheduled morning, midday, and evening dose, and 11/7/25 for the scheduled morning dose. 2. InterviewsOn 11/24/25, at approximately 1:45 p.m., the wellness director confirmed that an "11 code" on a resident MAR indicated the medication was missing and not administered to the resident during the scheduled time. The wellness director stated that multiple residents showing an "11 code" on their November 2025 MAR was due to discrepancies with the residence ' s pharmacy. The wellness director acknowledged that the residence ' s failure to provide medication to a resident per the practitioner ' s order was non-compliant with Chapter 7, 14.21. On 11/24/25, at approximately 4:23 p.m., the administrator stated that it was the responsibility of the wellness director and herself for ensuring all resident ' s authorized practitioner ' s orders associated with medication administration are followed when the residence staff administered those medications. The administrator stated she was unaware that there were several "11 codes" that indicated Resident #13, #14,#15, and Resident #19 had not received medication per the practitioner ' s order on their November 2025 MAR. The administrator acknowledged that this was non-compliant with Chapter 7, 14.21. On 11/25/25 at approximately 11:45 a.m., both the wellness director and the administrator acknowledged that it was the residence ' s expectation to provide Resident #19 with the medication prescribed by the practitioner. The wellness director and administrator further acknowledged that medication for Resident #19 was not administered because it was not available on 11/5-11/7/25.3. Evidence obtained during the onsite visit revealed the residence additionally failed to comply with practitioner ' s orders for Resident #13, #14, and #15.

Plan of correction · submitted by the facility

(Cross-reference U0540, U1530, U1600, & U1604)Documented training of all QMAPS was provided 11/11/25 and 11/13/25 to re-train on proper documentation of medication passes. The Executive Director and the Wellness Director are responsible for pulling the missed medication report daily to ensure all medications are being documented when completing a medication pass. For any missing medications there will be documented follow up and these reports will be reviewed weekly for a period of no less than 90 days. MAR to cart audits will be completed monthly by Executive Director and Wellness Director to ensure proper stock of all medications and these audits will be documented and available at monthly QA for a period of no less than 90 days. Resident #11, not #19, is required to attend her pain clinic appointments for refill of medications. Resident missed her appointment on 11/4/25 for the 11/5 refill and did not see her clinic until the 6th when medication was prescribed and delivered on the 7th and administration resumed. All QMAPs were trained on the 11/11/25 and 11/13/25 to ensure documentation is available in the chart stating why medication is missing, as well as WD documentation as to why medication is missing and what we have done about it. Our Regional Nurse will be on site every two weeks to audit resident files and documentation to ensure proper documentation and follow through of any concerns or missing medications for a period of no less than 90 days. These audits will be documented and reviewed at monthly QA.

1600Med/Med Adm-Rcrd Kpng MARS/S B▼

Findings

Based on interview and record review, the residence failed to ensure all prescribed and PRN (as needed) medication was listed on a medication administration record (MAR) and that the resident's medication administration record (MAR) contained accurate information, affecting three of 14 sample residents (#13, #14, #15). (Cross-reference U0540, U1530, U1568, & U1604)Findings include:1. Record ReviewResident #13 was admitted to the residence on 3/1/23 with diagnoses including congestive heart failure.a. Furosemide 20mgThe November 2025 medication administration record (MAR) for Resident #13 directed the residence to administer Furosemide 20mg by mouth daily. On 11/18/25 and 11/23/25, the MAR for Resident #13 was left blank,.b. Diclofenac Gel 1%The November 2025 MAR for Resident #13 directed the residence to administer four grams of Diclofenac gel 1% topically four times a day for joint pain. On 11/18/25, all four scheduled medication administration records were left blank, and on 11/23/25, the scheduled midday medication administration record was blank. On 11/24/25, at approximately 1:45 p.m., the wellness director confirmed that the blanks on Resident #13 ' s November 2025 MAR indicated medication administration was not properly documented or administered by residence staff. The wellness director stated that residents have not properly received medications in the past due to discrepancies with the residences ' preferred pharmacy. The wellness director went on to state documentation of correspondence with the residence pharmacy regarding discrepancies was also not performed by residence staff. The wellness director acknowledged that failure to ensure all resident medication administration records contained accurate information was non-compliant with Chapter 7, 14.29. On 11/24/25, at approximately 4:23 p.m., the administrator stated that it was the responsibility of the wellness director and herself for ensuring all resident MAR ' s contained accurate information. The administrator stated she was unaware that there were several blanks on Resident #13, #14, and #15 ' s November 2025 MAR ' s. The administrator acknowledged that failure to ensure all resident MAR ' s contained accurate information was non-compliant with Chapter 7, 14.29.3. Evidence obtained during the onsite visit revealed the residence additionally failed to ensure medication administration records contained accurate information for Resident #14 and Resident #15.

Plan of correction · submitted by the facility

(Cross-reference U0540, U1530, U1568, & U1604)Documented training of all QMAPS was provided 11/11/25 and 11/13/25 to re-train on proper documentation of medication passes. The Executive Director and the Wellness Director are responsible for pulling the missed medication report daily to ensure all medications are being documented when completing a medication pass. For any missing medications there will be documented follow up and these reports will be reviewed weekly for a period of no less than 90 days. MAR to cart audits will be completed monthly by Executive Director and Wellness Director to ensure proper stock of all medications. Our Regional Nurse will be on site every 2 weeks and will audit medication passes and documentation to ensure proper documentation and follow through of any concerns, for a period of no less than 90 days. These audits will be documented and reviewed at monthly QA.

1604Med/Med Adm-Rcrd Kpng Qrtly AuditS/S B▼

Findings

Based on interview and record review, the residence failed to provide quarterly basis audits ensuring accuracy, complete medication administration records, controlled substance lists, medication error reports and medication disposal records, affecting all 14 sample residents. (Cross-reference U0540, U1530, U1568, & U1600)Findings Include:On 11/24/25, at 7:44 a.m., during the onsite visit, quarterly medication audits were requested from the administrator, however, none were provided. On 11/24/25, at approximately 9:15 a.m., quarterly medication audits were requested from the administrator again, however, none were provided. On 11/25/25 at approximately 11:45 a.m., the administrator stated that she reviewed all resident medications on a weekly basis, but could not provide documentation of these medication reviews. The administrator went on to state that quarterly medication audits were not being done by herself or residence staff, that she believed it should be done, however, she was unsure that it would be done by residence staff. The administrator acknowledged that failure to audit the accuracy and completeness of medication administration records, controlled substance lists, medication error reports, and medication disposal records on a quarterly basis, and document these audits was non-compliant with Chapter 7, 14.31.

Plan of correction · submitted by the facility

(Cross-reference U0540, U1530, U1568, & U1600)Medication audits will be completed monthly by the Executive Director and Wellness Director for a period of no less than 90 days with the audits being available. Daily Medication Administration reports are also completed by the Executive Director and Wellness Director and counseling of staff when there are issues. Beginning in January, our community is also changing pharmacy providers to enable access to a 7 day a week provider to decrease missed medications when there are changes or we need orders stat. Our Regional Nurse will also be on site every 2 weeks to audit resident files, medication including medication passes and check documentation to ensure proper documentation and follow through of any concerns, for a period of no less than 90 days. These audits will be documented and reviewed at monthly QA.

2222HIR-Cnfd/Ac F/S LawS/S B▼

Findings

Based on observations and interviews, the residence failed to protect the confidentiality of the residents' records, affecting 108 current residents. (Cross-reference U0540)Findings Include:On 11/24/25 at 8:08 a.m., an environmental tour revealed an unlocked storage closet on the third floor, accessible to anyone with access to the residence. The closet contained multiple boxes of residents' protected health information (PHI) and protected personnel files. The closet is in a high traffic halway, multiple people were observed walking past the closet. On 11/25/25 at 12:03 p.m., the administrator agreed the closet should have been locked and acknowledged the violation of confidentiality requirements.

Plan of correction · submitted by the facility

(Cross-reference U0540)The storage door in question lock has been changed so the only staff with access in maintenance and administration. All doors are being monitored daily through Executive Director and Maintenance rounds, those records are available. These audits will be documented and reviewed at monthly QA.

9999Final ObservationsSurveyor note▼

Findings

THIS PORTION OF THE REPORT IS FOR INFORMATIONAL PURPOSES ONLY. No response is necessary. The residence was advised that it must review and maintain the following processes in accordance with existing program regulations found at 6 CCR 1011-1, Chapter 7.(U1312) 13.12 The assisted living residence shall develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin. Such policies and procedures shall include, but not be limited to, the following requirements:(A) The assisted living residence shall identify and document resident injuries for which the origin of the injury was not observed by or otherwise known by staff, and either:(1) The resident cannot explain how the injury occurred; or(2) The resident can explain the source of the injury, but the source could be addressed to prevent future injuries.(B) The assisted living residence shall document the following:(1) The investigation and identification of any injury identified in (A), above.(2) The implementation and outcome of the following for injuries for which the investigation determines the source/origin:(a) Compliance with Part 13.11, when the source/origin of the injury is suspected to be abuse, neglect, or exploitation; or(b) The steps taken to prevent or mitigate future injuries of like nature for both the injured resident and other residents when the source/origin of the injury is not suspected abuse, neglect, or exploitation. Such steps may include, but not be limited to:(i) Staff or volunteer corrective action and/or additional training; or(ii) Modification of the assisted living residence ' s policies, procedures or physical environment.(3) When the source of the injury remains undetermined, the steps taken to monitor the resident in an effort identify and prevent similar injuries.(C) All documentation of the investigation, outcomes, and steps taken shall be retained by the assisted living residence, including, but not limited to, details of any interviews and/or records used in the investigation. Such documentation shall be made available for review at the Department ' s request.(1) Documentation on the investigation, outcomes, and steps taken may be maintained separately from the resident record, in which case a summary of the investigation and steps taken shall be included in the resident ' s care plan and progress notes.(D) The assisted living residence shall notify the resident ' s representative of the outcome of the investigation and steps taken.

Plan of correction

The state did not require a plan of correction for this citation.

10/21/2025Revisit: Licensure Complaint · ID 8UVP121 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 10/21/25 for the previous deficiency cited on 8/20/25. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

1110Res Care Srvs-Min Srvs Res AgrS/S B▼

Findings

Based on observation and interview, the residence failed to provide a physically safe environment, including measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting 107 current residents. This deficiency was cited previously during a state licensure survey on 8/20/25. Although the facility corrected the deficiency, based on the findings below, the facility has not maintained compliance with this regulatory requirement. Findings include:1. ObservationOn 10/21/25 from 7:30 a.m. to 2:30 p.m., an environmental tour of the residence revealed the following:In the apartment of Resident #9, two oxygen cylinders were lying on their side and not stored upright. In the apartment of Resident #10, approximately 19 oxygen cylinders were in various locations of the living room, one was lying on its side and none were stored in cradles. In the medication room of the third floor, six oxygen cylinders were on the floor and not stored in cradles. 2. InterviewOn 10/21/25 at 2:45 p.m., the administrator stated she preferred oxygen cylinders to be stored outside of resident rooms, or at least in a cart or cradle if stored inside the rooms to prevent the cylinders from falling over. The administrator stated cylinders at risk of falling over or lying on their sides were unsafe if they were damaged by improper storage methods. The administrator stated the deficiency was not corrected from the previous survey because maintenance had not followed the plan to store the tanks outside of resident rooms or at least in crates or cradles.

Plan of correction · submitted by the facility

On October 29, 2025 a company came to the community to remove all of their miscellaneous cylinders that were throughout the community and not stored correctly. On October 24th and 27th numerous oxygen storage cradles were ordered/delivered to the community and the Wellness Director was responsible for room to room inspection of residents with oxygen and get all of the oxygen stored properly in the crates. Cylinders will remain in individual apartments in o2 crates so they are stableAll current staff educated about this deficiency 11.11.25 and 11.13.25 and this was documented with staff signatures. Weekly, for a period of no less than 90 days the wellness director/or designee will be responsible for inspecting all resident apartments that are prescribed oxygen, to ensure this practice is followed moving forward. This checklist will be discussed and verified by the executive director at QA meeting monthly.

10/21/2025Licensure Complaint · ID E5XG113 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO41027, was completed on 10/21/25. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

1110Res Care Srvs-Min Srvs Res AgrS/S B▼

Findings

Based on observation and interview, the residence failed to provide a physically safe environment, including measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population, affecting 107 current residents. Findings include:1. ObservationOn 10/21/25 from 7:30 a.m. to 2:30 p.m., an environmental tour of the residence revealed the following:In the apartment of Resident #9, two oxygen cylinders were lying on their side and not stored upright. In the apartment of Resident #10, approximately 19 oxygen cylinders were in various locations of the living room, one was lying on its side and none were stored in cradles. In the medication room of the third floor, six oxygen cylinders were on the floor and not stored in cradles. 2. InterviewOn 10/21/25 at 2:45 p.m., the administrator stated she preferred oxygen cylinders to be stored outside of resident rooms, or at least in a cart or cradle if stored inside the rooms to prevent the cylinders from falling over. The administrator stated cylinders at risk of falling over or lying on their sides were unsafe if they were damaged by improper storage methods.

Plan of correction · submitted by the facility

On October 29, 2025 Apria came to the community to remove all of their miscellaneous cylinders that were throughout the community and not stored correctly. On October 24th and 27th numerous oxygen storage cradles were ordered/delivered to the community and the Wellness Director was responsible for room to room inspection of residents with oxygen and get all of the oxygen stored properly in the crates. Future oxygen cylinders be stored in Individual apartments in 02 crates so they are stable. All staff meeting was held on 11.11.25/11.13.25 and staff signatures were obtained. Weekly, for a period of no less than 90 days the wellness director/or designee will be responsible for inspecting all resident apartments that are prescribed oxygen, to ensure this practice is followed moving forward. This checklist will be discussed and verified by the executive director at QA meeting monthly.

2620In Env-H/L/VentS/S B▼

Findings

Based on observations, record review and interviews the residence failed to heat sufficiently to meet the needs of the residents, affecting four of ten (#2, #4, #6 and #7) sample residents. (Cross reference U2690)Findings include:1. Observation and interviewOn 10/21/25 at 8:54 a.m., Resident #4 said her apartment was cold, there was no heat and her thermostat was not working and displayed only a blank screen. A thermostat located on the wall of the apartment failed to turn on when the power button was pushed and the screen was blank. On 10/21/25 at 9:30 a.m., Resident #7 said her apartment was cold and her thermostat was not working. The thermostat revealed a temperature of 68 degrees. Resident #7 said she had adjusted the thermostat for a higher temperature but the vents had not produced heat and the temperature continued to read 68 degrees F. 2. Record reviewAn electronic correspondence, dated 9/17/25, from a heating, ventilation and air conditioning (HVAC) company to the administrator of the residence read: "There are components on each system that will need to be replaced. We will conduct a diagnoses, and repair small items as possible, and anything that may take more than 1 day to repair I will send you estimates on, ok? If we can start this process this Friday we will try, but I have our technician scheduled for a few days starting Monday, 9/29."An electronic correspondence, dated 9/21/25, from an HVAC company read in part:Units 340-345 have no refrigerant in the system, the system was leaking. We can fill the system with refrigerant to get it working ASAP, but there is no guarantee of how long this will last, depending upon the size of the leak. The preferable action was to pressurize the system, find the leak(s), repair them, and fill it. Unit 238 (this system covers units 237-249) The reversing valve was out of order and needed to be replaced. Our technician spent the day recovering refrigerant, removing the reversing valve, and picking up a new one. The goal was to replace this valve and today, and pressure test the system overnight. If it leaks this could turn into a longer delay. Unit 111 we have been able to diagnose yet. 3. InterviewsOn 10/21/25 at 7:30 am., Resident #2 said there had been issues with the HVAC system for at least seven months and currently the heating was not working. Resident #2 said the residence was not doing anything to provide him with extra warmth. On 10/21/25 at 8:00 a.m., the maintenance director (MD) said he started with the residence the day before the onsite investigation (10/20/25), and was made aware of heating issues from the HVAC company servicing the building. The MD said resident apartments are staying between 65 - 70 degrees F, but was not keeping any temperature logs. The MD said he was not aware of any accommodations being provided to residents who expressed dissatisfaction with apartment temperatures. On 10/21/25 at 8:54 a.m., Resident #4 said the heat in her apartment had not worked for weeks and that she was always cold in the mornings. Resident #4 said HVAC people were in her apartment on 10/20/25 to look at the heating vent and thermostat but nothing was fixed. Resident #4 said the residence had not offered anything to provide for warmth. On 10/21/25 at 9:05 a.m., Resident #7 said her room had been cooler than she liked for several days. Resident #7 said the temperature in her apartment had not been working correctly for several months. Resident #7 said the residence had provided a small space heater that she did not use but had not offered anything else to accommodate the lack of heat. Resident #7 said people were always working on the HVAC system but nothing had been fixed. On 10/21/25 at 9:16 a.m., a family member of Resident #6 said he [Resident #6] had complained of his apartment being cold on several occasions, specifically in the mornings and most recently the morning of 10/18/25. The family member of Resident #6 said the residence had provided aspace heater to Resident #6. The family member said the residence had offered no other resolutions and they were only told that it was being worked on by staff. Family of Resident #6 did not have specific staff names. On 10/21/25 at 9:45 a.m. Staff #3 said Resident's #4, #6 and #7 had complained of their apartment's being cold, specifically in the mornings. Staff #3 said the HVAC system had not been working properly since July or August 2025, when resident rooms and hallways were too hot. Staff #3 stated now that the weather was getting cooler the residence discovered the heating was not working properly either. Staff #3 stated the residence was working with an HVAC company but Staff #3 was unaware of specifics. Staff #3 said she was not aware of what was being done by the residence to accommodate residents with warmth while the HVAC system was being worked on. On 10/21/25 at 10:00 a.m., the administrator said she became aware of heating issues three weeks ago when residents complained of apartments being cold. The administrator said there were issues with the HVAC system in the summer months with cooling and now that the weather was cooler there were issues with heating elements as well. The administrator said the residence was currently working with an HVAC company to fix the issues and she was aware residents were unhappy with the apartment temperatures being too cold. On 10/21/25 at 1:00 p.m., Staff #4 said multiple residents complained about their apartment being cold. Staff #4 said she informed residents the heating was being worked on but offered no other resolutions for warmth. On 10/21/25 at 1:05 Staff #1 said she was aware of resident dissatisfaction with heat not working in some apartments. Staff #1 said she was not aware of anything being offered to the residents for extra warmth. On 10/21/25 at 2:16 the administrator said residents had been offered room changes or to use the respite room if they expressed dissatisfaction with heating issues in their apartments or offered blankets.

Plan of correction · submitted by the facility

(Cross reference POC to Tag U2690)As of 10/31/2025, there was a change completed in HVAC companies anticipating a greater sense of urgency. To date, system has been fully charged on 3rd floor allowing for heat in resident apartments. However, the thermostats are not fully operational for residents control. 2nd floor heat will be operational end of week 11/13/25, again, the thermostats will not be fully operational. There are clusters on 2nd and 3rd floor of apartments still out while awaiting sensors to be replaced. This replacement will enable control of the thermostats in these clusters that are not working. Residents apartments with reports of no heat are being measured daily by the Facilities Manager and documented. Residents that feel it is too cold are being offered a move to other apartments, this information has been disclosed since the issue came to my attention and I do have documentation that families are aware of that communication, as well. The community has removed all space heaters and disposed of them so they are no longer accessible in the community. Room inspections will be completed weekly for a period of no less than 90 days by the facilities manager ensuring there are no prohibited items in resident apartments including space heaters. This information will be discussed at monthly QA to ensure compliance. Also, on 11/5/2025 on the spot staff training is being conducted regarding our grievance procedure and the necessity of all staff reporting complaints and/or concerns to their supervisor whether they feel we are aware of the issue or not. Facilities Management is controlling the heat temperate. What is the current temperature the new HVAC heating system is being kept at? It is not a new system, maximum temp is 85, lowest is 64. What current rooms or clusters areas are not working? 334-356Addendum:Tentatively completed 11/28/25 for all repairs, unless we find more issue and delays in ordersTwi current residents have moved rooms, 1 slept in respite apartment until heat was fixed, one has moved permanently to another apartment. Weekly room inspections being documented on a temperature log, kept in state binder.

2690In Env-Heat Dvcs Port HeatS/S B▼

Findings

Based on observation and interview, the residence failed to prohibit the use of portable heaters in resident rooms, affecting two (#6 and #7) of 10 sample residents. (Cross reference U2620)Findings include:1. Observation and interviewOn 10/21/25 at 9:05 a.m., Resident #7 said the residence had provided a small space heater (date unknown) while the heating, ventilation and air conditioning (HVAC) system was being repaired. A small space heater was located in the bedroom of the apartment. On 10/21/25 at 9:16 a.m., a family member of Resident #6 said the residence had provided a space heater (date unknown) to Resident #6 while the HVAC system was being repaired. Upon entering the apartment of Resident #6 a space heater was located in the bedroom. 2. InterviewOn 10/21/25 at 2:47 p.m., the administrator said the use of space heaters in resident apartments was prohibited and a fire hazard.

Plan of correction · submitted by the facility

(Cross reference U2620)The community has removed all space heaters and disposed of them so they are no longer accessible in the community. All staff meeting agenda, documented by signatures on 11/11/25, 11/13/25. All current residents informed on regulation about space heaters during a town hall. Individual residents were notified and families were notified via email. Room inspections will be completed weekly for a period of no less than 90 days by the facilities manager ensuring there are no prohibited items in resident apartments including space heaters.

8/20/2025Licensure Complaint · ID 8UVP111 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO40756, was completed on 8/20/25. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

1110Res Care Srvs-Min Srvs Res AgrS/S B▼

Findings

Based on observations, record reviews, and interviews, the residence failed to provide a physically safe and sanitary environment, affecting 107 current residents. Findings Include:1. ObservationsAn environmental tour of the residence on 8/20/25 from 10:00 to 10:45 a.m. revealed wasp nests above the main doors, bird nests on the roof and overhangs, and bird droppings accumulating on resident chairs and windows. Furthermore, there were missing and damaged window screens, a discarded and disassembled washer, broken pallets, and wooden boards. Additionally, two discarded propane tanks and a mattress were located near a shed that contained oxygen canisters, which were not secured in cradles. Sidewalks with rocks next to them had drop-offs of more than five inches. Resident #1's room contained five green oxygen tanks that were also improperly stored. Furthermore, a door had been propped open with a rock, and the air conditioning system is not functioning adequately in several areas of the residence. 2. InterviewsOn 8/20/25 at approximately 10:00 a.m., Resident #3 reported that the portable air conditioning (AC) unit does not work. She added that she has had been using an extra fan to cool off her apartment and circulate the air. During the interview, Resident #3 requested to prop her door open to improve air circulation in her apartment. On 8/20/25 at approximately 1:45 p.m., Resident #4 reported that the portable AC unit does not work. She mentioned that her apartment is either too hot or too cold. She stated that she had brought this issue to the administrator several times and is waiting for a resolution. On 8/20/25 at 3:10 p.m., the administrator's designee stated that he was unaware of many of the issues but acknowledged that the wasp nests were a problem that would need to be addressed, along with the bird droppings and pigeon nesting.

Plan of correction · submitted by the facility

As of 9/5/2025, the external storage areas have been decluttered with the washer, pallets, wooden board and propane tanks removed. The window screens are being repaired and/or replace with a completion date of 9/28/2025. A/C work provided by Compass Mechanical will continue until system is up an running 100%.There will be weekly grounds walks by the facilities manager for a period of no less than 90 days to ensure the area remains clean and safe. This walk and documentation will be part of the QAPI process monthly to verify, for no less than 3 months. During the grounds walks expected by the facilities manager weekly, it will be ensured that all screens on windows will continue to be in good condition and not removed for a period of no less than 90 days. This walk and documentation will be part of the QAPI process monthly to verify for a period no less than 3 months. Continued efforts will be ongoing to ensure permanent removal of bird infestation and wasps nests. While this is happening the grounds will remain clean and verified on the grounds walk required by Facilities Manager weekly for a period of no less than 90 days. Documentation will be part of the QAPI process for no less than 3 months. Staff will be educated on proper a/c operation to more be able to assist the residents in their apartments as needed. This education will be documented in QAPI and the community will continue to offer assistance to those that continuously complain of being uncomfortable until the time the full system is working at full capacity. A/C units on 3rd floor have been fixed as of September 12, 2025. Compass Mechanical continues to work on minor fixes to ensure continuity. Portable A/C units have been removed from affected apartments.

9999Final ObservationsSurveyor note▼

Findings

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 7.10.1 The assisted living residence shall have readily available a roster of current residents, their room assignments and emergency contact information, along with a facility diagram showing room locations. 18.9 The confidentiality of the resident record including all medical, psychological, and sociological information shall be protected in accordance with all applicable federal and state laws and regulations. Each resident or legal representative of a resident shall be allowed to inspect that resident ' s own record in accordance with Section 25-1-801, C.R.S. Upon request, resident records shall also be made available for inspection by the state long-term care ombudsman and local ombudsman pursuant to Section 26-11.5-108, C.R.S., Department representatives and other lawfully authorized individuals. Resident records shall contain, but not be limited to, the following items: (C) Individualized resident care plan; (D) Progress notes which shall include information on resident status and wellbeing, as well as 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;

Plan of correction

The state did not require a plan of correction for this citation.

7/11/2025Revisit: Licensure Complaint · ID 2G1D1ANo deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 7/11/25 for previous deficiencies cited on 4/22/25. The agency is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

7/11/2025Revisit: Licensure Complaint · ID B28U15No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 7/11/25 for previous deficiencies cited on 4/22/25. The agency is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

7/11/2025Revisit: Licensure (Re-licensure) · ID PPWN14No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A revisit survey was completed on 7/11/25 for previous deficiencies cited on 4/22/25. The agency is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

7/11/2025Revisit: Licensure Complaint · ID QNJD16No deficiencies▼

0000Initial CommentsSurveyor note2 building records▼

Findings · record 1 of 2

A revisit survey was completed on 7/11/25 for previous deficiencies cited on 4/22/25. The agency is in compliance with all regulations surveyed.

Findings · record 2 of 2

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

Plan of correction

The state did not require a plan of correction for this citation.

4/22/2025Revisit: Licensure Complaint · ID ERDJ16No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 4/22/25 for the previous deficiency cited on 9/17/24. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

4/22/2025Revisit: Licensure Complaint · ID WIL612No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 4/22/25 for all previous deficiencies cited on 9/17/24. No deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

4/22/2025Revisit: Licensure (Re-licensure) · ID PPWN131 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A relicensure survey revisit was completed on 4/22/25 for all previous deficiencies cited on 9/17/24. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S A▼

Findings

Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting, four of 10 sample residents (#60, #62, #66, #68). This deficiency was cited previously during a revisit on 9/17/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #60 was admitted to the residence on 7/27/23. A written practitioner's order, dated 2/11/25 and 3/21/25, directed the residence to administer hydrocodone 5-325 mg three times daily. However, the March and April 2025 medication administration records (MARs) read the medication was out of stock and not administered 3/13 evening dose, 3/14-3/20 and 3/21/25 morning dose, for a total of 23 missed doses in March 2025 and 4/20 afternoon and evening doses, 4/21 and 4/22 morning dose, for a total of six missed doses in April 2025. On 4/22/25 at 8:00 a.m., Staff #53 said the residence did not administer Resident #60's hydrocodone because the medication was out of stock. On 4/22/25 at approximately 12:00 p.m., the wellness director said the hydrocodone was not administered because the medication was out of stock. On 4/22/25 at approximately 2:30 p.m., the acting administrator said she was aware the residence was responsible for complying with authorized practitioner's orders. She added this deficiency that was previously cited was not corrected because the plan of correction was not followed. During the onsite visit on 4/22/25, additional deficient practice was found that revealed the residence failed to comply with authorized practitioner's orders for Resident #62, #66 and #68.

Plan of correction · submitted by the facility

#1 A description of how the licensee will correct each identified deficiency. The facility has a system in place for weekly auditing of adequate and sufficient medication supplies for resident #60 and all other residents in care at the facility for compliance. Given that the narcotic in question for resident #60 requires monthly re-fill orders from their provider, the provider will be contacted when there is a 10-day supply remaining in order to give the provider ample time to generate the re-fill order.#2 A description of how the licensee will monitor the corrective action to ensure each deficiency is remedied and will not occur. Weekly audits are conducted by Wellness Director and Wellness Nurse of narcotics and non-cycle fill medications and re-fills are requested in a timely manner to insure compliance with providers orders. If a medication is out of re-fills, the pharmacy contacts the provider daily until re-fill orders are obtained. Pharmacy also contacts facility and informs them that re-fill orders are needed. Facility staff also contacts the provider with requests for re-fill orders. Wellness Director and Wellness nurses monitor Qmap documentation of any missing medication daily and follow up with the pharmacy for any reasons a medication could me missing. Documentation done daily.#3 Follow-up on daily and weekly audits. There will be an IDT review monthly at facility QAPI meeting where the ED, BOM, WD, and WC will review the previous month's audits and look at improvement opportunities. Compliance POC will also be reviewed to insure all steps are being followed to comply with regulations. The date of completion is May 22, 2025, for compliance from the date the deficiency was cited.#4 Completion DateOn May 22, 2025, the facility will achieve compliance with on-going monitoring of the systems implemented and processes to meet the plan in place of full compliance. Corrective action has been applied to all active residents/participants having the potential to be affected by the deficient practice.

4/22/2025Revisit: Licensure Complaint · ID QNJD151 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 4/22/25 for all previous deficiencies cited on 9/17/24. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S A▼

Findings

Plan of correction · submitted by the facility

4/22/2025Revisit: Licensure Complaint · ID B28U141 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 4/22/25 for all previous deficiencies cited on 9/17/24. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S A▼

Findings

Plan of correction · submitted by the facility

4/22/2025Revisit: Licensure Complaint · ID 2G1D191 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 4/22/25 for the previous deficiency cited on 9/17/24. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S A▼

Findings

Plan of correction · submitted by the facility

4/22/2025CHOW and Licensure Complaint (Combined) · ID 83FM11No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO38868, was completed on 4/22/25. No deficiencies were cited. A change of ownership occurred on 1/31/25.

Plan of correction

The state did not require a plan of correction for this citation.

9999Final ObservationsSurveyor note▼

Findings

Plan of correction

The state did not require a plan of correction for this citation.

9/16/2024Revisit: Licensure Complaint · ID 2G1D182 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 9/17/24 for all previous deficiencies cited on 12/27/23. A deficiency was cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24.

Plan of correction

The state did not require a plan of correction for this citation.

1110Res Care Srvs-Min Srvs Res AgrS/S B▼

Findings

Based on observation and interview, the residence failed to provide a safe environment, affecting 112 current residents. This deficiency was cited previously during a complaint revisit on 12/27/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 9/16/24, at approximately 7:30 a.m., an environmental tour of the residence was conducted. During the tour, a surveyor tripped on a raised lip in the stairwell. On 9/16/24, at approximately 8:35 a.m., Resident #59 was observed using staircase number four. The residence had several staircases to take to get down and arrive at different locations within the building. Stairwell number four led down to the health and wellness center. On 9/16/24 at 8:35 a.m., Resident #59 stated she used the stairs because the elevator took too long. On 9/17/24, at 9:23 a.m., the administrator stated he expected the residence to be free of potential trip hazards and fall risks.

Plan of correction · submitted by the facility

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S C▼

Findings

Based on record review, interview, and observation, the residence failed to follow the practitioner's orders, affecting five of 11 sample residents (#22, #51, #53, and #54). This deficiency was cited previously during a complaint revisit on 12/27/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, a written practitioner's order, dated 8/20/24, directed the residence to apply a 15 mcg buprenorphine patch transdermally to the skin once every seven days to Resident #54 for chronic pain. However, residence staff failed to administer the patch after the practitioner ' s order was given until 8/27/24, leaving the resident without the patch for three doses per the August 2024 medication administration record (MAR) and one dose in September. The resident experienced flu-like symptoms from withdrawal due to not being administered the medication as ordered. Findings include:1. Resident #54 was admitted to the residence on 6/24/24 with a diagnosis of type two diabetes, metabolic encephalopathy, emphysema, acute pancreatitis, and cognitive communication deficit. A written practitioner's order, dated 8/20/24, directed the residence to apply a buprenorphine 15 mcg patch one time every seven days for chronic pain. However, the August 2024 electronic medication administration record (eMAR) read staff notes on 8/22/24, 8/23/24, and 8/26/24, stating the medication was not given due to having the wrong order and pending pharmacy delivery. Further, the medication was not applied in the seven-day window; her last dose was given on 8/18/24, and she was due to get her next dose on 8/25/24. The residence failed to have the medication on-site on 8/25/24 and 8/26/24. She was not administered the dose until the evening of 8/27/24, which led to Resident #54 having withdrawal symptoms during two and a half days of missed doses. An external provider note, dated 8/27/24, read Resident #54 "reports pain patch has not been received and she had not worn the new decreased dose. The (residence) feels she is withdrawing as she states she feels unwell, groggy, and shaky. Patient states she feels like she is tired with a small cold."On 9/16/24 at 3:36 p.m., Staff #52 stated that Resident #54 had diarrhea during one of her last shifts in the last week of August 2024. However, a progress note was not found in the electronic database. On 9/17/24 at 8:09 a.m., the health and wellness director (HWD), regional resource nurse, and administrator stated that the residence was unaware she was feeling poorly after not getting her buprenorphine patch. 2. Additionally, there was evidence that the residence failed to comply with the other medications for four other medications for Resident #54. In August 2024, the residence failed to administer duloxetine for 27 days. In September 2024, the residence failed to give a lidocaine patch for eight days, missed a dose of insulin glargine and failed to administer three doses of farxiga. 3. Evidence obtained during the on-site visit revealed that the residence failed to comply with authorized practitioner orders regarding medication administration for Resident #54.4. Record review and interview revealed similar deficient practices for Residents #22, #52, and #53.

Plan of correction · submitted by the facility

9/16/2024Revisit: Licensure Complaint · ID B28U134 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A relicensure revisit was completed on 9/17/24 for all previous deficiencies cited on 1/17/24. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter II regulations were implemented on 6/14/23 and the Chapter VII regulations were implemented on 7/1/24.

Plan of correction

The state did not require a plan of correction for this citation.

1110Res Care Srvs-Min Srvs Res AgrS/S B▼

Findings

Based on observation and interview, the residence failed to provide a safe environment, affecting 112 current residents. This deficiency was cited previously during a complaint revisit on 1/17/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 9/16/24, at approximately 7:30 a.m., an environmental tour of the residence was conducted. During the tour, a surveyor tripped on a raised lip in the stairwell. On 9/16/24, at approximately 8:35 a.m., Resident #59 was observed using staircase number four. The residence had several staircases to take to get down and arrive at different locations within the building. Stairwell number four led down to the health and wellness center. On 9/16/24 at 8:35 a.m., Resident #59 stated she used the stairs because the elevator took too long. On 9/17/24, at 9:23 a.m., the administrator stated he expected the residence to be free of potential trip hazards and fall risks.

Plan of correction · submitted by the facility

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S C▼

Findings

Based on record review, interview, and observation, the residence failed to follow the practitioner's orders, affecting five of 11 sample residents (#22, #51, #53, and #54). This deficiency was cited previously during a complaint revisit on 1/17/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, a written practitioner's order, dated 8/20/24, directed the residence to apply a 15 mcg buprenorphine patch transdermally to the skin once every seven days to Resident #54 for chronic pain. However, residence staff failed to administer the patch after the practitioner ' s order was given until 8/27/24, leaving the resident without the patch for three doses per the August 2024 medication administration record (MAR) and one dose in September. The resident experienced flu-like symptoms from withdrawal due to not being administered the medication as ordered. Findings include:1. Resident #54 was admitted to the residence on 6/24/24 with a diagnosis of type two diabetes, metabolic encephalopathy, emphysema, acute pancreatitis, and cognitive communication deficit. A written practitioner's order, dated 8/20/24, directed the residence to apply a buprenorphine 15 mcg patch one time every seven days for chronic pain. However, the August 2024 electronic medication administration record (eMAR) read staff notes on 8/22/24, 8/23/24, and 8/26/24, stating the medication was not given due to having the wrong order and pending pharmacy delivery. Further, the medication was not applied in the seven-day window; her last dose was given on 8/18/24, and she was due to get her next dose on 8/25/24. The residence failed to have the medication on-site on 8/25/24 and 8/26/24. She was not administered the dose until the evening of 8/27/24, which led to Resident #54 having withdrawal symptoms during two and a half days of missed doses. An external provider note, dated 8/27/24, read Resident #54 "reports pain patch has not been received and she had not worn the new decreased dose. The (residence) feels she is withdrawing as she states she feels unwell, groggy, and shaky. Patient states she feels like she is tired with a small cold."On 9/16/24 at 3:36 p.m., Staff #52 stated that Resident #54 had diarrhea during one of her last shifts in the last week of August 2024. However, a progress note was not found in the electronic database. On 9/17/24 at 8:09 a.m., the health and wellness director (HWD), regional resource nurse, and administrator stated that the residence was unaware she was feeling poorly after not getting her buprenorphine patch. 2. Additionally, there was evidence that the residence failed to comply with the other medications for four other medications for Resident #54. In August 2024, the residence failed to administer duloxetine for 27 days. In September 2024, the residence failed to give a lidocaine patch for eight days, missed a dose of insulin glargine and failed to administer three doses of farxiga. 3. Evidence obtained during the on-site visit revealed that the residence failed to comply with authorized practitioner orders regarding medication administration for Resident #54.4. Record review and interview revealed similar deficient practices for Residents #22, #52, and #53.

Plan of correction · submitted by the facility

1600Med/Med Adm-Rcrd Kpng MARS/S A▼

Findings

Based on record review and interview the facility failed to accurately document medication administration on the medication administration record (MAR) affecting one of six sample residents (#50). This deficiency was cited previously during a complaint revisit on 1/17/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #50 was admitted to the residence on 6/17/24.a. TrazodoneA written practitioner's order, dated 6/26/24, directed the residence to administer trazodone 50 mg at bedtime. However, the August 2024 electronic medication administration record (eMAR), contained a blank space on 8/14/24, for a total of one inaccurately documented dose.b. MetoprololA written practitioner's order, dated 6/18/24, directed the residence to administer metoprolol tartrate 25 mg twice daily. However, the August 2024 eMAR, contained a blank space the evening of 8/14/24, for a total of one inaccurately documented dose.c. SimvastatinA written practitioner's order, dated 6/18/24, directed the residence to administer simvastatin 5 mg at bedtime. However, the August 2024 eMAR, contained a blank space the evening of 8/14/24, for a total of one inaccurately documented dose.d. MelatoninA written practitioner's order, dated 6/18/24, directed the residence to administer melatonin 10 mg at bedtime. However, the August 2024 eMAR, contained a blank space the evening of 8/14/24, for a total of one inaccurately documented dose. 2. InterviewsOn 9/16/24 at 2:21 p.m., the regional nurse stated there should never be a blank space in the eMAR and would expect staff to document whether a medication was administered or not. On 9/17/24 at 9:23 a.m., the administrator stated he was aware of the requirement for accurate eMAR documentation and would expect that to have occurred. He further stated blank spaces meant that staff did not document and would expect staff to document whether a medication was administered, refused or otherwise. The administrator stated he was unsure why the deficiency had not been corrected.

Plan of correction · submitted by the facility

2230HIR-Cntnt IncldS/S A▼

Findings

Based on the interview and record review, the residence failed to require staff members to document, 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, affecting one of 11 sample residents (#54). This deficiency was cited previously during a complaint revisit on 1/17/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:Resident #54 was admitted to the residence on 6/24/24 with a diagnosis of type two diabetes, metabolic encephalopathy, emphysema, acute pancreatitis, and cognitive communication deficit. An external provider note, dated 8/27/24, read Resident #54 "reports pain patch has not been received and she had not worn the new decreased dose. The (residence) feels she is withdrawing as she states she feels unwell, is groggy, and shaky. Patient states she feels like she is tired with a small cold."On 9/16/24 at 3:36 p.m., Staff #52 stated that Resident #54 had diarrhea during one of her last shifts in the last weeks of August 2024. However, a progress note was not found in the electronic database to document the diarrhea or other flu-like/withdrawal symptoms. On 9/17/24 at 8:09 a.m., the health and wellness director (HWD), regional resource nurse, and administrator stated that the residence was not aware that she was feeling poorly after not getting her buprenorphine patch and did not make a progress note.

Plan of correction · submitted by the facility

9999Final ObservationsSurveyor note▼

Findings

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

Plan of correction

The state did not require a plan of correction for this citation.

9/16/2024Revisit: Licensure Complaint · ID ERDJ151 deficiency▼

0000Initial CommentsSurveyor note2 building records▼

Findings · record 1 of 2

A complaint revisit was completed on 9/17/24 for all previous deficiencies cited on 12/27/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24.

Findings · record 2 of 2

A complaint revisit was completed on 9/17/24 for the previous deficiency cited on 12/27/23. The residence is in compliance with all regulations surveyed. The regulations governing Assisted Living Residences were revised, and the new regulations were implemented on 7/1/24.

Plan of correction

The state did not require a plan of correction for this citation.

1110Res Care Srvs-Min Srvs Res AgrS/S B▼

Findings

Plan of correction · submitted by the facility

9/16/2024Revisit: Licensure (Re-licensure) · ID PPWN124 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A relicensure survey revisit was completed on 9/17/24 for all previous deficiencies cited on 12/27/23. Deficiencies were cited. The regulations governing Assisted Living Residences were revised. The new Chapter VII regulations were implemented on 7/1/24.

Plan of correction

The state did not require a plan of correction for this citation.

1110Res Care Srvs-Min Srvs Res AgrS/S B▼

Findings

Based on observation and interview, the residence failed to provide a safe environment, affecting 112 current residents. This deficiency was cited previously during a state licensure survey on 12/27/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:On 9/16/24, at approximately 7:30 a.m., an environmental tour of the residence was conducted. During the tour, a surveyor tripped on a raised lip in the stairwell. On 9/16/24, at approximately 8:35 a.m., Resident #59 was observed using staircase number four. The residence had several staircases to take to get down and arrive at different locations within the building. Stairwell number four led down to the health and wellness center. On 9/16/24 at 8:35 a.m., Resident #59 stated she used the stairs because the elevator took too long. On 9/17/24, at 9:23 a.m., the administrator stated he expected the residence to be free of potential trip hazards and fall risks.

Plan of correction · submitted by the facility

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S C▼

Findings

Based on record review, interview, and observation, the residence failed to follow the practitioner's orders, affecting five of 11 sample residents (#22, #51, #53, and #54). This deficiency was cited previously during a state licensure survey on 12/27/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, a written practitioner's order, dated 8/20/24, directed the residence to apply a 15 mcg buprenorphine patch transdermally to the skin once every seven days to Resident #54 for chronic pain. However, residence staff failed to administer the patch after the practitioner's order was given until 8/27/24, leaving the resident without the patch for three doses per the August 2024 medication administration record (MAR) and one dose in September. The resident experienced flu-like symptoms from withdrawal due to not being administered the medication as ordered. Findings include:1. Resident #54 was admitted to the residence on 6/24/24 with a diagnosis of type two diabetes, metabolic encephalopathy, emphysema, acute pancreatitis, and cognitive communication deficit. A written practitioner's order, dated 8/20/24, directed the residence to apply a buprenorphine 15 mcg patch one time every seven days for chronic pain. However, the August 2024 electronic medication administration record (eMAR) read staff notes on 8/22/24, 8/23/24, and 8/26/24, stating the medication was not given due to having the wrong order and pending pharmacy delivery. Further, the medication was not applied in the seven-day window; her last dose was given on 8/18/24, and she was due to get her next dose on 8/25/24. The residence failed to have the medication on-site on 8/25/24 and 8/26/24. She was not administered the dose until the evening of 8/27/24, which led to Resident #54 having withdrawal symptoms during two and a half days of missed doses. An external provider note, dated 8/27/24, read Resident #54 "reports pain patch has not been received and she had not worn the new decreased dose. The (residence) feels she is withdrawing as she states she feels unwell, groggy, and shaky. Patient states she feels like she is tired with a small cold."On 9/16/24 at 3:36 p.m., Staff #52 stated that Resident #54 had diarrhea during one of her last shifts in the last week of August 2024. However, a progress note was not found in the electronic database. On 9/17/24 at 8:09 a.m., the health and wellness director (HWD), regional resource nurse, and administrator stated that the residence was unaware she was feeling poorly after not getting her buprenorphine patch. 2. Additionally, there was evidence that the residence failed to comply with the other medications for four other medications for Resident #54. In August 2024, the residence failed to administer duloxetine for 27 days. In September 2024, the residence failed to give a lidocaine patch for eight days, missed a dose of insulin glargine and failed to administer three doses of farxiga. 3. Evidence obtained during the on-site visit revealed that the residence failed to comply with authorized practitioner orders regarding medication administration for Resident #54.4. Record review and interview revealed similar deficient practices for Residents #22, #52, and #53.

Plan of correction · submitted by the facility

1600Med/Med Adm-Rcrd Kpng MARS/S A▼

Findings

Based on record review and interview the facility failed to accurately document medication administration on the medication administration record (MAR) affecting one of six sample residents (#50). This deficiency was cited previously during a state licensure survey on 12/27/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #50 was admitted to the residence on 6/17/24.a. TrazodoneA written practitioner's order, dated 6/26/24, directed the residence to administer trazodone 50 mg at bedtime. However, the August 2024 electronic medication administration record (eMAR), contained a blank space on 8/14/24, for a total of one inaccurately documented dose.b. MetoprololA written practitioner's order, dated 6/18/24, directed the residence to administer metoprolol tartrate 25 mg twice daily. However, the August 2024 eMAR, contained a blank space the evening of 8/14/24, for a total of one inaccurately documented dose.c. SimvastatinA written practitioner's order, dated 6/18/24, directed the residence to administer simvastatin 5 mg at bedtime. However, the August 2024 eMAR, contained a blank space the evening of 8/14/24, for a total of one inaccurately documented dose.d. MelatoninA written practitioner's order, dated 6/18/24, directed the residence to administer melatonin 10 mg at bedtime. However, the August 2024 eMAR, contained a blank space the evening of 8/14/24, for a total of one inaccurately documented dose. 2. InterviewsOn 9/16/24 at 2:21 p.m., the regional nurse stated there should never be a blank space in the eMAR and would expect staff to document whether a medication was administered or not. On 9/17/24 at 9:23 a.m., the administrator stated he was aware of the requirement for accurate eMAR documentation and would expect that to have occurred. He further stated blank spaces meant that staff did not document and would expect staff to document whether a medication was administered, refused or otherwise. The administrator stated he was unsure why the deficiency had not been corrected.

Plan of correction · submitted by the facility

2230HIR-Cntnt IncldS/S A▼

Findings

Based on the interview and record review, the residence failed to require staff members to document, 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, affecting one of 11 sample residents (#54). This deficiency was cited previously during a state licensure survey on 12/27/24. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:Resident #54 was admitted to the residence on 6/24/24 with a diagnosis of type two diabetes, metabolic encephalopathy, emphysema, acute pancreatitis, and cognitive communication deficit. An external provider note, dated 8/27/24, read Resident #54 "reports pain patch has not been received and she had not worn the new decreased dose. The (residence) feels she is withdrawing as she states she feels unwell, is groggy, and shaky. Patient states she feels like she is tired with a small cold."On 9/16/24 at 3:36 p.m., Staff #52 stated that Resident #54 had diarrhea during one of her last shifts in the last weeks of August 2024. However, a progress note was not found in the electronic database to document the diarrhea or other flu-like/withdrawal symptoms. On 9/17/24 at 8:09 a.m., the health and wellness director (HWD), regional resource nurse, and administrator stated that the residence was not aware that she was feeling poorly after not getting her buprenorphine patch and did not make a progress note.

Plan of correction · submitted by the facility

9999Final ObservationsSurveyor note▼

Findings

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

Plan of correction

The state did not require a plan of correction for this citation.

9/16/2024Revisit: Licensure Complaint · ID QNJD143 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

Plan of correction

The state did not require a plan of correction for this citation.

1110Res Care Srvs-Min Srvs Res AgrS/S B▼

Findings

Plan of correction · submitted by the facility

1568Med/Med Adm-Ordrs Cmpy w/OrdrsS/S C▼

Findings

Plan of correction · submitted by the facility

1600Med/Med Adm-Rcrd Kpng MARS/S A▼

Findings

Based on record review and interview the facility failed to accurately document medication administration on the medication administration record (MAR) affecting one of six sample residents (#50). This deficiency was cited previously during a complaint revisit on 12/27/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Resident #50 was admitted to the residence on 6/17/24.a. TrazodoneA written practitioner's order, dated 6/26/24, directed the residence to administer trazodone 50 mg at bedtime. However, the August 2024 electronic medication administration record (eMAR), contained a blank space on 8/14/24, for a total of one inaccurately documented dose.b. MetoprololA written practitioner's order, dated 6/18/24, directed the residence to administer metoprolol tartrate 25 mg twice daily. However, the August 2024 eMAR, contained a blank space the evening of 8/14/24, for a total of one inaccurately documented dose.c. SimvastatinA written practitioner's order, dated 6/18/24, directed the residence to administer simvastatin 5 mg at bedtime. However, the August 2024 eMAR, contained a blank space the evening of 8/14/24, for a total of one inaccurately documented dose.d. MelatoninA written practitioner's order, dated 6/18/24, directed the residence to administer melatonin 10 mg at bedtime. However, the August 2024 eMAR, contained a blank space the evening of 8/14/24, for a total of one inaccurately documented dose. 2. InterviewsOn 9/16/24 at 2:21 p.m., the regional nurse stated there should never be a blank space in the eMAR and would expect staff to document whether a medication was administered or not. On 9/17/24 at 9:23 a.m., the administrator stated he was aware of the requirement for accurate eMAR documentation and would expect that to have occurred. He further stated blank spaces meant that staff did not document and would expect staff to document whether a medication was administered, refused or otherwise. The administrator stated he was unsure why the deficiency had not been corrected.

Plan of correction · submitted by the facility

9999Final ObservationsSurveyor note▼

Findings

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

Plan of correction

The state did not require a plan of correction for this citation.

9/16/2024Licensure Complaint · ID WIL6111 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO37012, was completed on 9/17/24. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

1110Res Care Srvs-Min Srvs Res AgrS/S B▼

Findings

Based on observation and interview, the residence failed to provide a safe environment, affecting 112 current residents. Findings include:On 9/16/24, at approximately 7:30 a.m., an environmental tour of the residence was conducted. During the tour, a surveyor tripped on a raised lip in the stairwell. On 9/16/24, at approximately 8:35 a.m., Resident #59 was observed using staircase number four. The residence had several staircases to take to get down and arrive at different locations within the building. Stairwell number four led down to the health and wellness center. On 9/16/24 at 8:35 a.m., Resident #59 stated she used the stairs because the elevator took too long. On 9/17/24, at 9:23 a.m., the administrator stated he expected the residence to be free of potential trip hazards and fall risks.

Plan of correction · submitted by the facility

12/26/2023Licensure (Re-licensure) · ID PPWN1110 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A relicensure survey was completed on 12/27/23. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

1110Res Care Srvs-Min Srvs Res AgrS/S E▼

Findings

Based on observation, interview, and record review, the residence failed to provide protective oversight, affecting one sample resident (#46) Specifically, On 12/26/23 at 11:40 a.m., staff prepared medications to Resident #46. Staff did not crush or dissolve the medications. Upon entry into the resident's room, Resident #46 was observed slouched in a chair with two pills on his right upper chest. Staff noticed the pills on his body, picked them and stated he did not take his medications this morning. The staff subsequently placed the two pills into the cup and stated they would let the director of nursing know of the missed medication. During interviews it was revealed the resident had swallowing difficulties since his diagnosis of COVID-19 approximately two months prior to the on-site visit. Staff and external hospice stated that the resident was choking when being administered his medications and therefore he required his medications to be crushed/dissolved. However, during record review it was revealed the resident had a crush/dissolve order for medications, dated 12/7/23, which was not transcribed on the medication administration record (MAR). This failure created an immediate jeopardy risk of protective oversight to Resident #46. On 12/26/23, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. References and Resident Agreementa. Chapter VII regulations governing assisted living residences defines, in part 2.38, protective oversight as "guidance of a resident as required by the needs of the resident or as reasonably requested by the resident, including the following: (B) Monitoring the activities of the resident while on the premises to ensure the resident's health, safety and well-being, including monitoring the resident's needs and ensuring that the resident receives the services and care necessary to protect the resident's health, safety, and well-being."B. According to the National Library of Medicine, "administering crushed medications mixed with a soft food or liquid vehicle, or via a feeding tube, is a common strategy to circumvent swallowing difficulties in patients with dysphagia." Amie Blaszczyk (October 2023) Et.al Drugs Aging, Retrieved from: http://www.pubmed.ncbi.nlm.nih.govc. The residence ' s Medication Policy, dated 7/26/16, read in part that the residence ensured medications were dispensed in a safe manner as required by state licensure. All medication received by the residence for administration were to be compared with the practitioner ' s order. d. The residence ' s Resident Agreement, read in part through its staff, would assist, or supervise, as appropriate, resident administration of medications directed by the resident ' s practitioner. 2. Resident #46 was admitted to the residence on 1/10/20, with diagnoses including frontotemporal dementia and dysphagia. a. Observations on 12/26/23 revealed the followingOn 12/26/23 at approximately 11:40 a.m., Staff #13 administered furosemide 20 mg tablet and potassium chloride 10 meq tablet. Both medications were administered whole per the medication administration record (MAR). Resident #46 subsequently began coughing. Staff #49 and Staff #19 then noticed that the resident had his morning medications sitting on his chest. Staff #49 and Staff #19 stated that his medications should have been crushed because he coughed during medication administration.b. Record ReviewA written practitioner ' s order, dated 12/7/23, directed the residence to crush all medications and dissolve tamsulosin and potassium chloride in water or orange juice. The residence ' s December 2023 MAR revealed no evidence the crush and dissolve order was transcribed onto the MAR and no evidence it was administered according to the written practitioner's order from 12/7-12/26/23 the day of the onsite visit. A progress note, dated 12/6/23 written by the external hospice registered nurse (RN), read in part: The qualified medication administration person (QMAP) had concerns with Resident #46 ' s ability to swallow his medications. An assessment for Resident #46, dated 10/23/23, read in part that the residence administered all medications to Resident #46. The residence staff provided spoon-feeding of medication as needed. The assessment contained no information about the resident experiencing swallowing difficulty. A care plan for Resident #46 dated 3/7/23, read in part that the residence administered all medication to Resident #46. The care plan contained no information about the resident experiencing swallowing difficulty. c. InterviewsOn 12/26/23 at approximately 11:40 a.m., Staff #13 and Staff #14 stated that they noticed a change in condition with Resident #46 and stated he was having difficulties swallowing his medications. On 12/26/23 at 1:19 p.m., the health and wellness director stated Resident #46 was seen by an external speech therapist. However, she stated she was not aware of the recommendations because she did not have the notes for the visit. The health and wellness director further stated the speech therapist would not write orders for the resident rather make recommendations. She further stated the residence had not received a crush order for Resident #46 and was not aware of any issues taking medications. On 12/26/23 at approximately 1:20 p.m., the external hospice nurse stated that she had seen a change in his condition approximately one month prior to the onsite visit when he was diagnosed with COVID-19. She stated Resident #46 never regained some of his abilities after his diagnosis. The external hospice nurse further stated she had written the crush order for the medications because staff was reporting he was having difficulty swallowing his medications. She stated she consulted with the resident's pharmacist who stated the potassium chloride and tamsulosin needed to be dissolved and not crushed. Additionally, the external hospice nurse stated that the residence needed to follow the orders because he was at immediate risk for aspiration and choking. On 12/26/23 at 2:50 p.m., the administrator stated he was not aware that Resident #46 had a crush/dissolve order and it was not being followed. He stated the pharmacy transcribed orders onto the MARs and the health and wellness director was responsible for ensuring the MARs were correct and all orders were added to the MARs. The administrator further stated he expected the residence to comply with all written practitioners orders associated with medication administration. d. Immediate Jeopardy - Written Evidence, Immediate CorrectionThe investigation established that the findings above placed Resident #46 at immediate jeopardy risk of choking and aspiration, due to difficulties with swallowing. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 12/26/23 at 3:53 p.m., the administrator submitted written evidence that read in pertinent part: "1. The wellness director or designee will provide immediate education for all QMAP (qualified medication administration person) personnel currently on the shift in the community regarding which residents are currently on crush orders. The wellness director or designee will provide education to all QMAP personnel currently on the shift in the community on the notification screen of the electronic health record (EHR) which identifies which resident is on crushed orders. 2. The wellness director or designee will provide education to 100% all QMAP personnel employed with the community regarding who in the community is on crush orders. This education will be completed in the next 48 hours. The wellness director or designee will provide education to 100% of all QMAP personnel employed with the community regarding the notification screen of the EHR which identifies if a resident is on crush orders. This education will be provided in the next 48 hours. The wellness director will work together with the practitioner and pharmacy to ensure that each individual medication can be crushed the, "To be crushed," verbiage in the order itself. This will be completed in the next 48 hours. The wellness director will work together with the practitioner and pharmacy to ensure that each resident whose medication can be crushed has an individual treatment order stating that the resident ' s medication is to be crushed per physician ' s orders for QMAP personnel to sign off on during each medication pass. This will be completed in 24 hours. 3. The wellness director, memory care director, or resident care coordinator will audit each resident with a crush order to ensure those medications are being crushed per practitioner orders. This audit will occur daily x 3 weeks, then weekly x 3 weeks to ensure compliance. Wellness director will audit all new orders daily Monday through Friday to ensure all new crushed orders are implemented on the MAR with the correct, "to be crushed," verbiage as well as the treatment order stating that the resident ' s medications are to be crushed per physician ' s orders. 4. The results of these audits will be reviewed daily Monday through Friday in clinical meeting three months to ensure ongoing compliance. The results of these audits will be reviewed monthly x 3 in QAPI meeting to ensure compliance.``However, the written evidence did not demonstrate the risk had been removed because it did not include specific information regarding Resident #46, education element for the health and wellness director, and a change of timeframe for the residence to provide education to the residence ' s QMAPs. The administrator was directed to submit additional written evidence. On 12/26/23 at 4:26 p.m., the administrator submitted written evidence that read in pertinent part: "1. The crush order for Resident #46 was updated in the MAR on 12/26/23 ... Education will be provided to the wellness director regarding proper process and procedure for order transcription within the MAR. This will be completed by (home office) director of health services on 12/26/23." Further, the administrator changed the timeframe for education for the QMAPs from within 48 hours to prior to the next shift. The administrator added verbiage regarding monitoring of medication administration by residence QMAPs. However, the written evidence did not indicate the risk had been removed because it did not include the administrator ' s oversight. The administrator was directed to submit additional written evidence. On 12/27/23 at 7:53 a.m., the administrator submitted written evidence that read in pertinent part: "The executive director (administrator) will spot check 5 orders per week x 1 month, then 5 orders per month x 2 months to ensure each order is transcribed properly."e. Continued deficient practice on 12/27/23On 12/27/23 at approximately 8:30 a.m., Staff #49 crushed all of Resident #46 ' s medications including the potassium chloride tablet which was ordered to be dissolved. However, the staff disposed of the medications because he was in the middle of eating. On 12/27/23 at 9:26 a.m., the memory care director prepared the medications for a second time and subsequently crushed all of them including the potassium chloride tablet. An updated December 2023 MAR for Resident #46 was requested on 12/27/23 at 10:43 a.m. and again at 12:11 p.m. The updated MAR was received at approximately 1:00 p.m. and directed staff to crush medications that were crushable and to dissolve the potassium chloride and tamsulosin. However, the MAR revealed the dissolve order was not added to the MAR until after morning medication pass. On 12/27/23 at 11:00 a.m., a pharmacist For Resident #46 stated that not dissolving potassium chloride could cause the resident gastrointestinal distress.

Plan of correction · submitted by the facility

Responses to the cited deficiencies do not constitute an admission or agreement by the community to the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and state law. A) With respect to HOW the facility will CORRECT the problem identified in the deficiency list:1. The Crush order for Resident #46 was updated in the MAR on 12/26/2023.2. The Wellness Director or designee provided education for all QMAP personnel currently on shift in the community regarding which residents are currently on crush orders. This education occurred on 12/26/2024.3. Education was provided to the Wellness Director regarding proper process and procedure for order transcription within the MAR. This was completed by the Stellar Director of Health Services on 12/26/2023. 4. The Wellness Director or designee provided immediate education to all QMAP personnel currently on shift in the community on the notification screen in ECP which identifies a resident is on crush orders. This education occurred on 12/26/2024.5. The Wellness Director or designee provided immediate education for all QMAP personnel currently on shift in the community regarding staying with a resident to ensure medications have been swallowed before leaving resident. This education occurred on 12/26/2024.6. The Wellness Director or designee provided immediate education for all QMAP personnel currently on shift in the community detailing the process of communicating concerns with orders to the Wellness Director. This education occurred on 12/26/2024. B) With respect to what the facility will do to PREVENT the same deficiency from recurring:1. The Wellness Director or designee will provide education to 100% of all QMAP personnel employed with the community regarding who in the community is on crush orders. This education will be completed prior to their next shift. 2. The Wellness Director or designee will provide education to 100% of all QMAP personnel employed with the community regarding the notification screen in ECP which identifies a resident is on crush orders. This education will be completed prior to their next shift. 3. The Wellness Director or designee will provide education to 100% of all QMAP personnel employed with the community staying with a resident to ensure medications have been swallowed before leaving resident. This education will be completed prior to their next shift. 4. The Wellness Director or designee will provide education to 100% of all QMAP personnel employed with the community detailing the process of communicating concerns with orders to the Wellness Director. This education will be completed prior to their next shift. 5. The Wellness Director, together with the practitioner and pharmacy audited resident eMARs to ensure that each individual medication which can be crushed the “To be crushed“ verbiage in the order itself. This was completed on 12/29/23.6. The Wellness Director together with the practitioner and pharmacy audited all resident eMARs to ensure that each resident whose medication can be crushed has an individual treatment order stating that the resident’s medication is to be crushed per physician’s orders for QMAP personnel to sign off on during each medication pass. This was be completed on 12/27/2023.7. The Wellness Director, Memory Care Director, or Resident Care Coordinator will audit each resident with a crush order to ensure that those medications are being crushed per practitioner’s orders. This audit will occur daily x 3 weeks, then weekly x 3 weeks to ensure compliance. This audit will be documented on an audit form for entry into the clinical meeting minutes. 8. Wellness Director will audit all new orders daily Monday thru Friday to ensure that all new crush orders are implemented on the MAR with the correct “to be crushed“ verbiage as well as the treatment order stating that the resident’s medications are to be crushed per physician’s orders. This audit will be documented on an audit form for entry into the clinical meeting minutes. 9. The Executive Director will spot check 5 orders per week x 1 month, then 5 orders per month x 2 months to ensure each order is transcribed on the MAR properly. 10. The results of these audits will be reviewed daily Monday through Friday by the Executive Director in clinical meeting for 3 months to ensure ongoing compliance. 11. Results of these audits will be submitted to the QAPI committee x 6 months to ensure substantial compliance achieved.

1360Res Rts-Inv Ab/Neg Alleg or Inj Unk Org A/NS/S B▼

Findings

Based on record review and interviews, the residence failed to investigate allegations of abuse, in accordance with regulation and written policy affecting 19 current residents in the secure environment. (Cross-reference Q2130, Q2960)Findings include:1. Reference and Residence PolicyChapter VII regulations governing assisted living residences, requires in part 13.11, that the assisted living residence shall investigate all allegations of abuse, neglect, or exploitation of residents in accordance with its written policy. The written policy is required to include the following:(A) Reporting requirements to the appropriate agencies, such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator; (B) A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation; (C) The process for investigating such allegations; (D) How the assisted living residence will document the investigation process to evidence the required reporting and that a thorough investigation was conducted; (E) A requirement that the resident shall be protected from potential future abuse or neglect, and/or exploitation while the investigation is being conducted; (F) A requirement that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action; and (G) A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review. The residence's Resident Abuse Prevention policy, dated 8/2/23, defined abuse as the non-accidental act of physical mistreatment. The policy read in part that each resident had the right to be free from physical abuse and that the residence took immediate, corrective action when an abuse allegation was verified to ensure that the abuse did not re-occur. Further, the residence protected any resident involved in an investigation, such as increased resident supervision by staff or family presence while conducting the investigation using the residence's Abuse Investigation Report Form. 2. Resident #43 was admitted to the residence on 8/11/23 with diagnoses including dementia and agitation.a. Allegation of abuse on 11/9/23A review of the residence ' s investigations of abuse revealed an incident report, dated 11/9/23, the report read in part that the incident classification was behavior, danger to others. The report read in part: Resident #43 was discovered yelling at an Former Resident #49 with an external service provider (ESP) standing between Resident #43 and the Former Resident #49. A residence staff member attempted to redirect the residents, and Resident #43 became very angry and pointed his finger in the face of Former Resident #49. Former Resident #49 no longer wanted to participate in the confrontation. As the other resident began to walk away, Resident #43 pushed the resident in the middle of the chest and the other resident fell on his bottom. The residence led the other resident away and Resident #43 stayed in the activity room for lunch. Further, the incident report contained no information regarding how the residence kept the residents safe during the investigation. A review of the service (care) plan, and service plan tasks, dated 11/13/23, revealed that the residence put no measures in place that protected all residents involved from potential future abuse while the investigation was being conducted. Further, the review revealed no increased safety checks were added on or after 11/9/23. Per the residence's Resident Abuse Prevention policy, the residence failed to ensure each resident's right to be from abuse was ensured, that the residence had taken immediate action, and that the resident protected any resident involved in an investigation. On 12/27/23 at 3:14 p.m., the administrator stated that the residence was required to detail how the residence kept residents safe while the residence conducted an abuse. He added he was unaware that the residence put no measures in place in the care plan that protected or provided protection from Resident #43 during or after abuse was alleged on 11/9/23On 12/27/23 at 3:56 p.m., the health and wellness director (HWD) stated that she was aware that there was a requirement for the residence to put measures in place to protect all residents involved with an allegation of abuse from future abuse. She stated that contrary to the investigation notes for the incident on 11/9/23 that detailed Resident #43 yelled, appeared angry, and pushed another resident that fell to the ground, that Resident #43 was not aggressive. She added that Resident #43 was triggered when others entered his personal space. She added that safety checks were the only intervention put in place contrary to the safety checks the day prior to the incident and the day of and days after the incident remaining the same, she was unable to confirm that the residence increased safety checks for the resident. She affirmed that the care plan was not updated during the investigation to include the resident's behavioral expressions when another resident stepped into Resident #43's personal space.b. Allegation of abuse on 12/26/23On 12/26/23 at approximately 8:40 a.m., Staff #49 stated that Resident #43 was often aggressive with other residents. She also stated that he fought with another female resident on a regular basis. On 12/26/23 at 8:57 a.m., the memory care director (MCD) stated that when Resident #43 became aggressive and they moved the other residents away from him. She also stated that Resident #43 became aggressive when residents got near his room. On 12/27/23 at 11:13 a.m., Staff #40 stated that Resident #43 was aggressive with a female resident on 12/26/23 in the afternoon. She stated Resident #48 was wandering, attempting to enter other resident's rooms. Staff #40 further stated that Resident #48 wandered into Resident #43's room and that was we he "man-handled (Resident #48)." She stated staff did their best to keep an eye on Resident #43 and keep his door locked to prevent resident to resident abuse. On 12/27/23 at 1:05 p.m., Staff #50 stated there was in incident of resident to resident abuse with Resident #43 and Resident #48, she stated the MCD had handled the situation. The staff further stated Resident #43 had been refusing his medications, including his psychotropic medications for a while. Staff #50 stated the HWD was aware the resident had been refusing his medications and that he was aggressive towards other residents. Staff #50 further stated Resident #43's aggression tended to come in waves. On 12/27/23 at 1:12 p.m., the MCD stated that there was not an incident with Resident #43 on 12/26/23. She then recalled the incident and stated had to physically pull away a female resident from Resident #43. She stated that she had not considered that an allegation of abuse and stated she failed to document that encounter. On 12/27/23 at 3:14 p.m., the administrator stated that he was made aware at approximately 2:14 p.m. on 12/27/23 that an additional allegation of abuse was reported on 12/26/23 involving Resident #43; however, he was unaware if the residence put documented measures in place that protected or provided protection from Resident #43 since the allegation was made. He added the measures should have been put into place if they were not. On 12/27/23 at 3:56 p.m., the HWD stated that the residence was investigating the incident that occurred on 12/26/23 involving Resident #43; however, she stated no measures the residence was taking to protect or provide protection from Resident #43 were included in the reported investigation.

Plan of correction · submitted by the facility

1362Res Rts-Inv Ab/Neg Alleg or Inj Unk Org IUOS/S B▼

Findings

Based on record review and interview, the residence failed to develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin, affecting 107 current residents. Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, requires in part 13.12, that the assisted living residence shall develop and implement policies and procedures for the identification, reporting, and investigation of injuries of unknown origin. Such policies and procedures shall include, but not be limited to, the following requirements:- the residence must identify and document resident injuries for which the origin of the injury was not observed by or otherwise known by staff, and either the resident cannot explain how the injury occurred, or the resident can explain the source of the injury, but the source could be addressed to prevent future injuries.- the residence is required to document the following: The investigation and identification of any injury identified above. The implementation and outcome of the following for injuries for which the investigation determines the source/origin.- when the source/origin of the injury is suspected to be abuse, neglect, or exploitation; the residence is required to take steps to prevent or mitigate future injuries of like nature. Such steps were to include, but not limited to: Staff or volunteer corrective action and/or additional training. Modification of the residence's policies, procedures or physical environment. - if the source of the injuries is undetermined, the residence is required to take steps to monitor the resident in an effort to prevent similar injuries. - all documentation of the investigation, outcomes and steps taken are to be retained by the residence to include, but not limited to, details of any interviews and/or records used in the investigation. - the documentation has to be made available for review at the Department's request. - the documentation may be maintained separately and not in the resident's record, but the summary of the investigation must be in the resident's care plan and progress notes.- the residence is required to notify the resident's representative of the outcome of the investigation and steps taken.b. The residence's Injury of Unknown Origin Policy, dated 8/3/23, read in part: "an injury of unknown origin is an injury where the source of the injury was not witnessed or known by any person and the source of the injury could not be explained by the resident. When an injury of unknown origin is identified the community will investigate the cause of the injury. If unexplained the community will place a resident on alert charting to monitor the resident in an effort to identify and prevent similar injuries. If the cause of the injury cannot be determined, the community will ensure that all allegations of mistreatment, neglect or abuse, as well as injuries of unknown source, are reported immediately to the administrator or to other officials in accordance with state law as outlined in the abuse prevention policy. If the source of the injury is explained by the resident, the community will take steps to mitigate future injuries of like nature for both the injured resident and other residents." However, the policy per regulation was missing the following elements:-that all documentation of the investigation, outcomes and steps taken are to be retained by the residence to include, but not limited to, details of any interviews and/or records used in the investigation. - the documentation has to be made available for review at the Department's request. - the documentation may be maintained separately and not in the resident's record, but the summary of the investigation must be in the resident's care plan and progress notes.- the residence is required to notify the resident's representative of the outcome of the investigation and steps taken. 2. Resident #22 was admitted to the residence on 11/19/21. An observation (progress) note, dated 12/25/23 written by the licensed practical nurse (LPN), read in part: "resident came out of the room this morning and said her right hand was bleeding. She did not remember bumping it. Small skin tear (was observed on the) outer right side of her right hand. Cleaned the area and applied sterile strips and a bandage. Will continue to monitor."On 12/26/23 at 9:00 a.m., all investigations of abuse, neglect, and injuries of unknown origin over the last 90 days were requested. However, there was no evidence provided or found in the record for Resident #22, that the residence conducted an investigation on or after 12/25/23. On 12/27/23 at approximately 3:00 p.m. (30 hours later), the residence provided an investigation written by the health and wellness director (HWD) for Resident #22 which read in part, a skin tear was observed on Resident #22's right hand. Dressing was placed on the hand. After speaking with Resident #22 and clinically assessing the situation it appears the resident's hand slid down the inside of her recliner which resulted in a skin tear. Will continue to monitor. External hospice and the resident's family member was notified. However, the investigation failed to include which steps would be taken by the residence to mitigate future injuries. On 12/26/23 at 12:16 p.m., the HWD stated the LPN had informed her that Resident #22 had a skin tear when the incident occurred on 12/25/23 and Resident #22 had stated to the LPN that she bumped her hand on the wall. On 12/26/23 at 12:17 p.m., contrary to the HWD previous statement she stated she was unsure what happened to Resident #22 on 12/25/23 and had not had the chance to investigate the incident. On 12/27/23 at 7:21 a.m., Resident #22 was observed with a cut and bandage over her right hand. Contrary to the HWD statement Resident #22 stated she was unsure how the injury occurred and stated she did not bump her hand. Resident #22 further stated she had sustained a fall and believed the wound from the fall started bleeding. On 12/27/23 at 8:25 a.m., contrary to the HWD statement the LPN stated she informed the HWD on 12/25/23 Resident #22 "might have bumped her hand on the door" based on the way the injury appeared; however, stated there was no known source of the injury since Resident #22 was not aware how the injury occurred. The LPN stated the HWD responded to her report of the incident by saying "oh, it's (Resident #22)" and had not mentioned anything about looking into it further. On 12/27/23 at 1:00 p.m., the HWD stated Resident #22 was alert and stated no one hurt her. the HWD stated she was actively conducting the investigation for Resident #22. On 12/27/23 at 3:30 p.m., the administrator stated he was aware of the requirement to investigate injuries of unknown origin and expected it to have occurred for Resident #22 and #33. The administrator stated he would have expected an investigation to have occurred within 24 hours of when the injury occurred. The administrator stated the HWD or another nurse which included the LPN were responsible for conducting investigations. The administrator stated there were nurses seven days a week to conduct an investigation. He acknowledged he was aware steps were required to mitigate future injuries. On 12/27/23 at 4:16 p.m., contrary to the HWD previous statement where she had said Resident #22 stated she bumped her hand, the HWD stated Resident #22 sat down forcefully in her recliner and caught her hand on the inside of the recliner. Further the HWD stated she was aware of the requirement for injuries of unknown origin to be investigated right away and Resident #22's injury to be investigated specifically within 24 to 48 hours; however, had not had a chance to document the incident. There was similar deficient practice for Resident #33.

Plan of correction · submitted by the facility

1422Med/Med Adm-Gen Rq Proper AdmS/S B▼

Findings

Based on observation, record review, and interview, the residence failed to ensure that each resident received proper administration and/or monitoring of medications, affecting two of two sample residents with crush and/or dissolve practitioner orders (#38, #46). (Cross-reference Q1110) Findings include:1. Reference and Residence Policya. Chapter VII regulations governing assisted living residences, part 2.27, defines "medication monitoring" as (C) Visual observation of the resident to ensure compliance.b. The residence's Medication Policy, dated 7/26/16, read in part that the residence ensured medication was dispensed in a safe manner as required by state licensure. 2. Resident #46 was admitted to the residence on 1/10/20, with diagnoses including frontotemporal dementia and dysphagia. a. ObservationsOn 12/26/23 at approximately 11:40 a.m., Staff #13 administered furosemide 20 mg and potassium chloride 10 meq. Both medications were given whole per the medication administration record (MAR). Resident #46 began coughing. Furthermore, Staff #49 noticed that the resident had his morning medications sitting on his chest. Both staff members stated that his meds should be crushed because he coughs a lot after administering his medications..b. Record ReviewThe service (care) plan, dated 10/2023, read the residence administered all medications to Resident #46.c. InterviewsOn 12/26/23 at approximately 11:40 a.m., Staff #13 and Staff #14 stated that they have talked with the Resident #46's hospice nurse and the memory care director about their concerns regarding him coughing more after taking his medications. On 12/27/23 at 2:57 p.m., the administrator stated that he expected the residence staff to observe ingestion of a medication when they administered a medication to a resident. He added that the staff should have observed Resident #46 ingest his medication before leaving the resident's presence. On 12/27/23 at 3:40 p.m., the health and wellness director (HWD) stated that the expectation for residence staff administering medication was for them to stay until the resident has taken the medication appropriately. She added she believed that the residence staff failed to stay and observe Resident #46 ingest his medication on 12/26/23.3. Additionally, the residence failed to ensure that each resident received proper administration and/or monitoring of medications for Resident #38.

Plan of correction · submitted by the facility

1468Med/Med Adm-Ordrs Cmpy w/OrdrsS/S C▼

Findings

Based on observation, interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting six of nine sample residents whose medications were reviewed (#15, #22, #33, #38, #45 and #47). Specifically, Resident #47 was prescribed timolol 0.5% eye drops twice daily for glaucoma. From 12/25-12/27/23 the medication was out of stock and Resident #47 stated she experienced painful pressure in her eyes. The pharmacist for Resident #47 stated that increased eye pressure and blurred vision were common side effects due to not being administered timolol timely. Findings include:1. Reference and Residence Policya. According to Mayo Clinic, Timolol eye drops "are used to treat increased pressure in the eye that is caused by open-angle glaucoma or a condition called ocular (eye) hypertension. The medication must be used exactly as directed by a doctor ..." Mayo Clinic (12/1/23), Timolol (Ophthalmic Route), retrieved from: https://www.mayoclinic.org/drugs-supplements/timolol-ophthalmic-route/precautions/drg-20071111b. According to the National Health Service "It's important to use your eye drops regularly and go for check-ups with your eye specialist to stop your sight getting worse. Do not stop timolol suddenly without talking to your doctor, as it may make your eye condition worse ..." NHS (8/25/22), How and When to Use Timolol Eye Drops, retrieved from: https://www.nhs.uk/medicines/timolol-eye-drops/how-and-when-to-use-timolol-eye-drops/c. The residence's Medication Administration Policy, dated 7/26/16, read in part: "ensure medications are dispensed in a safe manner in the community ... employees who are appropriately licensed ... (are) to assist with and/or administer medications (including opioids) in the community as dictated by state regulations."2. Resident #47 was admitted to the residence on 9/20/23 with a diagnosis of glaucoma.a. TimololA written practitioner's order, dated 11/28/23, directed the residence to instill timolol ophthalmic solution 0.5% one drop in each eye twice daily. However, the December 2023 electronic medication administration record (eMAR) read timolol was not administered on 12/25 in the evening, 12/26 in the morning, and interviews revealed the medication was not administered 12/26 in the evening of 12/27/23 in the morning either due to the medication being out of stock, for a total of four missed doses. b. LatanoprostA written practitioner's order, dated 11/28/23, directed the residence to instill latanoprost ophthalmic solution 0.005% one drop in each eye at bedtime. However, the December 2023 eMAR read latanoprost was not administered 12/19-12/21/23 due to the medication being out of stock, for a total of three missed doses. c. Benztropine A written practitioner's order, dated 11/28/23, directed the residence to administer benztropine mesylate 1 mg once daily. However, the December 2023 eMAR read benztropine was not administered 12/7 and 12/8/23 due to the medication being out of stock, for a total of two missed doses.d. Vitamin b12A written practitioner's order, dated 11/28/23, directed the residence to administer vitamin b12 1000 mcg daily. However, the December 2023 eMAR read vitamin b12 was not administered 12/13 and 12/14/23 due to the medication being out of stock, for a total of two missed doses. e. LactuloseA written practitioner's order, dated 11/28/23, directed the residence to administer Lactulose 45 mL once daily. However, the December 2023 eMAR read Lactulose was not administered 12/17/23 due to the medication being out of stock, for a total of one missed dose. On 12/27/23 at 7:42 a.m., Resident #47 stated she had experienced issues with not getting her medication as ordered from the residence and stated her timolol was still out of stock. She further stated "there is no exception for not getting my medication. I am paying so much money each month to live here and am about ready to get an order to manage my own medications. Ask any of the other residents, it is not just me who is having issues getting medications."On 12/27/23 at 8:35 a.m., Resident #47 stated that the residence had not administered her timolol eye drops since 12/22/23 and she had experienced painful pressure in her eyes that made her want to, "scratch her eyes out of her head." On 12/27/23 at 10:01 a.m., the health and wellness director (HWD) stated Resident #47 had cycle filled medications and the insurance provider for Resident #47 would not pay to fill timolol since it had just been filled in December 2023. The HWD stated staff may have accidentally missed administered drops in the eye and the medication ran out early. The HWD stated Resident #47 had expressed concerns to her that if her eye pressure was too high from not having received her timolol drops, she would be unable to have her cataract surgery in January 2024. On 12/27/23 at 10:33 a.m., the residence's preferred pharmacy's pharmacist stated effects to Resident #47 not being administered her timolol, included increased eye pressure and blurred vision. The pharmacist further stated timolol was last delivered to the residence on 12/14/23 and was unsure how the medication could have been out of stock. He further stated insurance would not cover the medication being lost or used up within 30 days. On 12/27/23 at 11:51 a.m., a medication cart audit was conducted for Resident #47 and revealed her timolol which was not administered and had been marked as out of stock, was found in an unlabeled section of the bottom drawer of the medication cart instead of the top drawer of the medication cart where Resident #47's eye drops were stored. On 12/27/23 at 3:15 p.m., the administrator stated the HWD was responsible for ordering medications and ensuring they were in stock for both the assisted living and secure environment. The administrator stated he would expect the residence to have complied with practitioner's orders related to medication administration and was unaware it had not occurred. On 12/27/23 at 4:05 p.m., the HWD stated she was responsible for ordering medications and ensuring they were in stock alongside the licensed practical nurse (LPN). The HWD acknowledged she would expect medications to be administered in accordance with practitioner's orders. She acknowledged she was aware there were medications that were not delivered by the pharmacy when they were supposed to be; however, stated "when you and I go to the pharmacy even we have to wait for medications to come in stock." Additional non compliance with practitioner's orders was revealed with Resident #15, #22, #33, #38 and #45.

Plan of correction · submitted by the facility

1514Med/Med Adm-Rcrd Kpng Qrtly AuditS/S B▼

Findings

Based on record review and interview, the residence failed to ensure the administrator and the qualified medication administration person (QMAP) supervisor audited the accuracy and completeness of the medication administration record (MAR) on a quarterly basis, affecting 7 of eleven sample residents (#15, #22, #33, #38, #45, #46, #47). (Cross-reference Q1110, Q1468, Q1522)Findings include:The residence ' s medication policy, dated 7/26/16, read in part that the residence checked all practitioner orders and medication to ensure proper administration as required by state licensure regulations. The residence provided Quality Assessment Med Storage forms, Weekly Med Cart forms, a handwritten Med Cart Audit, and a list titled Carts Reviewed when quarterly medication audits were requested. The Quality Assessment Med Storage forms, dated 8/14/23 and 10/10/23, read in part that the member of the performance improvement committee will review compliance with Medication Cart Audits per pharmacy for proper medication storage. The form criteria included one element involving MARs, "Medication in cart, not on MARs." The audits failed to meet the requirement of auditing the accuracy and completeness of the medication administration record (MAR). Further, the LPN completed the forms that were not the identified QMAP supervisor, the resident care coordinator (RCC). A review of the Weekly Med Cart forms, dated 5/22/23, 5/23/23, 6/5/23, and 7/3/23, revealed the form contained no elements involving the accuracy of the MARs and was not conducted by the QMAP supervisor, the RCC.A review of the handwritten Med Cart Audit, dated 7/30/23, revealed the form contained no elements involving the accuracy of the MARs and was not conducted by the QMAP supervisor, the RCC.Review of the Carts Reviewed lists, dated 8/14/23-11/26/23, revealed the form contained no elements involving the accuracy of the MARs and was not conducted by the QMAP supervisor, the RCC.On 12/27/23 at 2:59 p.m., the administrator stated that quarterly audits should contain elements to ensure the accuracy of the MAR. He added that he signed off on the cart audit lists. He added that the residence utilized forms created by the pharmacy. He stated he was unaware that the residence was not meeting the requirement with the existing form and that the residence would create new forms to include the accuracy of the MARs as that was not included on the existing quarterly audits. He added that some of the non-compliance with medication administration may have been identified if the audits had contained all of the required elements. On 12/27/23 at 3:45 p.m., the health and wellness director (HWD) stated that the forms the residence provided for audits would not have caught the issues found with MARs and that the residence utilized a form created by the pharmacy to audit carts. She added that having a different form to identify problems with the MAR would be ideal. She stated that the QMAP supervisor was the RCC and not LPN. She added that she was unaware that the QMAP supervisor was required to conduct the quarterly audits.

Plan of correction · submitted by the facility

1522Med/Med Adm-Rprt Pract/Rep NtfdS/S B▼

Findings

Based on record review and interview, the residence failed to ensure that the resident's authorized practitioner was promptly notified of a resident's pattern of refusal, affecting one sample resident (#46) for sixteen of 26 instances of medication administration that were refused. (Cross-reference Q1360, Q2130) Findings include:The residence's Change in Condition policy, dated 12/26/23, read in part that the residence notified the practitioner and the resident ' s representative when the resident experienced a change in condition. Resident #43 was admitted to the residence on 8/11/23 with diagnoses including dementia and agitation. A written practitioner's order, dated 8/8/23, directed the residence to administer one tablet of aripiprazole 20 mg at bedtime. However, the December 2023 medication administration records (MAR) revealed that Resident #43 refused the medication on 12/11-12/25/23. However, there was no documentation that the residence notified the resident's family member or practitioner that Resident #46 routinely refused medication until the date of the onsite visit. A written practitioner's order, dated 8/8/23, directed the residence to administer one tablet of folic acid 1 mg in the morning. However, the December 2023 MAR revealed that Resident #43 refused the medication on 12/11-12/26/23. A written practitioner's order, dated 8/8/23, directed the residence to administer Lisinopril 10 mg in the morning. However, the December 2023 MAR revealed that Resident #43 refused the medication on 12/11-12/26/23. A written practitioner's order, dated 8/8/23, directed the residence to administer mirtazapine 7.5 mg at bedtime. However, the December 2023 MAR revealed that Resident #43 refused the medication on 12/11-12/25/23. A written practitioner's order, dated 8/8/23, directed the residence to administer vitamin B-1 100 mg once daily. However, the December 2023 MAR revealed that Resident #43 refused the medication on 12/11-12/26/23. On 12/27/23 at approximately 12:30 p.m., the practitioner for Resident #43 stated he was unaware the resident had been refusing his medications for the past 16 days. The practitioner stated on 12/27/23 (the second day of the onsite visit) he was notified by the health and wellness director of this situation. The practitioner further stated he was told that Resident #43 was not taking showers and refusing his medications, but was not made aware of the recent altercation that took place on 12/26/23. The practitioner stated he was very concerned because some of his medications were prescribed to maintain his mental health. He stated that when Resident #43 refused his medications he would become very anxious and have an increase in behavioral expressions. On 12/27/23 at 12:54 p.m., the power of attorney for Resident #43 stated that he was not notified until 12/26/23 of Resident #43 refusing his medications. On 12/2723 at 1:05 p.m., Staff #40 and #50 stated Resident #43 had been refusing his medications for the past couple of weeks. They stated Resident #43 had informed staff that he was no longer going to take his medications. They both stated the health and wellness director had been notified of the refusals. On 12/27/23 at approximately 1:30 p.m., the director of health and wellness stated that she was not notified of Resident #43 refused his medications until 12/26/23, the date of the onsite visit. She also stated she should have been made aware of this situation. On 12/27/23 at 3:34 p.m., the administrator stated he had been notified earlier in the day of Resident #43's refusals. The administrator stated he expected the resident's practitioner and responsible party to be notified right away when refusals started to occur. The administrator further stated the resident only trusted one practitioner in particular and that practitioner did not practice in the state.

Plan of correction · submitted by the facility

(Cross-reference Q1360, Q2130)Responses to the cited deficiencies do not constitute an admission or agreement by the community to the truth of the facts alleged or conclusion set forth in the statement of deficiencies. The plan of correction is prepared solely as a matter of compliance with federal and state law. A) With respect to HOW the facility will CORRECT the problem identified in the deficiency list:1. The Wellness Director notified Nurse practitioner and family of Resident #46 regarding medication refusals. Resident refused to be seen, family and Nurse practitioner decided to discontinue all medications as of 1/17/2024. B) With respect to what the facility will do to PREVENT the same deficiency from recurring:2. The Wellness Director/ designee educated QMAPs to report all medication refusals as an incident report for proper follow-up by the clinical team. This education occurred on 1/16/2024.3. Medication refusal incident reports will be reviewed daily in clinical meeting (M-F) to ensure proper notifications and follow-up completed. 4. The Wellness Director/ designee will track and trend medication refusal incident reports monthly for submission to the QAPI committee x 6 months to ensure substantial compliance.

1542Med/Med Adm-Med Strge LckdS/S B▼

Findings

Based on observation, record review, and interview, the residence failed to ensure all medications were stored in a locked cabinet, cart, or storage area when unattended by a qualified medication administration person or other licensed staff, affecting 19 current residents in the secure environment. Findings include: 1. Residence PolicyThe residence ' s Medication Policy, dated 7/26/16, read in part that the residence ensured medications were dispensed in a safe manner as required by state licensure. Resident medications were stored in a secure location. 2. ObservationsOn 12/26/23 at 7:36 a.m., Staff #18 unlocked the medication cart then walked away to the residence's kitchen and returned with tea for a resident. At that time eight residents were waiting for breakfast near the medication cart that was left unlocked. On 12/26/23 at 7:41 a.m., Staff #18 left the medication cart unlocked and left 5 medications sitting on top of the cart and administered medication to a resident in the dining room . At that time there were 12 residents in the area of the unlocked medication cart. On 12/26/23 at 7:43 a.m., Staff #18 arrived back at the unlocked medication cart. She then subsequently left leaving the cart unlocked and unsupervised and went in to the qualified medication administration office to obtain tissue. Staff #18 subsequently came back to the medication cart and locked it at 7:44 a.m. On 12/26/23 at 7:48 a.m., Staff #18 unlocked the medication cart and prepared medications for another resident. She dropped a pill on the floor and dispensed a replacement medication into the medication cup. Staff #18 subsequently left the bubble packages of the medications on top of the medication cart and went into the dining room to administer the medication. At that time there were 12 residents in the area of the unlocked medication cart with bubble packages of medications on top of the cart and one pill on the floor. On 12/26/23 at 7:53 a.m., Staff #18 arrived back at the medication cart, put the medications away and picked up the medication that had fallen on the floor. 3. InterviewOn 12/27/23 at 3:02 p.m., the administrator stated medication carts should have been locked when unattended. He further stated he had not been made aware of Staff #18 leaving the medication unlocked and unattended. On 12/27/2023 at 3:45 p.m., the director of health and wellness stated the medication cart should have been locked when unattended.

Plan of correction · submitted by the facility

2130HIR-Cntnt IncldS/S B▼

Findings

Based on record review, and interview, the residence failed to ensure that resident records contained progress notes, which included documentation regarding any out-of-the-ordinary event or issue that affected a resident, and failed to ensure that the resident records contained documentation of ongoing services provided by external service providers (ESP). Additionally, the residence failed to ensure staff members documented, before the end of their shift, events or issues regarding a resident that they observed or was reported to them, affecting nine of eleven sample residents (#15, #22, #33, #36, #38, #43-#46). (Cross-reference Q1360, Q1362, Q1522)Findings include: 1. Residence PolicyThe residence's Resident Health Information Record –Content policy, dated 12/26/23, read in part that the residence maintained appropriate and accurate records for each resident. Further, resident records contained progress notes and documentation of ongoing services by ESPs. The residence ' s Fall Risk Management policy, dated 12/26/23, read in part that the residence documented information regarding resident falls in progress notes. 2. Resident #36 was admitted to the residence on 3/31/23 with diagnoses including Parkinson ' s disease, a history of falling, and dysphagia. The progress notes, dated 10/29/23-12/22/23 read in part:On 11/14/23, an incident report was created for an unwitnessed fall. On 11/18/23, an incident report was created for an unwitnessed fall. On 12/06/23, an incident report was created for an unwitnessed fall. On 12/14/23, an incident report was created for an unwitnessed fall. However, the progress notes contained no specific information regarding the circumstances of the falls sustained by the resident. A review of the resident's record revealed no care plan completed by the resident ' s external hospice provider (EHP). On 12/27/23 at 1:23 p.m., the EHP provided a care plan for Resident #36 with a start-of-care date by the EHP of 6/23/23. On 12/27/23 at approximately 1:25 p.m., the residence subsequently provided an EHP care plan for the resident. 3. InterviewsOn 12/26/23 at 1:39 p.m., the EHP nurse stated that the EHP had a care plan for Resident #36; however, she could not recall if the residence had a copy of the care plan. On 12/26/23 at approximately 2:30 p.m., the health and wellness director (HWD) stated that the residence did not have a copy of the care plan from the EHP as the EHP was required to add the care plan to the resident record and had not. On 12/27/23 at 3:17 p.m., the administrator stated the residence should have been documented in residents ' progress notes and that incident reports did not replace progress notes. He added that if an incident report was documented as created in the progress notes, the residence should have documented an associated progress note. On 12/27/23 at 4:02 p.m., the HWD stated that the residence should have documented progress notes for out-of-the-ordinary events experienced by residents. She added she was unaware of the requirement that progress notes be documented before a staff member ' s shift ends. She stated that she would not consider an incident report a progress note. She stated that she was aware that there were incident reports without associated progress notes, and added that there were times when a nurse was not onsite to document. She added that the home office required documentation to be completed only by residence nurses. 4. Additionally, the residence failed to ensure that resident records contained progress notes, which included documentation regarding any out-of-the-ordinary event or issue that affected a resident, and failed to ensure that the resident records contained documentation of ongoing services provided by an ESP. Further, the residence failed to ensure staff members documented, before the end of their shift, events or issues regarding a resident that they observed or was reported to them for Residents #15, #22, #33, #38, #43-#46.

Plan of correction · submitted by the facility

2960Sec Env-Enhncd Rsdnt CP IncldS/S B▼

Findings

Based on record review and interview, the residence failed to ensure resident care plans contained a description of the resident's known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact, and the care plans contained a description of how the resident will have continuous independent access to his or her individual room, along with the residence ' s plan to protect the resident from unwanted visitation by other residents; affecting four of four sample residents who resided in the secure environment (#33, #38, #43, #46). (Cross-reference Q1360, Q2130)The residence ' s Care Plan policy, dated 2014, read in part that the residence ' s care plan for each resident would identify priority problems and how to be addressed by the residence. The residence's Enhanced Resident Care Plan policy, dated 12/26/23, read in part that the residence created and updated an enhanced care plan for each resident who resided in the secure environment. The policy required that an enhanced care plan contained a description of the residents ' behavioral expressions and individualized staff approaches to protect the resident and other residents with whom they have contact. Further, the enhanced care plan included how the resident had independent access to his or her room and a plan to prevent unwanted visitation by other residents. Resident #43 was admitted to the residence on 8/11/23 with diagnoses including dementia and agitation. A review of the residence ' s investigations of abuse revealed an incident report, dated 11/9/23, the report read in part that the incident classification was behavior –danger to others. The report read in part that Resident #43 was discovered yelling at an unidentified resident with an external service provider (ESP) standing between Resident #43 and the other resident. A residence staff member attempted to redirect the residents, and Resident #43 became very angry and pointed his finger in the other resident ' s face. The other resident no longer wanted to participate in the confrontation. As the other resident began to walk away, Resident #43 pushed the resident in the middle of the chest and the other resident fell on his bottom. The residence led the other resident away and Resident #43 stayed in the activity room for lunch. Further, the incident report contained no information regarding how the residence kept the residents safe during the investigation. A review of the service (care) plan, and service plan tasks, dated 11/13/23, revealed that the residence failed to update the residents ' care plans with descriptions of the resident's known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact, and his care plan contained no description of how the resident had continuous independent access to his individual room. On 12/26/23 at approximately 8:40 a.m., Staff #49 stated that Resident #43 was often aggressive with other residents. On 12/26/23 at 8:57 a.m., the memory care director (MCD) stated that Resident #43 became aggressive when residents got near his room. On 12/27/23 at 11:13 a.m., Staff #40 stated that Resident # 43 "man-handled" a female resident on 12/26/23 because she had attempted to enter his room. On 12/27/23 at 3:33 p.m., the administrator stated that he was aware that a resident ' s behavioral expressions and a plan for unwanted visitation were required in the enhanced care plan. He added that he was aware there were residents missing those elements in the enhanced care plans in the secure environment. On 12/27/23 at 4:23 p.m., the health and wellness director (HWD) stated that she assisted with the creation and updating of care plans for residents in the secure environment; however, she was unaware that behavioral expressions and staff approaches to protect residents, and a plan for unwanted visitation were required. She added that it was probably accurate that those elements were not in the care plans for residents in the secure environment. Additional non compliance with enhanced care plans was revealed with Residents #33, #38, #43 and #46.

Plan of correction · submitted by the facility

9999Final ObservationsSurveyor note▼

Findings

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 along with care coordination arrangements; and(F) Identify formal, planned, and informal spontaneous engagement opportunities that match the resident ' s personal choices and needs. 14.44 The assisted living residence shall have policies and procedures regarding the destruction and disposal of outdated, unused, discontinued, and/or expired medications which are not returned to the resident or legal representative. At a minimum, the policies and procedures shall include the following requirements:(A) Outdated, discontinued, and/or expired medications shall be destroyed in accordance with federal, state, and local regulations within thirty (30) days.(1) Medication shall be destroyed in the presence of two individuals, each of whom are either a qualified medication administration person, nurse, or practitioner;(2) All medications shall be destroyed in a manner that renders the substances totally non-retrievable to prevent diversion of the medication; and(3) There shall be documentation which identifies the medications, the date, and the method of destruction, and the signatures of the witnesses performing the medication destruction.

Plan of correction

The state did not require a plan of correction for this citation.

12/26/2023Revisit: Licensure Complaint · ID ZIBB13No deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 12/27/23 for the previous deficiency cited on 4/20/23. The residence is in compliance with all regulations surveyed.

Plan of correction

The state did not require a plan of correction for this citation.

12/26/2023Revisit: Licensure Complaint · ID QNJD133 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 12/27/23 for all previous deficiencies cited on 4/20/23. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

1110Res Care Srvs-Min Srvs Res AgrS/S E▼

Findings

Based on observation, interview, and record review, the residence failed to provide protective oversight, affecting one sample resident (#46). This deficiency was cited previously during a state licensure survey 4/20/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, On 12/26/23 at 11:40 a.m., staff prepared medications to Resident #46. Staff did not crush or dissolve the medications. Upon entry into the resident's room, Resident #46 was observed slouched in a chair with two pills on his right upper chest. Staff noticed the pills on his body, picked them and stated he did not take his medications this morning. The staff subsequently placed the two pills into the cup and stated they would let the director of nursing know of the missed medication. During interviews it was revealed the resident had swallowing difficulties since his diagnosis of COVID-19 approximately two months prior to the on-site visit. Staff and external hospice stated that the resident was choking when being administered his medications and therefore he required his medications to be crushed/dissolved. However, during record review it was revealed the resident had a crush/dissolve order for medications, dated 12/7/23, which was not transcribed on the medication administration record (MAR). This failure created an immediate jeopardy risk of protective oversight to Resident #46. On 12/26/23, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. References and Resident Agreementa. Chapter VII regulations governing assisted living residences defines, in part 2.38, protective oversight as "guidance of a resident as required by the needs of the resident or as reasonably requested by the resident, including the following: (B) Monitoring the activities of the resident while on the premises to ensure the resident's health, safety and well-being, including monitoring the resident's needs and ensuring that the resident receives the services and care necessary to protect the resident's health, safety, and well-being."B. According to the National Library of Medicine, "administering crushed medications mixed with a soft food or liquid vehicle, or via a feeding tube, is a common strategy to circumvent swallowing difficulties in patients with dysphagia." Amie Blaszczyk (October 2023) Et.al Drugs Aging, Retrieved from: http://www.pubmed.ncbi.nlm.nih.govc. The residence ' s Medication Policy, dated 7/26/16, read in part that the residence ensured medications were dispensed in a safe manner as required by state licensure. All medication received by the residence for administration were to be compared with the practitioner ' s order. d. The residence ' s Resident Agreement, read in part through its staff, would assist, or supervise, as appropriate, resident administration of medications directed by the resident ' s practitioner. 2. Resident #46 was admitted to the residence on 1/10/20, with diagnoses including frontotemporal dementia and dysphagia. a. Observations on 12/26/23 revealed the followingOn 12/26/23 at approximately 11:40 a.m., Staff #13 administered furosemide 20 mg tablet and potassium chloride 10 meq tablet. Both medications were administered whole per the medication administration record (MAR). Resident #46 subsequently began coughing. Staff #49 and Staff #19 then noticed that the resident had his morning medications sitting on his chest. Staff #49 and Staff #19 stated that his medications should have been crushed because he coughed during medication administration.b. Record ReviewA written practitioner ' s order, dated 12/7/23, directed the residence to crush all medications and dissolve tamsulosin and potassium chloride in water or orange juice. The residence ' s December 2023 MAR revealed no evidence the crush and dissolve order was transcribed onto the MAR and no evidence it was administered according to the written practitioner's order from 12/7-12/26/23 the day of the onsite visit. A progress note, dated 12/6/23 written by the external hospice registered nurse (RN), read in part: The qualified medication administration person (QMAP) had concerns with Resident #46 ' s ability to swallow his medications. An assessment for Resident #46, dated 10/23/23, read in part that the residence administered all medications to Resident #46. The residence staff provided spoon-feeding of medication as needed. The assessment contained no information about the resident experiencing swallowing difficulty. A care plan for Resident #46 dated 3/7/23, read in part that the residence administered all medication to Resident #46. The care plan contained no information about the resident experiencing swallowing difficulty. c. InterviewsOn 12/26/23 at approximately 11:40 a.m., Staff #13 and Staff #14 stated that they noticed a change in condition with Resident #46 and stated he was having difficulties swallowing his medications. On 12/26/23 at 1:19 p.m., the health and wellness director stated Resident #46 was seen by an external speech therapist. However, she stated she was not aware of the recommendations because she did not have the notes for the visit. The health and wellness director further stated the speech therapist would not write orders for the resident rather make recommendations. She further stated the residence had not received a crush order for Resident #46 and was not aware of any issues taking medications. On 12/26/23 at approximately 1:20 p.m., the external hospice nurse stated that she had seen a change in his condition approximately one month prior to the onsite visit when he was diagnosed with COVID-19. She stated Resident #46 never regained some of his abilities after his diagnosis. The external hospice nurse further stated she had written the crush order for the medications because staff was reporting he was having difficulty swallowing his medications. She stated she consulted with the resident's pharmacist who stated the potassium chloride and tamsulosin needed to be dissolved and not crushed. Additionally, the external hospice nurse stated that the residence needed to follow the orders because he was at immediate risk for aspiration and choking. On 12/26/23 at 2:50 p.m., the administrator stated he was not aware that Resident #46 had a crush/dissolve order and it was not being followed. He stated the pharmacy transcribed orders onto the MARs and the health and wellness director was responsible for ensuring the MARs were correct and all orders were added to the MARs. The administrator further stated he expected the residence to comply with all written practitioners orders associated with medication administration. d. Immediate Jeopardy - Written Evidence, Immediate CorrectionThe investigation established that the findings above placed Resident #46 at immediate jeopardy risk of choking and aspiration, due to difficulties with swallowing. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 12/26/23 at 3:53 p.m., the administrator submitted written evidence that read in pertinent part: "1. The wellness director or designee will provide immediate education for all QMAP (qualified medication administration person) personnel currently on the shift in the community regarding which residents are currently on crush orders. The wellness director or designee will provide education to all QMAP personnel currently on the shift in the community on the notification screen of the electronic health record (EHR) which identifies which resident is on crushed orders. 2. The wellness director or designee will provide education to 100% all QMAP personnel employed with the community regarding who in the community is on crush orders. This education will be completed in the next 48 hours. The wellness director or designee will provide education to 100% of all QMAP personnel employed with the community regarding the notification screen of the EHR which identifies if a resident is on crush orders. This education will be provided in the next 48 hours. The wellness director will work together with the practitioner and pharmacy to ensure that each individual medication can be crushed the, "To be crushed," verbiage in the order itself. This will be completed in the next 48 hours. The wellness director will work together with the practitioner and pharmacy to ensure that each resident whose medication can be crushed has an individual treatment order stating that the resident ' s medication is to be crushed per physician ' s orders for QMAP personnel to sign off on during each medication pass. This will be completed in 24 hours. 3. The wellness director, memory care director, or resident care coordinator will audit each resident with a crush order to ensure those medications are being crushed per practitioner orders. This audit will occur daily x 3 weeks, then weekly x 3 weeks to ensure compliance. Wellness director will audit all new orders daily Monday through Friday to ensure all new crushed orders are implemented on the MAR with the correct, "to be crushed," verbiage as well as the treatment order stating that the resident ' s medications are to be crushed per physician ' s orders. 4. The results of these audits will be reviewed daily Monday through Friday in clinical meeting three months to ensure ongoing compliance. The results of these audits will be reviewed monthly x 3 in QAPI meeting to ensure compliance.``However, the written evidence did not demonstrate the risk had been removed because it did not include specific information regarding Resident #46, education element for the health and wellness director, and a change of timeframe for the residence to provide education to the residence ' s QMAPs. The administrator was directed to submit additional written evidence. On 12/26/23 at 4:26 p.m., the administrator submitted written evidence that read in pertinent part: "1. The crush order for Resident #46 was updated in the MAR on 12/26/23 ... Education will be provided to the wellness director regarding proper process and procedure for order transcription within the MAR. This will be completed by (home office) director of health services on 12/26/23." Further, the administrator changed the timeframe for education for the QMAPs from within 48 hours to prior to the next shift. The administrator added verbiage regarding monitoring of medication administration by residence QMAPs. However, the written evidence did not indicate the risk had been removed because it did not include the administrator ' s oversight. The administrator was directed to submit additional written evidence. On 12/27/23 at 7:53 a.m., the administrator submitted written evidence that read in pertinent part: "The executive director (administrator) will spot check 5 orders per week x 1 month, then 5 orders per month x 2 months to ensure each order is transcribed properly."e. Continued deficient practice on 12/27/23On 12/27/23 at approximately 8:30 a.m., Staff #49 crushed all of Resident #46's medications including the potassium chloride tablet which was ordered to be dissolved. However, the staff disposed of the medications because he was in the middle of eating. On 12/27/23 at 9:26 a.m., the memory care director prepared the medications for a second time and subsequently crushed all of them including the potassium chloride tablet. An updated December 2023 MAR for Resident #46 was requested on 12/27/23 at 10:43 a.m. and again at 12:11 p.m. The updated MAR was received at approximately 1:00 p.m. and directed staff to crush medications that were crushable and to dissolve the potassium chloride and tamsulosin. However, the MAR revealed the dissolve order was notadded to the MAR until after morning medication pass. On 12/27/23 at 11:00 a.m., a pharmacist For Resident #46 stated that not dissolving potassium chloride could cause the resident gastrointestinal distress. On 12/27/23 at 4:39 p.m., the administrator stated the deficiency had not been corrected because Resident #46 was administered medications improperly.

Plan of correction · submitted by the facility

1. Specific CorrectionThe residence will immediately implement effective protective oversight for resident medication administration orders consistent with the requirements of 6 CCR 1011-1 Chapter 7 Assisted Living Residences Part 12.1 (A)(B)(C)(D)(E). For Resident #46 (R46), if still residing in the residence, the administrator, resident care coordinator, health and wellness director, licensed nurse(s) and applicable members of the residence leadership team, shall:(1) Contact the pharmacist from the resident’s pharmacy to ensure the facility may safely crush or dissolve each medication prescribed for R46. If the pharmacist identifies a discrepancy in the safety of crushing or dissolving a prescribed medication, the facility will coordinate with the pharmacy and the resident’s prescriber to use a medication that can be safely crushed or dissolved for administration.(2) Transcribe the applicable crush/dissolve order on to each of R46’s medication administration orders, as applicable, based on review by the pharmacist and, if needed, the prescriber.(3) Before their next shift, the licensed nurse will educate each qualified medication administration person (QMAP) on how to safely crush and/or dissolve medications for administration to R46. Each QMAP will complete a successful return demonstration of crushing and dissolving a medication for administration. As needed (PRN) medication administration staff and those presently on scheduled leave will receive this training and return demonstration before their next scheduled shift.(4) Update the care plan to reflect the R46’s swallowing deficit and the approaches the facility will implement to promote swallowing safety for medication administration. 2. Identification of Others Affected or Potentially AffectedThe administrator, resident care coordinator, health and wellness director, licensed nurse(s) and applicable members of the residence leadership team shall complete the following steps to identify others:(1) Conduct a record review of each resident receiving medication administration assistance to identify other residents with unimplemented crush/dissolve prescriber orders. The residence will obtain proper medication alteration practice instructions from the dispensing pharmacist for any unimplemented crush/dissolve order identified during the audit.(2) Audit the care plans for each resident with active crush/dissolve orders to ensure the care plans accurately reflect any swallowing precautions and crush/dissolve orders. 3. System Changes to Prevent RecurrenceThe administrator, resident care coordinator, health and wellness director, licensed nurse(s) and applicable members of the residence leadership team will oversee the development and implementation of a system to ensure prescriber medication crush/dissolve/alteration orders are promptly identified and implemented. This should include:(1) Develop and implement a daily prescriber order review to ensure all new prescriber orders, particularly orders for medication alteration are identified and are correctly entered in the medication administration records. The daily review will include:Verification of accurate medication order entry by a licensed nurse and a leader from the medication administration team. Updating the applicable resident care plan if the medication order reflects a change in the resident’s care needs. Educating medication administration staff on medication administration order changes and care plan changes. Documenting all medication change order reviews, changes, updates, and associated education on a daily log.(2) The administrator will educate all medication administration and nursing staff on their role in identifying and communicating new prescriber medication orders. This education will address the regulatory requirements specified in 6 CCR 1011-1 Chapter 7 Assisted Living Residences Part 12.1 (A)(B)(C)(D)(E). Educational topics will include:Examples of medication change orders that should be brought to leadership’s attention. Instructions on how to report any medication change orders to residence leadership. Instructions on administering crushed and dissolved medications. The administrator will conduct written, post-education evaluation of all residence staff to assure each staff member understands the education provided and will be able to identify and respond to any medication administration changes.(3) The residence will implement ongoing training for new-hire medication administration staff to ensure they can identify and report medication administration change orders to appropriate facility leadership.(4) The residence will implement ongoing verification that new-hire medication administration staff can correctly prepare and administer crushed medications and dissolved medications in accordance with prescriber orders and the plan of care. 4. Monitoring of Corrective ActionMonitoring of approaches to ensure the residence consistently identifies and mitigates all safety concerns in the resident environment will include:(1) Weekly, for no less than twelve weeks, administrator(s), wellness/care manager(s), and applicable members of the residence leadership team, will:Review all the log for medication administration order changes to ensure orders are being identified and implemented in accordance with 6 CCR 1011-1 Chapter 7 Assisted Living Residences Part 12.1 (A)(B)(C)(D)(E). Observe medication administration for any resident with a change order to ensure staff are implementing changes in accordance with the requirements for 6 CCR 1011-1 Chapter 7 Assisted Living Residences Part 12.1 (A)(B)(C)(D)(E). After twelve consecutive weeks monitoring that demonstrates staff are consistently identifying and addressing medication administration order changes, the frequency of rounding audit reviews will reduce from weekly to monthly and shall continue monthly for no less than three additional months or until there are three consecutive months of satisfactory performance.(2) The administrator shall track and trend the success of all quality management program activities related to ensuring a protective oversight of the medication administration process. Such tracking and trending data shall be reported to the quality management program committee monthly for no less than three months and shall continue until all performance plan objectives related to identification, investigation, and reporting of abuse and neglect are consistently maintained. 5. Correction Date05/14/2024

1468Med/Med Adm-Ordrs Cmpy w/OrdrsS/S C▼

Findings

Based on observation, interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting six of nine sample residents whose medications were reviewed (#15, #22, #33, #38, #45 and #47). This deficiency was cited previously during a state licensure survey 4/20/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Resident #47 was prescribed timolol 0.5% eye drops twice daily for glaucoma. From 12/25-12/27/23 the medication was out of stock and Resident #47 stated she experienced painful pressure in her eyes. The pharmacist for Resident #47 stated that increased eye pressure and blurred vision were common side effects due to not being administered timolol timely. Findings include:1. Reference and Residence Policya. According to Mayo Clinic, Timolol eye drops "are used to treat increased pressure in the eye that is caused by open-angle glaucoma or a condition called ocular (eye) hypertension. The medication must be used exactly as directed by a doctor ..." Mayo Clinic (12/1/23), Timolol (Ophthalmic Route), retrieved from: https://www.mayoclinic.org/drugs-supplements/timolol-ophthalmic-route/precautions/drg-20071111b. According to the National Health Service "It's important to use your eye drops regularly and go for check-ups with your eye specialist to stop your sight getting worse. Do not stop timolol suddenly without talking to your doctor, as it may make your eye condition worse ..." NHS (8/25/22), How and When to Use Timolol Eye Drops, retrieved from: https://www.nhs.uk/medicines/timolol-eye-drops/how-and-when-to-use-timolol-eye-drops/c. The residence's Medication Administration Policy, dated 7/26/16, read in part: "ensure medications are dispensed in a safe manner in the community ... employees who are appropriately licensed ... (are) to assist with and/or administer medications (including opioids) in the community as dictated by state regulations."2. Resident #47 was admitted to the residence on 9/20/23 with a diagnosis of glaucoma.a. TimololA written practitioner's order, dated 11/28/23, directed the residence to instill timolol ophthalmic solution 0.5% one drop in each eye twice daily. However, the December 2023 electronic medication administration record (eMAR) read timolol was not administered on 12/25 in the evening, 12/26 in the morning, and interviews revealed the medication was not administered 12/26 in the evening of 12/27/23 in the morning either due to the medication being out of stock, for a total of four missed doses. b. LatanoprostA written practitioner's order, dated 11/28/23, directed the residence to instill latanoprost ophthalmic solution 0.005% one drop in each eye at bedtime. However, the December 2023 eMAR read latanoprost was not administered 12/19-12/21/23 due to the medication being out of stock, for a total of three missed doses. c. Benztropine A written practitioner's order, dated 11/28/23, directed the residence to administer benztropine mesylate 1 mg once daily. However, the December 2023 eMAR read benztropine was not administered 12/7 and 12/8/23 due to the medication being out of stock, for a total of two missed doses.d. Vitamin b12A written practitioner's order, dated 11/28/23, directed the residence to administer vitamin b12 1000 mcg daily. However, the December 2023 eMAR read vitamin b12 was not administered 12/13 and 12/14/23 due to the medication being out of stock, for a total of two missed doses. e. LactuloseA written practitioner's order, dated 11/28/23, directed the residence to administer Lactulose 45 mL once daily. However, the December 2023 eMAR read Lactulose was not administered 12/17/23 due to the medication being out of stock, for a total of one missed dose. On 12/27/23 at 7:42 a.m., Resident #47 stated she had experienced issues with not getting her medication as ordered from the residence and stated her timolol was still out of stock. She further stated "there is no exception for not getting my medication. I am paying so much money each month to live here and am about ready to get an order to manage my own medications. Ask any of the other residents, it is not just me who is having issues getting medications."On 12/27/23 at 8:35 a.m., Resident #47 stated that the residence had not administered her timolol eye drops since 12/22/23 and she had experienced painful pressure in her eyes that made her want to, "scratch her eyes out of her head." On 12/27/23 at 10:01 a.m., the health and wellness director (HWD) stated Resident #47 had cycle filled medications and the insurance provider for Resident #47 would not pay to fill timolol since it had just been filled in December 2023. The HWD stated staff may have accidentally missed administered drops in the eye and the medication ran out early. The HWD stated Resident #47 had expressed concerns to her that if her eye pressure was too high from not having received her timolol drops, she would be unable to have her cataract surgery in January 2024. On 12/27/23 at 10:33 a.m., the residence's preferred pharmacy's pharmacist stated effects to Resident #47 not being administered her timolol, included increased eye pressure and blurred vision. The pharmacist further stated timolol was last delivered to the residence on 12/14/23 and was unsure how the medication could have been out of stock. He further stated insurance would not cover the medication being lost or used up within 30 days. On 12/27/23 at 11:51 a.m., a medication cart audit was conducted for Resident #47 and revealed her timolol which was not administered and had been marked as out of stock, was found in an unlabeled section of the bottom drawer of the medication cart instead of the top drawer of the medication cart where Resident #47's eye drops were stored. On 12/27/23 at 3:15 p.m., the administrator stated the HWD was responsible for ordering medications and ensuring they were in stock for both the assisted living and secure environment. The administrator stated he would expect the residence to have complied with practitioner's orders related to medication administration and was unaware it had not occurred. On 12/27/23 at 4:05 p.m., the HWD stated she was responsible for ordering medications and ensuring they were in stock alongside the licensed practical nurse (LPN). The HWD acknowledged she would expect medications to be administered in accordance with practitioner's orders. She acknowledged she was aware there were medications that were not delivered by the pharmacy when they were supposed to be; however, stated "when you and I go to the pharmacy even we have to wait for medications to come in stock." On 12/27/23 at 4:39 p.m., the administrator stated he was unsure as to why this deficiency had not been corrected. Additional non compliance with practitioner's orders was revealed with Resident #15, #22, #33, #38 and #45.

Plan of correction · submitted by the facility

1. Specific CorrectionThe residence will immediately implement corrective action to ensure the residence complies with authorized practitioner orders for those medications administer by the residence, in accordance with the requirements of 6 CCR 1011-1 Chapter 7 Section 14.21. The qualified medication administration person (QMAP) supervisor and applicable members of the interdisciplinary team (IDT), will complete the following for Residents #15, #22, #33, #38, #45 and #47:(1) Audit current medication administration record (MAR) and practitioner orders to ensure the authorized practitioner order for each medication the resident is presently receiving is accurately reflected on the current MAR. Any medications identified with a discrepancy will be reported to the authorized practitioner for resolution of the discrepancy.(2) Audit all current authorized practitioner orders to ensure a sufficient (not less than seven days) supply of each medication is on hand for administration to the resident. Any medication with less than a seven-day supply will be reordered immediately. Any medication without an authorized practitioner order will be removed from the medication cart/storage area and returned to the resident or disposed of, in accordance with residence policy.(3) Identify the staff members involved in these residents’ medications errors. Provide these staff with education on how to address discrepancies in authorized practitioner orders and preventing and addressing out-of-stock medications, in accordance with residence policy. 2. Identification of Others Affected or Potentially AffectedThe QMAP supervisor and applicable members of the IDT shall employ the following steps to identify other residents for whom the residence failed to administer medications per authorized practitioner orders:(1) Audit the medication regimens for all residents receiving medication assistance to determine if each authorized practitioner order matches the current MAR. The residence will contact the residents authorized practitioner for resolution of any ongoing discrepancy identified during the medication regimen audit.(2) Audit all current authorized practitioner orders for residents receiving medication assistance to ensure a sufficient (not less than seven days) supply of each medication is on hand for administration to the resident. Any medication with less than a seven-day supply will be reordered immediately. Any medication without an authorized practitioner order will be removed from the medication cart/storage area and returned to the resident or disposed of, in accordance with residence policy.(3) Identify any staff members involved in any newly identified failures to administer medications per authorized practitioner orders. Provide these staff with education on how to prevent and mitigate such failures, in accordance with residence policy. 3. System Changes to Prevent RecurrenceThe QMAP supervisor and applicable members of the IDT, shall oversee the development and implementation of procedures to ensure staff administer medications per authorized practitioner orders. This should include but not be limited to:(1) Developing and implementing an effective action plan to ensure each medication order is accurately and timely transcribed to the MAR. This plan must also include timely discontinuing medications, as ordered by the authorized practitioner.(2) Developing and implementing an effective action plan to ensure the residence maintains a minimum par level of each medication administered by the residence on hand to prevent each medication’s being out of stock.(3) Educating all nurses and QMAPs on: The seven rights of medication administration – right patient, right drug, right dose, right time, right route, right reason, and right documentation. Each staff’s role in implementing the action plans for administering medications in accordance with authorized practitioner orders and ensuring sufficient and accurate stock of each ordered/discontinued medication in the resident’s medication regimen. Educating staff on the potential outcomes that could experienced by Residents #22, #28, #34, #35, #37 and #38 that result from not administering medications per practitioner orders. 4. Monitoring of Corrective ActionThe residence will implement a program of ongoing monitoring to ensure corrective actions are effective and sustained.(1) Weekly, for no less than three months, the QMAP supervisor and pertinent interdisciplinary team members will audit/monitor the residence’s compliance with administering medication per authorized practitioner orders to ensure the actions taken to correct deficient practice continue and are effective. The monitoring includes:Auditing MARs and authorized practitioner orders for Residents #15, #22, #33, #38, #45 and #47 and at least one other resident on each unit/floor/neighborhood to ensure medications are administered per authorized practitioner orders. Auditing authorized practitioner orders with medication storage/carts for Residents #15, #22, #33, #38, #45 and #47 and at least one other resident on each unit/floor/neighborhood to ensure medications are maintained in sufficient amounts to administer medications per authorized practitioner orders. When monitoring audits demonstrate consistent compliance with administering medications per authorized practitioner orders the frequency of monitoring audits will reduce from weekly to monthly and will continue for no less three months.(2) The administrator/designee shall track and trend the success of all quality assurance performance improvement activities related to administering medications per authorized practitioner orders. Such tracking and trending data will be reported to the quality assurance performance improvement committee monthly for no less than three months and shall continue until all performance plan objectives related to maintaining a timely updated state license is consistently implemented. 5. Correction Date05/14/2024

1510Med/Med Adm-Rcrd Kpng MARS/S A▼

Findings

Based on interview and record review the residence failed to ensure medication was documented at the time of administration affecting one sample resident (46). Findings include: Resident #46 was admitted to the residence on 1/10/20, with diagnoses including frontotemporal dementia and dysphagia. A written practitioner's order, dated 12/8/23, directed the residence to administer cephalexin 500 mg twice daily for five days. However, the December 2023 medication administration record (MAR) read the medication was administered from 12/9-12/15/23 for a total of 11 doses administered. On 12/2723 at 3:45 p.m., the administrator stated he expected if the medication was administered staff should have documented on the MAR at the time of administration.

Plan of correction · submitted by the facility

9999Final ObservationsSurveyor note▼

Findings

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 along with care coordination arrangements; and(F) Identify formal, planned, and informal spontaneous engagement opportunities that match the resident ' s personal choices and needs. 14.44 The assisted living residence shall have policies and procedures regarding the destruction and disposal of outdated, unused, discontinued, and/or expired medications which are not returned to the resident or legal representative. At a minimum, the policies and procedures shall include the following requirements:(A) Outdated, discontinued, and/or expired medications shall be destroyed in accordance with federal, state, and local regulations within thirty (30) days.(1) Medication shall be destroyed in the presence of two individuals, each of whom are either a qualified medication administration person, nurse, or practitioner;(2) All medications shall be destroyed in a manner that renders the substances totally non-retrievable to prevent diversion of the medication; and(3) There shall be documentation which identifies the medications, the date, and the method of destruction, and the signatures of the witnesses performing the medication destruction.

Plan of correction

The state did not require a plan of correction for this citation.

12/26/2023Revisit: Licensure Complaint · ID B28U128 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 12/27/23 for all previous deficiencies cited on 4/20/23. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0246LicProc-IssueLic Cond LicS/S B▼

Findings

Based on interviews and record review, the residence failed to comply with conditions imposed by the department on the license, affecting 107 current residents. Findings include:The department completed a complaint investigation on April 20, 2023. Eleven deficiencies were cited: Tag 540 B, 736 B, 1110 A, 1146 B, 1180 D, 1360 E, 1430 A, 1468 B, 1510 B, 2130 B, and 290 B. Tag 1180 was cited ata D level, pattern of harm, as the residence failed to implement a fall management program. Tag 1360 was cited at E level, immediate jeopardy, as the residence failed to investigate allegations of abuse. Part 3.16 of the Chapter 7 regulations requires the department to impose a fine for all E level deficiencies. The department imposed a civil fine of $2000, payable by 10/19/23. Department records revealed that the residence had not paid the required civil fine on October 19, 2023. On 1/17/24 at 10:29 a.m., the administrator stated that he was unaware that the residence had an unpaid fine that was overdue to the department. He added he was not surprised the residence failed to pay the fine since the residence had many citations and many letters in the communication portal with the department.

Plan of correction · submitted by the facility

1110Res Care Srvs-Min Srvs Res AgrS/S E▼

Findings

Based on observation, interview, and record review, the residence failed to provide protective oversight, affecting one sample resident (#46) (Cross-reference Q1146). This deficiency was cited previously during a state licensure survey 4/20/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, On 12/26/23 at 11:40 a.m., staff prepared medications to Resident #46. Staff did not crush or dissolve the medications. Upon entry into the resident's room, Resident #46 was observed slouched in a chair with two pills on his right upper chest. Staff noticed the pills on his body, picked them and stated he did not take his medications this morning. The staff subsequently placed the two pills into the cup and stated they would let the director of nursing know of the missed medication. During interviews it was revealed the resident had swallowing difficulties since his diagnosis of COVID-19 approximately two months prior to the on-site visit. Staff and external hospice stated that the resident was choking when being administered his medications and therefore he required his medications to be crushed/dissolved. However, during record review it was revealed the resident had a crush/dissolve order for medications, dated 12/7/23, which was not transcribed on the medication administration record (MAR). This failure created an immediate jeopardy risk of protective oversight to Resident #46. On 12/26/23, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. References and Resident Agreementa. Chapter VII regulations governing assisted living residences defines, in part 2.38, protective oversight as "guidance of a resident as required by the needs of the resident or as reasonably requested by the resident, including the following: (B) Monitoring the activities of the resident while on the premises to ensure the resident's health, safety and well-being, including monitoring the resident's needs and ensuring that the resident receives the services and care necessary to protect the resident's health, safety, and well-being."B. According to the National Library of Medicine, "administering crushed medications mixed with a soft food or liquid vehicle, or via a feeding tube, is a common strategy to circumvent swallowing difficulties in patients with dysphagia." Amie Blaszczyk (October 2023) Et.al Drugs Aging, Retrieved from: http://www.pubmed.ncbi.nlm.nih.govc. The residence's Medication Policy, dated 7/26/16, read in part that the residence ensured medications were dispensed in a safe manner as required by state licensure. All medication received by the residence for administration were to be compared with the practitioner ' s order. d. The residence's Resident Agreement, read in part through its staff, would assist, or supervise, as appropriate, resident administration of medications directed by the resident ' s practitioner. 2. Resident #46 was admitted to the residence on 1/10/20, with diagnoses including frontotemporal dementia and dysphagia. a. Observations on 12/26/23 revealed the followingOn 12/26/23 at approximately 11:40 a.m., Staff #13 administered furosemide 20 mg tablet and potassium chloride 10 meq tablet. Both medications were administered whole per the medication administration record (MAR). Resident #46 subsequently began coughing. Staff #49 and Staff #19 then noticed that the resident had his morning medications sitting on his chest. Staff #49 and Staff #19 stated that his medications should have been crushed because he coughed during medication administration.b. Record ReviewA written practitioner's order, dated 12/7/23, directed the residence to crush all medications and dissolve tamsulosin and potassium chloride in water or orange juice. The residence's December 2023 MAR revealed no evidence the crush and dissolve order was transcribed onto the MAR and no evidence it was administered according to the written practitioner's order from 12/7-12/26/23 the day of the onsite visit. A progress note, dated 12/6/23 written by the external hospice registered nurse (RN), read in part: The qualified medication administration person (QMAP) had concerns with Resident #46's ability to swallow his medications. An assessment for Resident #46, dated 10/23/23, read in part that the residence administered all medications to Resident #46. The residence staff provided spoon-feeding of medication as needed. The assessment contained no information about the resident experiencing swallowing difficulty. A care plan for Resident #46 dated 3/7/23, read in part that the residence administered all medication to Resident #46. The care plan contained no information about the resident experiencing swallowing difficulty. c. InterviewsOn 12/26/23 at approximately 11:40 a.m., Staff #13 and Staff #14 stated that they noticed a change in condition with Resident #46 and stated he was having difficulties swallowing his medications. On 12/26/23 at 1:19 p.m., the health and wellness director stated Resident #46 was seen by an external speech therapist. However, she stated she was not aware of the recommendations because she did not have the notes for the visit. The health and wellness director further stated the speech therapist would not write orders for the resident rather make recommendations. She further stated the residence had not received a crush order for Resident #46 and was not aware of any issues taking medications. On 12/26/23 at approximately 1:20 p.m., the external hospice nurse stated that she had seen a change in his condition approximately one month prior to the onsite visit when he was diagnosed with COVID-19. She stated Resident #46 never regained some of his abilities after his diagnosis. The external hospice nurse further stated she had written the crush order for the medications because staff was reporting he was having difficulty swallowing his medications. She stated she consulted with the resident's pharmacist who stated the potassium chloride and tamsulosin needed to be dissolved and not crushed. Additionally, the external hospice nurse stated that the residence needed to follow the orders because he was at immediate risk for aspiration and choking. On 12/26/23 at 2:50 p.m., the administrator stated he was not aware that Resident #46 had a crush/dissolve order and it was not being followed. He stated the pharmacy transcribed orders onto the MARs and the health and wellness director was responsible for ensuring the MARs were correct and all orders were added to the MARs. The administrator further stated he expected the residence to comply with all written practitioners orders associated with medication administration. d. Immediate Jeopardy - Written Evidence, Immediate CorrectionThe investigation established that the findings above placed Resident #46 at immediate jeopardy risk of choking and aspiration, due to difficulties with swallowing. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 12/26/23 at 3:53 p.m., the administrator submitted written evidence that read in pertinent part: "1. The wellness director or designee will provide immediate education for all QMAP (qualified medication administration person) personnel currently on the shift in the community regarding which residents are currently on crush orders. The wellness director or designee will provide education to all QMAP personnel currently on the shift in the community on the notification screen of the electronic health record (EHR) which identifies which resident is on crushed orders. 2. The wellness director or designee will provide education to 100% all QMAP personnel employed with the community regarding who in the community is on crush orders. This education will be completed in the next 48 hours. The wellness director or designee will provide education to 100% of all QMAP personnel employed with the community regarding the notification screen of the EHR which identifies if a resident is on crush orders. This education will be provided in the next 48 hours. The wellness director will work together with the practitioner and pharmacy to ensure that each individual medication can be crushed the, "To be crushed," verbiage in the order itself. This will be completed in the next 48 hours. The wellness director will work together with the practitioner and pharmacy to ensure that each resident whose medication can be crushed has an individual treatment order stating that the resident's medication is to be crushed per physician's orders for QMAP personnel to sign off on during each medication pass. This will be completed in 24 hours. 3. The wellness director, memory care director, or resident care coordinator will audit each resident with a crush order to ensure those medications are being crushed per practitioner orders. This audit will occur daily x 3 weeks, then weekly x 3 weeks to ensure compliance. Wellness director will audit all new orders daily Monday through Friday to ensure all new crushed orders are implemented on the MAR with the correct, "to be crushed," verbiage as well as the treatment order stating that the resident's medications are to be crushed per physician ' s orders. 4. The results of these audits will be reviewed daily Monday through Friday in clinical meeting three months to ensure ongoing compliance. The results of these audits will be reviewed monthly x 3 in QAPI meeting to ensure compliance.``However, the written evidence did not demonstrate the risk had been removed because it did not include specific information regarding Resident #46, education element for the health and wellness director, and a change of timeframe for the residence to provide education to the residence's QMAPs. The administrator was directed to submit additional written evidence. On 12/26/23 at 4:26 p.m., the administrator submitted written evidence that read in pertinent part: "1. The crush order for Resident #46 was updated in the MAR on 12/26/23 ... Education will be provided to the wellness director regarding proper process and procedure for order transcription within the MAR. This will be completed by (home office) director of health services on 12/26/23." Further, the administrator changed the timeframe for education for the QMAPs from within 48 hours to prior to the next shift. The administrator added verbiage regarding monitoring of medication administration by residence QMAPs. However, the written evidence did not indicate the risk had been removed because it did not include the administrator's oversight. The administrator was directed to submit additional written evidence. On 12/27/23 at 7:53 a.m., the administrator submitted written evidence that read in pertinent part: "The executive director (administrator) will spot check 5 orders per week x 1 month, then 5 orders per month x 2 months to ensure each order is transcribed properly."e. Continued deficient practice on 12/27/23On 12/27/23 at approximately 8:30 a.m., Staff #49 crushed all of Resident #46's medications including the potassium chloride tablet which was ordered to be dissolved. However, the staff disposed of the medications because he was in the middle of eating. On 12/27/23 at 9:26 a.m., the memory care director prepared the medications for a second time and subsequently crushed all of them including the potassium chloride tablet. An updated December 2023 MAR for Resident #46 was requested on 12/27/23 at 10:43 a.m. and again at 12:11 p.m. The updated MAR was received at approximately 1:00 p.m. and directed staff to crush medications that were crushable and to dissolve the potassium chloride and tamsulosin. However, the MAR revealed the dissolve order was not added to the MAR until after morning medication pass. On 12/27/23 at 11:00 a.m., a pharmacist For Resident #46 stated that not dissolving potassium chloride could cause the resident gastrointestinal distress. On 12/27/23 at 4:39 p.m., the administrator stated the deficiency had not been corrected because Resident #46 was administered medications improperly.

Plan of correction

The state did not require a plan of correction for this citation.

1146Res Care Srvs-Comp Res Asmnt Annl/CICS/S A▼

Findings

Based on observation, interview and record review, the residence failed to update the comprehensive assessment whenever a resident's condition changed from baseline status affecting one sample resident (#46). (Cross-reference Q1110). This deficiency was cited previously during a state licensure survey 4/20/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. 1. ReferenceChapter VII regulations governing assisted living residences, part 12.7, requires that the comprehensive assessment shall include all the following items: (B) Information regarding the resident's overall health and physical functioning ability; (D) Communication ability and any specific needs to facilitate effective communication;(E) Current diagnoses and any known or anticipated need or impact related to the diagnoses and (F) Food and dining preferences, unique needs and restrictions; (G) Individual bathroom routines, sleep and awake patterns. 2. Resident #46 was admitted to the residence on 1/10/20, with diagnoses including frontotemporal dementia and dysphagia. On 12/27/23 at 9:26 a.m., the memory care director (MCD) was preparing to administer Resident #46's medication. Staff #49 came to reposition the resident before he received his medication and the MCD stopped her and said that she needed to have another person help her to reposition the resident. The MCD subsequently crushed the potassium chloride and tamsulosin, both of which had orders to be dissolved. On 12/5/23, the practitioner ordered that Resident #46 be on a mechanical soft diet. An external hospice nurse order, dated 12/6/23, read in part: The qualified medication administration person (QMAP) had concerns with Resident #46's ability to swallow his medications. An external hospice note, dated 12/16/23 read in part:Resident #46 has not gained strength back since his COVID-19 diagnosis. An assessment, dated 10/23/23, read in part: Resident #46 did not need any dietary preferences and was independent at meal times. The assessment failed to contain his change in condition, he required mechanical soft foods and medications to be crushed or dissolved. Additionally, the assessment read Resident #46 required a one-person assist with transfers. However, observations and interviews revealed Resident #46 required two-person assistance with transfers. Further, the assessment read that the resident was at risk for skin breakdown and failed to contain information about a pressure sore despite an interview that the resident had a pressure sore. On 12/26/23 at approximately 11:40 a.m., Staff #13 and Staff #14 stated that they noticed a change in condition with Resident #46 and stated he had difficulty swallowing his medications..On 12/26/23 at approximately 1:20 p.m., the external hospice nurse stated that she had seen a change in his condition approximately one month prior to the onsite visit following his diagnosis of COVID-19. She further stated Resident #46 had developed a pressure sore and required assistance from two to three staff for transfer assistance. On 12/27/23 at 3:45 p.m., the administrator stated that assessments should have been completed every six months for residents in the secure environment or updated with a change in condition.

Plan of correction · submitted by the facility

1360Res Rts-Inv Ab/Neg Alleg or Inj Unk Org A/NS/S B▼

Findings

Based on record review and interviews, the residence failed to investigate allegations of abuse, in accordance with regulation and written policy affecting 19 current residents in the secure environment. (Cross-reference Q2130)This deficiency was cited previously during a state licensure survey 4/20/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include:1. Reference and Residence PolicyChapter VII regulations governing assisted living residences, requires in part 13.11, that the assisted living residence shall investigate all allegations of abuse, neglect, or exploitation of residents in accordance with its written policy. The written policy is required to include the following:(A) Reporting requirements to the appropriate agencies, such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator; (B) A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation; (C) The process for investigating such allegations; (D) How the assisted living residence will document the investigation process to evidence the required reporting and that a thorough investigation was conducted; (E) A requirement that the resident shall be protected from potential future abuse or neglect, and/or exploitation while the investigation is being conducted; (F) A requirement that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action; and (G) A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review. The residence's Resident Abuse Prevention policy, dated 8/2/23, defined abuse as the non-accidental act of physical mistreatment. The policy read in part that each resident had the right to be free from physical abuse and that the residence took immediate, corrective action when an abuse allegation was verified to ensure that the abuse did not re-occur. Further, the residence protected any resident involved in an investigation, such as increased resident supervision by staff or family presence while conducting the investigation using the residence's Abuse Investigation Report Form. 2. Resident #43 was admitted to the residence on 8/11/23 with diagnoses including dementia and agitation.a. Allegation of abuse on 11/9/23A review of the residence ' s investigations of abuse revealed an incident report, dated 11/9/23, the report read in part that the incident classification was behavior, danger to others. The report read in part: Resident #43 was discovered yelling at an Former Resident #49 with an external service provider (ESP) standing between Resident #43 and the Former Resident #49. A residence staff member attempted to redirect the residents, and Resident #43 became very angry and pointed his finger in the face of Former Resident #49. Former Resident #49 no longer wanted to participate in the confrontation. As the other resident began to walk away, Resident #43 pushed the resident in the middle of the chest and the other resident fell on his bottom. The residence led the other resident away and Resident #43 stayed in the activity room for lunch. Further, the incident report contained no information regarding how the residence kept the residents safe during the investigation. A review of the service (care) plan, and service plan tasks, dated 11/13/23, revealed that the residence put no measures in place that protected all residents involved from potential future abuse while the investigation was being conducted. Further, the review revealed no increased safety checks were added on or after 11/9/23. Per the residence's Resident Abuse Prevention policy, the residence failed to ensure each resident's right to be from abuse was ensured, that the residence had taken immediate action, and that the resident protected any resident involved in an investigation. On 12/27/23 at 3:14 p.m., the administrator stated that the residence was required to detail how the residence kept residents safe while the residence conducted an abuse. He added he was unaware that the residence put no measures in place in the care plan that protected or provided protection from Resident #43 during or after abuse was alleged on 11/9/23On 12/27/23 at 3:56 p.m., the health and wellness director (HWD) stated that she was aware that there was a requirement for the residence to put measures in place to protect all residents involved with an allegation of abuse from future abuse. She stated that contrary to the investigation notes for the incident on 11/9/23 that detailed Resident #43 yelled, appeared angry, and pushed another resident that fell to the ground, that Resident #43 was not aggressive. She added that Resident #43 was triggered when others entered his personal space. She added that safety checks were the only intervention put in place contrary to the safety checks the day prior to the incident and the day of and days after the incident remaining the same, she was unable to confirm that the residence increased safety checks for the resident. She affirmed that the care plan was not updated during the investigation to include the resident's behavioral expressions when another resident stepped into Resident #43's personal space.b. Allegation of abuse on 12/26/23On 12/26/23 at approximately 8:40 a.m., Staff #49 stated that Resident #43 was often aggressive with other residents. She also stated that he fought with another female resident on a regular basis. On 12/26/23 at 8:57 a.m., the memory care director (MCD) stated that when Resident #43 became aggressive and they moved the other residents away from him. She also stated that Resident #43 became aggressive when residents got near his room. On 12/27/23 at 11:13 a.m., Staff #40 stated that Resident #43 was aggressive with a female resident on 12/26/23 in the afternoon. She stated Resident #48 was wandering, attempting to enter other resident's rooms. Staff #40 further stated that Resident #48 wandered into Resident #43's room and that was we he "man-handled (Resident #48)." She stated staff did their best to keep an eye on Resident #43 and keep his door locked to prevent resident to resident abuse. On 12/27/23 at 1:05 p.m., Staff #50 stated there was in incident of resident to resident abuse with Resident #43 and Resident #48, she stated the MCD had handled the situation. The staff further stated Resident #43 had been refusing his medications, including his psychotropic medications for a while. Staff #50 stated the HWD was aware the resident had been refusing his medications and that he was aggressive towards other residents. Staff #50 further stated Resident #43's aggression tended to come in waves. On 12/27/23 at 1:12 p.m., the MCD stated that there was not an incident with Resident #43 on 12/26/23. She then recalled the incident and stated had to physically pull away a female resident from Resident #43. She stated that she had not considered that an allegation of abuse and stated she failed to document that encounter. On 12/27/23 at 3:14 p.m., the administrator stated that he was made aware at approximately 2:14 p.m. on 12/27/23 that an additional allegation of abuse was reported on 12/26/23 involving Resident #43; however, he was unaware if the residence put documented measures in place that protected or provided protection from Resident #43 since the allegation was made. He added the measures should have been put into place if they were not. On 12/27/23 at 3:56 p.m., the HWD stated that the residence was investigating the incident that occurred on 12/26/23 involving Resident #43; however, she stated no measures the residence was taking to protect or provide protection from Resident #43 were included in the reported investigation. On 12/27/23 at 4:19 p.m., the administrator stated that the deficiency was not corrected as residence staff had not reported all of the suspected abuse to him.

Plan of correction · submitted by the facility

1468Med/Med Adm-Ordrs Cmpy w/OrdrsS/S C▼

Findings

Based on observation, interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting six of nine sample residents whose medications were reviewed (#15, #22, #33, #38, #45 and #47). This deficiency was cited previously during a state licensure survey 4/20/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, Resident #47 was prescribed timolol 0.5% eye drops twice daily for glaucoma. From 12/25-12/27/23 the medication was out of stock and Resident #47 stated she experienced painful pressure in her eyes. The pharmacist for Resident #47 stated that increased eye pressure and blurred vision were common side effects due to not being administered timolol timely. Findings include:1. Reference and Residence Policya. According to Mayo Clinic, Timolol eye drops "are used to treat increased pressure in the eye that is caused by open-angle glaucoma or a condition called ocular (eye) hypertension. The medication must be used exactly as directed by a doctor ..." Mayo Clinic (12/1/23), Timolol (Ophthalmic Route), retrieved from: https://www.mayoclinic.org/drugs-supplements/timolol-ophthalmic-route/precautions/drg-20071111b. According to the National Health Service "It's important to use your eye drops regularly and go for check-ups with your eye specialist to stop your sight getting worse. Do not stop timolol suddenly without talking to your doctor, as it may make your eye condition worse ..." NHS (8/25/22), How and When to Use Timolol Eye Drops, retrieved from: https://www.nhs.uk/medicines/timolol-eye-drops/how-and-when-to-use-timolol-eye-drops/c. The residence's Medication Administration Policy, dated 7/26/16, read in part: "ensure medications are dispensed in a safe manner in the community ... employees who are appropriately licensed ... (are) to assist with and/or administer medications (including opioids) in the community as dictated by state regulations."2. Resident #47 was admitted to the residence on 9/20/23 with a diagnosis of glaucoma.a. TimololA written practitioner's order, dated 11/28/23, directed the residence to instill timolol ophthalmic solution 0.5% one drop in each eye twice daily. However, the December 2023 electronic medication administration record (eMAR) read timolol was not administered on 12/25 in the evening, 12/26 in the morning, and interviews revealed the medication was not administered 12/26 in the evening of 12/27/23 in the morning either due to the medication being out of stock, for a total of four missed doses. b. LatanoprostA written practitioner's order, dated 11/28/23, directed the residence to instill latanoprost ophthalmic solution 0.005% one drop in each eye at bedtime. However, the December 2023 eMAR read latanoprost was not administered 12/19-12/21/23 due to the medication being out of stock, for a total of three missed doses. c. Benztropine A written practitioner's order, dated 11/28/23, directed the residence to administer benztropine mesylate 1 mg once daily. However, the December 2023 eMAR read benztropine was not administered 12/7 and 12/8/23 due to the medication being out of stock, for a total of two missed doses.d. Vitamin b12A written practitioner's order, dated 11/28/23, directed the residence to administer vitamin b12 1000 mcg daily. However, the December 2023 eMAR read vitamin b12 was not administered 12/13 and 12/14/23 due to the medication being out of stock, for a total of two missed doses. e. LactuloseA written practitioner's order, dated 11/28/23, directed the residence to administer Lactulose 45 mL once daily. However, the December 2023 eMAR read Lactulose was not administered 12/17/23 due to the medication being out of stock, for a total of one missed dose. On 12/27/23 at 7:42 a.m., Resident #47 stated she had experienced issues with not getting her medication as ordered from the residence and stated her timolol was still out of stock. She further stated "there is no exception for not getting my medication. I am paying so much money each month to live here and am about ready to get an order to manage my own medications. Ask any of the other residents, it is not just me who is having issues getting medications."On 12/27/23 at 8:35 a.m., Resident #47 stated that the residence had not administered her timolol eye drops since 12/22/23 and she had experienced painful pressure in her eyes that made her want to, "scratch her eyes out of her head." On 12/27/23 at 10:01 a.m., the health and wellness director (HWD) stated Resident #47 had cycle filled medications and the insurance provider for Resident #47 would not pay to fill timolol since it had just been filled in December 2023. The HWD stated staff may have accidentally missed administered drops in the eye and the medication ran out early. The HWD stated Resident #47 had expressed concerns to her that if her eye pressure was too high from not having received her timolol drops, she would be unable to have her cataract surgery in January 2024. On 12/27/23 at 10:33 a.m., the residence's preferred pharmacy's pharmacist stated effects to Resident #47 not being administered her timolol, included increased eye pressure and blurred vision. The pharmacist further stated timolol was last delivered to the residence on 12/14/23 and was unsure how the medication could have been out of stock. He further stated insurance would not cover the medication being lost or used up within 30 days. On 12/27/23 at 11:51 a.m., a medication cart audit was conducted for Resident #47 and revealed her timolol which was not administered and had been marked as out of stock, was found in an unlabeled section of the bottom drawer of the medication cart instead of the top drawer of the medication cart where Resident #47's eye drops were stored. On 12/27/23 at 3:15 p.m., the administrator stated the HWD was responsible for ordering medications and ensuring they were in stock for both the assisted living and secure environment. The administrator stated he would expect the residence to have complied with practitioner's orders related to medication administration and was unaware it had not occurred. On 12/27/23 at 4:05 p.m., the HWD stated she was responsible for ordering medications and ensuring they were in stock alongside the licensed practical nurse (LPN). The HWD acknowledged she would expect medications to be administered in accordance with practitioner's orders. She acknowledged she was aware there were medications that were not delivered by the pharmacy when they were supposed to be; however, stated "when you and I go to the pharmacy even we have to wait for medications to come in stock." On 12/27/23 at 4:39 p.m., the administrator stated he was unsure as to why this deficiency had not been corrected. Additional non compliance with practitioner's orders was revealed with Resident #15, #22, #33, #38 and #45.

Plan of correction

The state did not require a plan of correction for this citation.

1510Med/Med Adm-Rcrd Kpng MARS/S A▼

Findings

Based on interview and record review the residence failed to ensure medication was documented at the time of administration affecting one sample resident (46). This deficiency was cited previously during a state licensure survey 4/20/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: Resident #46 was admitted to the residence on 1/10/20, with diagnoses including frontotemporal dementia and dysphagia. A written practitioner's order, dated 12/8/23, directed the residence to administer cephalexin 500 mg twice daily for five days. However, the December 2023 medication administration record (MAR) read the medication was administered from 12/9-12/15/23 for a total of 11 doses administered. On 12/2723 at 3:45 p.m., the administrator stated he expected if the medication was administered staff should have documented on the MAR at the time of administration.

Plan of correction · submitted by the facility

1514Med/Med Adm-Rcrd Kpng Qrtly AuditS/S B▼

Findings

Based on record review and interview, the residence failed to ensure the administrator and the qualified medication administration person (QMAP) supervisor audited the accuracy and completeness of the medication administration record (MAR) on a quarterly basis, affecting 7 of eleven sample residents (#15, #22, #33, #38, #45, #46, #47). (Cross-reference Q1110, Q1468, Q1510)Findings include:The residence ' s medication policy, dated 7/26/16, read in part that the residence checked all practitioner orders and medication to ensure proper administration as required by state licensure regulations. The residence provided Quality Assessment Med Storage forms, Weekly Med Cart forms, a handwritten Med Cart Audit, and a list titled Carts Reviewed when quarterly medication audits were requested. The Quality Assessment Med Storage forms, dated 8/14/23 and 10/10/23, read in part that the member of the performance improvement committee will review compliance with Medication Cart Audits per pharmacy for proper medication storage. The form criteria included one element involving MARs, "Medication in cart, not on MARs." The audits failed to meet the requirement of auditing the accuracy and completeness of the medication administration record (MAR). Further, the LPN completed the forms that were not the identified QMAP supervisor, the resident care coordinator (RCC). A review of the Weekly Med Cart forms, dated 5/22/23, 5/23/23, 6/5/23, and 7/3/23, revealed the form contained no elements involving the accuracy of the MARs and was not conducted by the QMAP supervisor, the RCC.A review of the handwritten Med Cart Audit, dated 7/30/23, revealed the form contained no elements involving the accuracy of the MARs and was not conducted by the QMAP supervisor, the RCC.Review of the Carts Reviewed lists, dated 8/14/23-11/26/23, revealed the form contained no elements involving the accuracy of the MARs and was not conducted by the QMAP supervisor, the RCC.On 12/27/23 at 2:59 p.m., the administrator stated that quarterly audits should contain elements to ensure the accuracy of the MAR. He added that he signed off on the cart audit lists. He added that the residence utilized forms created by the pharmacy. He stated he was unaware that the residence was not meeting the requirement with the existing form and that the residence would create new forms to include the accuracy of the MARs as that was not included on the existing quarterly audits. He added that some of the non-compliance with medication administration may have been identified if the audits had contained all of the required elements. On 12/27/23 at 3:45 p.m., the health and wellness director (HWD) stated that the forms the residence provided for audits would not have caught the issues found with MARs and that the residence utilized a form created by the pharmacy to audit carts. She added that having a different form to identify problems with the MAR would be ideal. She stated that the QMAP supervisor was the RCC and not LPN 1. She added that she was unaware that the QMAP supervisor was required to conduct the quarterly audits.

Plan of correction · submitted by the facility

2130HIR-Cntnt IncldS/S B▼

Findings

Based on record review, and interview, the residence failed to ensure that resident records contained progress notes, which included documentation regarding any out-of-the-ordinary event or issue that affected a resident, and failed to ensure that the resident records contained documentation of ongoing services provided by external service providers (ESP). Additionally, the residence failed to ensure staff members documented, before the end of their shift, events or issues regarding a resident that they observed or was reported to them, affecting nine of eleven sample residents (#15, #22, #33, #36, #38, #43-#46). (Cross-reference Q1360, Q1362, Q1522)This deficiency was cited previously during a state licensure survey 4/20/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Findings include: 1. Residence PolicyThe residence's Resident Health Information Record -Content policy, dated 12/26/23, read in part that the residence maintained appropriate and accurate records for each resident. Further, resident records contained progress notes and documentation of ongoing services by ESPs. The residence ' s Fall Risk Management policy, dated 12/26/23, read in part that the residence documented information regarding resident falls in progress notes. 2. Resident #36 was admitted to the residence on 3/31/23 with diagnoses including Parkinson ' s disease, a history of falling, and dysphagia. The progress notes, dated 10/29/23-12/22/23 read in part:On 11/14/23, an incident report was created for an unwitnessed fall. On 11/18/23, an incident report was created for an unwitnessed fall. On 12/06/23, an incident report was created for an unwitnessed fall. On 12/14/23, an incident report was created for an unwitnessed fall. However, the progress notes contained no specific information regarding the circumstances of the falls sustained by the resident. A review of the resident's record revealed no care plan completed by the resident ' s external hospice provider (EHP). On 12/27/23 at 1:23 p.m., the EHP provided a care plan for Resident #36 with a start-of-care date by the EHP of 6/23/23. On 12/27/23 at approximately 1:25 p.m., the residence subsequently provided an EHP care plan for the resident. 3. InterviewsOn 12/26/23 at 1:39 p.m., the EHP nurse stated that the EHP had a care plan for Resident #36; however, she could not recall if the residence had a copy of the care plan. On 12/26/23 at approximately 2:30 p.m., the health and wellness director (HWD) stated that the residence did not have a copy of the care plan from the EHP as the EHP was required to add the care plan to the resident record and had not. On 12/27/23 at 3:17 p.m., the administrator stated the residence should have been documented in residents ' progress notes and that incident reports did not replace progress notes. He added that if an incident report was documented as created in the progress notes, the residence should have documented an associated progress note. On 12/27/23 at 4:02 p.m., the HWD stated that the residence should have documented progress notes for out-of-the-ordinary events experienced by residents. She added she was unaware of the requirement that progress notes be documented before a staff member ' s shift ends. She stated that she would not consider an incident report a progress note. She stated that she was aware that there were incident reports without associated progress notes, and added that there were times when a nurse was not onsite to document. She added that the home office required documentation to be completed only by residence nurses. 4. Additionally, the residence failed to ensure that resident records contained progress notes, which included documentation regarding any out-of-the-ordinary event or issue that affected a resident, and failed to ensure that the resident records contained documentation of ongoing services provided by an ESP. Further, the residence failed to ensure staff members documented, before the end of their shift, events or issues regarding a resident that they observed or was reported to them for Residents #15, #22, #33, #38, #43-#46.

Plan of correction · submitted by the facility

9999Final ObservationsSurveyor note▼

Findings

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 along with care coordination arrangements; and(F) Identify formal, planned, and informal spontaneous engagement opportunities that match the resident ' s personal choices and needs. 14.44 The assisted living residence shall have policies and procedures regarding the destruction and disposal of outdated, unused, discontinued, and/or expired medications which are not returned to the resident or legal representative. At a minimum, the policies and procedures shall include the following requirements:(A) Outdated, discontinued, and/or expired medications shall be destroyed in accordance with federal, state, and local regulations within thirty (30) days.(1) Medication shall be destroyed in the presence of two individuals, each of whom are either a qualified medication administration person, nurse, or practitioner;(2) All medications shall be destroyed in a manner that renders the substances totally non-retrievable to prevent diversion of the medication; and(3) There shall be documentation which identifies the medications, the date, and the method of destruction, and the signatures of the witnesses performing the medication destruction.

Plan of correction

The state did not require a plan of correction for this citation.

12/26/2023Revisit: Licensure Complaint · ID ERDJ141 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 12/27/23 for the previous deficiency cited on 4/20/23. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

1110Res Care Srvs-Min Srvs Res AgrS/S E▼

Findings

Based on observation, interview, and record review, the residence failed to provide protective oversight, affecting one sample resident (#46). This deficiency was cited previously during a state licensure survey 4/20/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, On 12/26/23 at 11:40 a.m., staff prepared medications to Resident #46. Staff did not crush or dissolve the medications. Upon entry into the resident's room, Resident #46 was observed slouched in a chair with two pills on his right upper chest. Staff noticed the pills on his body, picked them and stated he did not take his medications this morning. The staff subsequently placed the two pills into the cup and stated they would let the director of nursing know of the missed medication. During interviews it was revealed the resident had swallowing difficulties since his diagnosis of COVID-19 approximately two months prior to the on-site visit. Staff and external hospice stated that the resident was choking when being administered his medications and therefore he required his medications to be crushed/dissolved. However, during record review it was revealed the resident had a crush/dissolve order for medications, dated 12/7/23, which was not transcribed on the medication administration record (MAR). This failure created an immediate jeopardy risk of protective oversight to Resident #46. On 12/26/23, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. References and Resident Agreementa. Chapter VII regulations governing assisted living residences defines, in part 2.38, protective oversight as "guidance of a resident as required by the needs of the resident or as reasonably requested by the resident, including the following: (B) Monitoring the activities of the resident while on the premises to ensure the resident's health, safety and well-being, including monitoring the resident's needs and ensuring that the resident receives the services and care necessary to protect the resident's health, safety, and well-being."B. According to the National Library of Medicine, "administering crushed medications mixed with a soft food or liquid vehicle, or via a feeding tube, is a common strategy to circumvent swallowing difficulties in patients with dysphagia." Amie Blaszczyk (October 2023) Et.al Drugs Aging, Retrieved from: http://www.pubmed.ncbi.nlm.nih.govc. The residence ' s Medication Policy, dated 7/26/16, read in part that the residence ensured medications were dispensed in a safe manner as required by state licensure. All medication received by the residence for administration were to be compared with the practitioner's order. d. The residence ' s Resident Agreement, read in part through its staff, would assist, or supervise, as appropriate, resident administration of medications directed by the resident ' s practitioner. 2. Resident #46 was admitted to the residence on 1/10/20, with diagnoses including frontotemporal dementia and dysphagia. a. Observations on 12/26/23 revealed the following:On 12/26/23 at approximately 11:40 a.m., Staff #13 administered furosemide 20 mg tablet and potassium chloride 10 meq tablet. Both medications were administered whole per the medication administration record (MAR). Resident #46 subsequently began coughing. Staff #49 and Staff #19 then noticed that the resident had his morning medications sitting on his chest. Staff #49 and Staff #19 stated that his medications should have been crushed because he coughed during medication administration.b. Record ReviewA written practitioner's order, dated 12/7/23, directed the residence to crush all medications and dissolve tamsulosin and potassium chloride in water or orange juice. The residence's December 2023 MAR revealed no evidence the crush and dissolve order was transcribed onto the MAR and no evidence it was administered according to the written practitioner's order from 12/7-12/26/23 the day of the onsite visit. A progress note, dated 12/6/23 written by the external hospice registered nurse (RN), read in part: The qualified medication administration person (QMAP) had concerns with Resident #46's ability to swallow his medications. An assessment for Resident #46, dated 10/23/23, read in part that the residence administered all medications to Resident #46. The residence staff provided spoon-feeding of medication as needed. The assessment contained no information about the resident experiencing swallowing difficulty. A care plan for Resident #46 dated 3/7/23, read in part that the residence administered all medication to Resident #46. The care plan contained no information about the resident experiencing swallowing difficulty. c. InterviewsOn 12/26/23 at approximately 11:40 a.m., Staff #13 and Staff #14 stated that they noticed a change in condition with Resident #46 and stated he was having difficulties swallowing his medications. On 12/26/23 at 1:19 p.m., the health and wellness director stated Resident #46 was seen by an external speech therapist. However, she stated she was not aware of the recommendations because she did not have the notes for the visit. The health and wellness director further stated the speech therapist would not write orders for the resident rather make recommendations. She further stated the residence had not received a crush order for Resident #46 and was not aware of any issues taking medications. On 12/26/23 at approximately 1:20 p.m., the external hospice nurse stated that she had seen a change in his condition approximately one month prior to the onsite visit when he was diagnosed with COVID-19. She stated Resident #46 never regained some of his abilities after his diagnosis. The external hospice nurse further stated she had written the crush order for the medications because staff was reporting he was having difficulty swallowing his medications. She stated she consulted with the resident's pharmacist who stated the potassium chloride and tamsulosin needed to be dissolved and not crushed. Additionally, the external hospice nurse stated that the residence needed to follow the orders because he was at immediate risk for aspiration and choking. On 12/26/23 at 2:50 p.m., the administrator stated he was not aware that Resident #46 had a crush/dissolve order and it was not being followed. He stated the pharmacy transcribed orders onto the MARs and the health and wellness director was responsible for ensuring the MARs were correct and all orders were added to the MARs. The administrator further stated he expected the residence to comply with all written practitioners orders associated with medication administration. d. Immediate Jeopardy - Written Evidence, Immediate CorrectionThe investigation established that the findings above placed Resident #46 at immediate jeopardy risk of choking and aspiration, due to difficulties with swallowing. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 12/26/23 at 3:53 p.m., the administrator submitted written evidence that read in pertinent part: "1. The wellness director or designee will provide immediate education for all QMAP (qualified medication administration person) personnel currently on the shift in the community regarding which residents are currently on crush orders. The wellness director or designee will provide education to all QMAP personnel currently on the shift in the community on the notification screen of the electronic health record (EHR) which identifies which resident is on crushed orders. 2. The wellness director or designee will provide education to 100% all QMAP personnel employed with the community regarding who in the community is on crush orders. This education will be completed in the next 48 hours. The wellness director or designee will provide education to 100% of all QMAP personnel employed with the community regarding the notification screen of the EHR which identifies if a resident is on crush orders. This education will be provided in the next 48 hours. The wellness director will work together with the practitioner and pharmacy to ensure that each individual medication can be crushed the, "To be crushed," verbiage in the order itself. This will be completed in the next 48 hours. The wellness director will work together with the practitioner and pharmacy to ensure that each resident whose medication can be crushed has an individual treatment order stating that the resident ' s medication is to be crushed per physician ' s orders for QMAP personnel to sign off on during each medication pass. This will be completed in 24 hours. 3. The wellness director, memory care director, or resident care coordinator will audit each resident with a crush order to ensure those medications are being crushed per practitioner orders. This audit will occur daily x 3 weeks, then weekly x 3 weeks to ensure compliance. Wellness director will audit all new orders daily Monday through Friday to ensure all new crushed orders are implemented on the MAR with the correct, "to be crushed," verbiage as well as the treatment order stating that the resident ' s medications are to be crushed per physician ' s orders. 4. The results of these audits will be reviewed daily Monday through Friday in clinical meeting three months to ensure ongoing compliance. The results of these audits will be reviewed monthly x 3 in QAPI meeting to ensure compliance.``However, the written evidence did not demonstrate the risk had been removed because it did not include specific information regarding Resident #46, education element for the health and wellness director, and a change of timeframe for the residence to provide education to the residence's QMAPs. The administrator was directed to submit additional written evidence. On 12/26/23 at 4:26 p.m., the administrator submitted written evidence that read in pertinent part: "1. The crush order for Resident #46 was updated in the MAR on 12/26/23 ... Education will be provided to the wellness director regarding proper process and procedure for order transcription within the MAR. This will be completed by (home office) director of health services on 12/26/23." Further, the administrator changed the timeframe for education for the QMAPs from within 48 hours to prior to the next shift. The administrator added verbiage regarding monitoring of medication administration by residence QMAPs. However, the written evidence did not indicate the risk had been removed because it did not include the administrator's oversight. The administrator was directed to submit additional written evidence. On 12/27/23 at 7:53 a.m., the administrator submitted written evidence that read in pertinent part: "The executive director (administrator) will spot check 5 orders per week x 1 month, then 5 orders per month x 2 months to ensure each order is transcribed properly."e. Continued deficient practice on 12/27/23On 12/27/23 at approximately 8:30 a.m., Staff #49 crushed all of Resident #46's medications including the potassium chloride tablet which was ordered to be dissolved. However, the staff disposed of the medications because he was in the middle of eating. On 12/27/23 at 9:26 a.m., the memory care director prepared the medications for a second time and subsequently crushed all of them including the potassium chloride tablet. An updated December 2023 MAR for Resident #46 was requested on 12/27/23 at 10:43 a.m. and again at 12:11 p.m. The updated MAR was received at approximately 1:00 p.m. and directed staff to crush medications that were crushable and to dissolve the potassium chloride and tamsulosin. However, the MAR revealed the dissolve order was not added to the MAR until after morning medication pass. On 12/27/23 at 11:00 a.m., a pharmacist For Resident #46 stated that not dissolving potassium chloride could cause the resident gastrointestinal distress. On 12/27/23 at 4:39 p.m., the administrator stated the deficiency had not been corrected because Resident #46 was administered medications improperly.

Plan of correction · submitted by the facility

1. Specific CorrectionThe residence will immediately implement effective protective oversight for resident medication administration orders consistent with the requirements of 6 CCR 1011-1 Chapter 7 Assisted Living Residences Part 12.1 (A)(B)(C)(D)(E). For Resident #46 (R46), if still residing in the residence, the administrator, resident care coordinator, health and wellness director, licensed nurse(s) and applicable members of the residence leadership team, shall:(1) Contact the pharmacist from the resident's pharmacy to ensure the facility may safely crush or dissolve each medication prescribed for R46. If the pharmacist identifies a discrepancy in the safety of crushing or dissolving a prescribed medication, the facility will coordinate with the pharmacy and the resident's prescriber to use a medication that can be safely crushed or dissolved for administration.(2) Transcribe the applicable crush/dissolve order on to each of R46's medication administration orders, as applicable, based on review by the pharmacist and, if needed, the prescriber.(3) Before their next shift, the licensed nurse will educate each qualified medication administration person (QMAP) on how to safely crush and/or dissolve medications for administration to R46. Each QMAP will complete a successful return demonstration of crushing and dissolving a medication for administration. As needed (PRN) medication administration staff and those presently on scheduled leave will receive this training and return demonstration before their next scheduled shift.(4) Update the care plan to reflect the R46's swallowing deficit and the approaches the facility will implement to promote swallowing safety for medication administration. 2. Identification of Others Affected or Potentially AffectedThe administrator, resident care coordinator, health and wellness director, licensed nurse(s) and applicable members of the residence leadership team shall complete the following steps to identify others:(1) Conduct a record review of each resident receiving medication administration assistance to identify other residents with unimplemented crush/dissolve prescriber orders. The residence will obtain proper medication alteration practice instructions from the dispensing pharmacist for any unimplemented crush/dissolve order identified during the audit.(2) Audit the care plans for each resident with active crush/dissolve orders to ensure the care plans accurately reflect any swallowing precautions and crush/dissolve orders. 3. System Changes to Prevent RecurrenceThe administrator, resident care coordinator, health and wellness director, licensed nurse(s) and applicable members of the residence leadership team will oversee the development and implementation of a system to ensure prescriber medication crush/dissolve/alteration orders are promptly identified and implemented. This should include:(1) Develop and implement a daily prescriber order review to ensure all new prescriber orders, particularly orders for medication alteration are identified and are correctly entered in the medication administration records. The daily review will include:a. Verification of accurate medication order entry by a licensed nurse and a leader from the medication administration team.b. Updating the applicable resident care plan if the medication order reflects a change in the resident's care needs.c. Educating medication administration staff on medication administration order changes and care plan changes.d. Documenting all medication change order reviews, changes, updates, and associated education on a daily log.(2) The administrator will educate all medication administration and nursing staff on their role in identifying and communicating new prescriber medication orders. This education will address the regulatory requirements specified in 6 CCR 1011-1 Chapter 7 Assisted Living Residences Part 12.1 (A)(B)(C)(D)(E). Educational topics will include:a. Examples of medication change orders that should be brought to leadership's attention.b. Instructions on how to report any medication change orders to residence leadership.c. Instructions on administering crushed and dissolved medications. The administrator will conduct written, post-education evaluation of all residence staff to assure each staff member understands the education provided and will be able to identify and respond to any medication administration changes.(3) The residence will implement ongoing training for new-hire medication administration staff to ensure they can identify and report medication administration change orders to appropriate facility leadership.(4) The residence will implement ongoing verification that new-hire medication administration staff can correctly prepare and administer crushed medications and dissolved medications in accordance with prescriber orders and the plan of care. 4. Monitoring of Corrective ActionMonitoring of approaches to ensure the residence consistently identifies and mitigates all safety concerns in the resident environment will include:(1) Weekly, for no less than twelve weeks, administrator(s), wellness/care manager(s), and applicable members of the residence leadership team, will:a. Review all the log for medication administration order changes to ensure orders are being identified and implemented in accordance with 6 CCR 1011-1 Chapter 7 Assisted Living Residences Part 12.1 (A)(B)(C)(D)(E). b. Observe medication administration for any resident with a change order to ensure staff are implementing changes in accordance with the requirements for 6 CCR 1011-1 Chapter 7 Assisted Living Residences Part 12.1 (A)(B)(C)(D)(E). After twelve consecutive weeks monitoring that demonstrates staff are consistently identifying and addressing medication administration order changes, the frequency of rounding audit reviews will reduce from weekly to monthly and shall continue monthly for no less than three additional months or until there are three consecutive months of satisfactory performance.(2) The administrator shall track and trend the success of all quality management program activities related to ensuring a protective oversight of the medication administration process. Such tracking and trending data shall be reported to the quality management program committee monthly for no less than three months and shall continue until all performance plan objectives related to identification, investigation, and reporting of abuse and neglect are consistently maintained. 5. Correction Date05/14/2024

12/26/2023Revisit: Licensure Complaint · ID 2G1D173 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A complaint revisit was completed on 12/27/23 for the previous deficiency cited on 4/20/23. A deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

1110Res Care Srvs-Min Srvs Res AgrS/S E▼

Findings

Based on observation, interview, and record review, the residence failed to provide protective oversight, affecting one sample resident (#46). This deficiency was cited previously during a state licensure survey 4/20/23. Although the residence corrected the deficiency, based on the findings below, the residence has not maintained compliance with this regulatory requirement. Specifically, On 12/26/23 at 11:40 a.m., staff prepared medications to Resident #46. Staff did not crush or dissolve the medications. Upon entry into the resident's room, Resident #46 was observed slouched in a chair with two pills on his right upper chest. Staff noticed the pills on his body, picked them and stated he did not take his medications this morning. The staff subsequently placed the two pills into the cup and stated they would let the director of nursing know of the missed medication. During interviews it was revealed the resident had swallowing difficulties since his diagnosis of COVID-19 approximately two months prior to the on-site visit. Staff and external hospice stated that the resident was choking when being administered his medications and therefore he required his medications to be crushed/dissolved. However, during record review it was revealed the resident had a crush/dissolve order for medications, dated 12/7/23, which was not transcribed on the medication administration record (MAR). This failure created an immediate jeopardy risk of protective oversight to Resident #46. On 12/26/23, the department directed the residence to provide written evidence that the risk had been removed. Findings include:1. References and Resident Agreementa. Chapter VII regulations governing assisted living residences defines, in part 2.38, protective oversight as "guidance of a resident as required by the needs of the resident or as reasonably requested by the resident, including the following: (B) Monitoring the activities of the resident while on the premises to ensure the resident's health, safety and well-being, including monitoring the resident's needs and ensuring that the resident receives the services and care necessary to protect the resident's health, safety, and well-being."B. According to the National Library of Medicine, "administering crushed medications mixed with a soft food or liquid vehicle, or via a feeding tube, is a common strategy to circumvent swallowing difficulties in patients with dysphagia." Amie Blaszczyk (October 2023) Et.al Drugs Aging, Retrieved from: http://www.pubmed.ncbi.nlm.nih.govc. The residence's Medication Policy, dated 7/26/16, read in part that the residence ensured medications were dispensed in a safe manner as required by state licensure. All medication received by the residence for administration were to be compared with the practitioner's order. d. The residence's Resident Agreement, read in part through its staff, would assist, or supervise, as appropriate, resident administration of medications directed by the resident ' s practitioner. 2. Resident #46 was admitted to the residence on 1/10/20, with diagnoses including frontotemporal dementia and dysphagia. a. Observations on 12/26/23 revealed the followingOn 12/26/23 at approximately 11:40 a.m., Staff #13 administered furosemide 20 mg tablet and potassium chloride 10 meq tablet. Both medications were administered whole per the medication administration record (MAR). Resident #46 subsequently began coughing. Staff #49 and Staff #19 then noticed that the resident had his morning medications sitting on his chest. Staff #49 and Staff #19 stated that his medications should have been crushed because he coughed during medication administration.b. Record ReviewA written practitioner's order, dated 12/7/23, directed the residence to crush all medications and dissolve tamsulosin and potassium chloride in water or orange juice. The residence's December 2023 MAR revealed no evidence the crush and dissolve order was transcribed onto the MAR and no evidenceit was administered according to the written practitioner's order from 12/7-12/26/23 the day of the onsite visit. A progress note, dated 12/6/23 written by the external hospice registered nurse (RN), read in part: The qualified medication administration person (QMAP) had concerns with Resident #46's ability to swallow his medications. An assessment for Resident #46, dated 10/23/23, read in part that the residence administered all medications to Resident #46. The residence staff provided spoon-feeding of medication as needed. The assessment contained no information about the resident experiencing swallowing difficulty. A care plan for Resident #46 dated 3/7/23, read in part that the residence administered all medication to Resident #46. The care plan contained no information about the resident experiencing swallowing difficulty. c. InterviewsOn 12/26/23 at approximately 11:40 a.m., Staff #13 and Staff #14 stated that they noticed a change in condition with Resident #46 and stated he was having difficulties swallowing his medications. On 12/26/23 at 1:19 p.m., the health and wellness director stated Resident #46 was seen by an external speech therapist. However, she stated she was not aware of the recommendations because she did not have the notes for the visit. The health and wellness director further stated the speech therapist would not write orders for the resident rather make recommendations. She further stated the residence had not received a crush order for Resident #46 and was not aware of any issues taking medications. On 12/26/23 at approximately 1:20 p.m., the external hospice nurse stated that she had seen a change in his condition approximately one month prior to the onsite visit when he was diagnosed with COVID-19. She stated Resident #46 never regained some of his abilities after his diagnosis. The external hospice nurse further stated she had written the crush order for the medications because staff was reporting he was having difficulty swallowing his medications. She stated she consulted with the resident's pharmacist who stated the potassium chloride and tamsulosin needed to be dissolved and not crushed. Additionally, the external hospice nurse stated that the residence needed to follow the orders because he was at immediate risk for aspiration and choking. On 12/26/23 at 2:50 p.m., the administrator stated he was not aware that Resident #46 had a crush/dissolve order and it was not being followed. He stated the pharmacy transcribed orders onto the MARs and the health and wellness director was responsible for ensuring the MARs were correct and all orders were added to the MARs. The administrator further stated he expected the residence to comply with all written practitioners orders associated with medication administration. d. Immediate Jeopardy - Written Evidence, Immediate CorrectionThe investigation established that the findings above placed Resident #46 at immediate jeopardy risk of choking and aspiration, due to difficulties with swallowing. The residence was directed to provide the department with written evidence that the risk had been removed. Part 3.16 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 12/26/23 at 3:53 p.m., the administrator submitted written evidence that read in pertinent part: "1. The wellness director or designee will provide immediate education for all QMAP (qualified medication administration person) personnel currently on the shift in the community regarding which residents are currently on crush orders. The wellness director or designee will provide education to all QMAP personnel currently on the shift in the community on the notification screen of the electronic health record (EHR) which identifies which resident is on crushed orders. 2. The wellness director or designee will provide education to 100% all QMAP personnel employed with the community regarding who inthe community is on crush orders. This education will be completed in the next 48 hours. The wellness director or designee will provide education to 100% of all QMAP personnel employed with the community regarding the notification screen of the EHR which identifies if a resident is on crush orders. This education will be provided in the next 48 hours. The wellness director will work together with the practitioner and pharmacy to ensure that each individual medication can be crushed the, "To be crushed," verbiage in the order itself. This will be completed in the next 48 hours. The wellness director will work together with the practitioner and pharmacy to ensure that each resident whose medication can be crushed has an individual treatment order stating that the resident ' s medication is to be crushed per physician's orders for QMAP personnel to sign off on during each medication pass. This will be completed in 24 hours. 3. The wellness director, memory care director, or resident care coordinator will audit each resident with a crush order to ensure those medications are being crushed per practitioner orders. This audit will occur daily x 3 weeks, then weekly x 3 weeks to ensure compliance. Wellness director will audit all new orders daily Monday through Friday to ensure all new crushed orders are implemented on the MAR with the correct, "to be crushed," verbiage as well as the treatment order stating that the resident ' s medications are to be crushed per physician ' s orders. 4. The results of these audits will be reviewed daily Monday through Friday in clinical meeting three months to ensure ongoing compliance. The results of these audits will be reviewed monthly x 3 in QAPI meeting to ensure compliance.``However, the written evidence did not demonstrate the risk had been removed because it did not include specific information regarding Resident #46, education element for the health and wellness director, and a change of timeframe for the residence to provide education to the residence's QMAPs. The administrator was directed to submit additional written evidence. On 12/26/23 at 4:26 p.m., the administrator submitted written evidence that read in pertinent part: "1. The crush order for Resident #46 was updated in the MAR on 12/26/23 ... Education will be provided to the wellness director regarding proper process and procedure for order transcription within the MAR. This will be completed by (home office) director of health services on 12/26/23." Further, the administrator changed the timeframe for education for the QMAPs from within 48 hours to prior to the next shift. The administrator added verbiage regarding monitoring of medication administration by residence QMAPs. However, the written evidence did not indicate the risk had been removed because it did not include the administrator's oversight. The administrator was directed to submit additional written evidence. On 12/27/23 at 7:53 a.m., the administrator submitted written evidence that read in pertinent part: "The executive director (administrator) will spot check 5 orders per week x 1 month, then 5 orders per month x 2 months to ensure each order is transcribed properly."e. Continued deficient practice on 12/27/23On 12/27/23 at approximately 8:30 a.m., Staff #49 crushed all of Resident #46's medications including the potassium chloride tablet which was ordered to be dissolved. However, the staff disposed of the medications because he was in the middle of eating. On 12/27/23 at 9:26 a.m., the memory care director prepared the medications for a second time and subsequently crushed all of them including the potassium chloride tablet. An updated December 2023 MAR for Resident #46 was requested on 12/27/23 at 10:43 a.m. and again at 12:11 p.m. The updated MAR was received at approximately 1:00 p.m. and directed staff to crush medications that were crushable and to dissolve the potassium chloride and tamsulosin. However, the MAR revealed the dissolve order was notadded to the MAR until after morning medication pass. On 12/27/23 at 11:00 a.m., a pharmacist For Resident #46 stated that not dissolving potassium chloride could cause the resident gastrointestinal distress. On 12/27/23 at 4:39 p.m., the administrator stated the deficiency had not been corrected because Resident #46 was administered medications improperly.

Plan of correction · submitted by the facility

1360Res Rts-Inv Ab/Neg Alleg or Inj Unk Org A/NS/S B▼

Findings

Based on record review and interviews, the residence failed to investigate allegations of abuse, in accordance with regulation and written policy affecting 19 current residents in the secure environment. Findings include:1. Reference and Residence PolicyChapter VII regulations governing assisted living residences, requires in part 13.11, that the assisted living residence shall investigate all allegations of abuse, neglect, or exploitation of residents in accordance with its written policy. The written policy is required to include the following:(A) Reporting requirements to the appropriate agencies, such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator; (B) A requirement that the assisted living residence notify the legal representative about the allegation within 24 hours of the assisted living residence becoming aware of the allegation; (C) The process for investigating such allegations; (D) How the assisted living residence will document the investigation process to evidence the required reporting and that a thorough investigation was conducted; (E) A requirement that the resident shall be protected from potential future abuse or neglect, and/or exploitation while the investigation is being conducted; (F) A requirement that if the alleged neglect or abuse is verified, the assisted living residence shall take appropriate corrective action; and (G) A requirement that a copy of the report with the investigation findings shall be retained by the facility and available for Department review. The residence's Resident Abuse Prevention policy, dated 8/2/23, defined abuse as the non-accidental act of physical mistreatment. The policy read in part that each resident had the right to be free from physical abuse and that the residence took immediate, corrective action when an abuse allegation was verified to ensure that the abuse did not re-occur. Further, the residence protected any resident involved in an investigation, such as increased resident supervision by staff or family presence while conducting the investigation using the residence's Abuse Investigation Report Form. 2. Resident #43 was admitted to the residence on 8/11/23 with diagnoses including dementia and agitation.a. Allegation of abuse on 11/9/23A review of the residence ' s investigations of abuse revealed an incident report, dated 11/9/23, the report read in part that the incident classification was behavior, danger to others. The report read in part: Resident #43 was discovered yelling at an Former Resident #49 with an external service provider (ESP) standing between Resident #43 and the Former Resident #49. A residence staff member attempted to redirect the residents, and Resident #43 became very angry and pointed his finger in the face of Former Resident #49. Former Resident #49 no longer wanted to participate in the confrontation. As the other resident began to walk away, Resident #43 pushed the resident in the middle of the chest and the other resident fell on his bottom. The residence led the other resident away and Resident #43 stayed in the activity room for lunch. Further, the incident report contained no information regarding how the residence kept the residents safe during the investigation. A review of the service (care) plan, and service plan tasks, dated 11/13/23, revealed that the residence put no measures in place that protected all residents involved from potential future abuse while the investigation was being conducted. Further, the review revealed no increased safety checks were added on or after 11/9/23. Per the residence's Resident Abuse Prevention policy, the residence failed to ensure each resident's right to be from abuse was ensured, that the residence had taken immediate action, and that the resident protected any resident involved in an investigation. On 12/27/23 at 3:14 p.m., the administrator stated that the residence was required to detailhow the residence kept residents safe while the residence conducted an abuse. He added he was unaware that the residence put no measures in place in the care plan that protected or provided protection from Resident #43 during or after abuse was alleged on 11/9/23On 12/27/23 at 3:56 p.m., the health and wellness director (HWD) stated that she was aware that there was a requirement for the residence to put measures in place to protect all residents involved with an allegation of abuse from future abuse. She stated that contrary to the investigation notes for the incident on 11/9/23 that detailed Resident #43 yelled, appeared angry, and pushed another resident that fell to the ground, that Resident #43 was not aggressive. She added that Resident #43 was triggered when others entered his personal space. She added that safety checks were the only intervention put in place contrary to the safety checks the day prior to the incident and the day of and days after the incident remaining the same, she was unable to confirm that the residence increased safety checks for the resident. She affirmed that the care plan was not updated during the investigation to include the resident's behavioral expressions when another resident stepped into Resident #43's personal space.b. Allegation of abuse on 12/26/23On 12/26/23 at approximately 8:40 a.m., Staff #49 stated that Resident #43 was often aggressive with other residents. She also stated that he fought with another female resident on a regular basis. On 12/26/23 at 8:57 a.m., the memory care director (MCD) stated that when Resident #43 became aggressive and they moved the other residents away from him. She also stated that Resident #43 became aggressive when residents got near his room. On 12/27/23 at 11:13 a.m., Staff #40 stated that Resident #43 was aggressive with a female resident on 12/26/23 in the afternoon. She stated Resident #48 was wandering, attempting to enter other resident's rooms. Staff #40 further stated that Resident #48 wandered into Resident #43's room and that was we he "man-handled (Resident #48)." She stated staff did their best to keep an eye on Resident #43 and keep his door locked to prevent resident to resident abuse. On 12/27/23 at 1:05 p.m., Staff #50 stated there was in incident of resident to resident abuse with Resident #43 and Resident #48, she stated the MCD had handled the situation. The staff further stated Resident #43 had been refusing his medications, including his psychotropic medications for a while. Staff #50 stated the HWD was aware the resident had been refusing his medications and that he was aggressive towards other residents. Staff #50 further stated Resident #43's aggression tended to come in waves. On 12/27/23 at 1:12 p.m., the MCD stated that there was not an incident with Resident #43 on 12/26/23. She then recalled the incident and stated had to physically pull away a female resident from Resident #43. She stated that she had not considered that an allegation of abuse and stated she failed to document that encounter. On 12/27/23 at 3:14 p.m., the administrator stated that he was made aware at approximately 2:14 p.m. on 12/27/23 that an additional allegation of abuse was reported on 12/26/23 involving Resident #43; however, he was unaware if the residence put documented measures in place that protected or provided protection from Resident #43 since the allegation was made. He added the measures should have been put into place if they were not. On 12/27/23 at 3:56 p.m., the HWD stated that the residence was investigating the incident that occurred on 12/26/23 involving Resident #43; however, she stated no measures the residence was taking to protect or provide protection from Resident #43 were included in the reported investigation. On 12/27/23 at 4:19 p.m., the administrator stated that the deficiency was not corrected as residence staff had not reported all of the suspected abuse to him.

Plan of correction · submitted by the facility

1468Med/Med Adm-Ordrs Cmpy w/OrdrsS/S C▼

Findings

Based on observation, interview and record review, the residence failed to comply with authorized practitioner orders associated with medication administration except for those medications which a resident self-administers, affecting six of nine sample residents whose medications were reviewed (#15, #22, #33, #38, #45 and #47). Specifically, Resident #47 was prescribed timolol 0.5% eye drops twice daily for glaucoma. From 12/25-12/27/23 the medication was out of stock and Resident #47 stated she experienced painful pressure in her eyes. The pharmacist for Resident #47 stated that increased eye pressure and blurred vision were common side effects due to not being administered timolol timely. Findings include:1. Reference and Residence Policya. According to Mayo Clinic, Timolol eye drops "are used to treat increased pressure in the eye that is caused by open-angle glaucoma or a condition called ocular (eye) hypertension. The medication must be used exactly as directed by a doctor ..." Mayo Clinic (12/1/23), Timolol (Ophthalmic Route), retrieved from: https://www.mayoclinic.org/drugs-supplements/timolol-ophthalmic-route/precautions/drg-20071111b. According to the National Health Service "It's important to use your eye drops regularly and go for check-ups with your eye specialist to stop your sight getting worse. Do not stop timolol suddenly without talking to your doctor, as it may make your eye condition worse ..." NHS (8/25/22), How and When to Use Timolol Eye Drops, retrieved from: https://www.nhs.uk/medicines/timolol-eye-drops/how-and-when-to-use-timolol-eye-drops/c. The residence's Medication Administration Policy, dated 7/26/16, read in part: "ensure medications are dispensed in a safe manner in the community ... employees who are appropriately licensed ... (are) to assist with and/or administer medications (including opioids) in the community as dictated by state regulations."2. Resident #47 was admitted to the residence on 9/20/23 with a diagnosis of glaucoma.a. TimololA written practitioner's order, dated 11/28/23, directed the residence to instill timolol ophthalmic solution 0.5% one drop in each eye twice daily. However, the December 2023 electronic medication administration record (eMAR) read timolol was not administered on 12/25 in the evening, 12/26 in the morning, and interviews revealed the medication was not administered 12/26 in the evening of 12/27/23 in the morning either due to the medication being out of stock, for a total of four missed doses. b. LatanoprostA written practitioner's order, dated 11/28/23, directed the residence to instill latanoprost ophthalmic solution 0.005% one drop in each eye at bedtime. However, the December 2023 eMAR read latanoprost was not administered 12/19-12/21/23 due to the medication being out of stock, for a total of three missed doses. c. Benztropine A written practitioner's order, dated 11/28/23, directed the residence to administer benztropine mesylate 1 mg once daily. However, the December 2023 eMAR read benztropine was not administered 12/7 and 12/8/23 due to the medication being out of stock, for a total of two missed doses.d. Vitamin b12A written practitioner's order, dated 11/28/23, directed the residence to administer vitamin b12 1000 mcg daily. However, the December 2023 eMAR read vitamin b12 was not administered 12/13 and 12/14/23 due to the medication being out of stock, for a total of two missed doses. e. LactuloseA written practitioner's order, dated 11/28/23, directed the residence to administer Lactulose 45 mL once daily. However, the December 2023 eMAR read Lactulose was not administered 12/17/23 due to the medication being out of stock, for a total of one missed dose. On 12/27/23 at 7:42 a.m., Resident #47 stated she had experienced issues with not getting her medication as ordered from the residence and stated her timolol was still out of stock. She further stated "there is no exception for not getting my medication. I am paying so much money each month to live here and am about ready to get an order to manage my own medications. Ask any of the other residents, it is not just me who is having issues getting medications."On 12/27/23 at 8:35 a.m., Resident #47 stated that the residence had not administered her timolol eye drops since 12/22/23 and she had experienced painful pressure in her eyes that made her want to, "scratch her eyes out of her head." On 12/27/23 at 10:01 a.m., the health and wellness director (HWD) stated Resident #47 had cycle filled medications and the insurance provider for Resident #47 would not pay to fill timolol since it had just been filled in December 2023. The HWD stated staff may have accidentally missed administered drops in the eye and the medication ran out early. The HWD stated Resident #47 had expressed concerns to her that if her eye pressure was too high from not having received her timolol drops, she would be unable to have her cataract surgery in January 2024. On 12/27/23 at 10:33 a.m., the residence's preferred pharmacy's pharmacist stated effects to Resident #47 not being administered her timolol, included increased eye pressure and blurred vision. The pharmacist further stated timolol was last delivered to the residence on 12/14/23 and was unsure how the medication could have been out of stock. He further stated insurance would not cover the medication being lost or used up within 30 days. On 12/27/23 at 11:51 a.m., a medication cart audit was conducted for Resident #47 and revealed her timolol which was not administered and had been marked as out of stock, was found in an unlabeled section of the bottom drawer of the medication cart instead of the top drawer of the medication cart where Resident #47's eye drops were stored. On 12/27/23 at 3:15 p.m., the administrator stated the HWD was responsible for ordering medications and ensuring they were in stock for both the assisted living and secure environment. The administrator stated he would expect the residence to have complied with practitioner's orders related to medication administration and was unaware it had not occurred. On 12/27/23 at 4:05 p.m., the HWD stated she was responsible for ordering medications and ensuring they were in stock alongside the licensed practical nurse (LPN). The HWD acknowledged she would expect medications to be administered in accordance with practitioner's orders. She acknowledged she was aware there were medications that were not delivered by the pharmacy when they were supposed to be; however, stated "when you and I go to the pharmacy even we have to wait for medications to come in stock." On 12/27/23 at 4:39 p.m., the administrator stated he was unsure as to why this deficiency had not been corrected. Additional non compliance with practitioner's orders was revealed with Resident #15, #22, #33, #38 and #45.

Plan of correction

The state did not require a plan of correction for this citation.

4/18/2023Revisit: Licensure Complaint · ID 2G1D161 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A licensure revisit was completed on 4/20/23 for the previous deficiency cited on 8/11/22. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

1110Res Care Srvs-Min Srvs Res AgrS/S A▼

Findings

Based on observation, record review, and interview, the residence failed to provide a physically safe and sanitary environment, affecting two of thirteen sample residents (#28, and #38). Findings include:1. Reference and Residence Policya. According to the Patient Safety Network, "wrongful resuscitation happens when a patient has a DNR (do not resuscitate)... and is resuscitated against their expressed wishes ... These incidents occur often due to inadequate communication and when end-of-life wishes have not been clarified." Retrieved from: https://psnet.ahrq.gov/web-mm/wrongful-resuscitationb. The residence's undated Resident Agreement read in order to assist in communicating Resident's health care choices to health professionals and any signed advance directives. The community (residence) would provide copies to healthcare professionals who may be called to the residence or to assist the resident in care. 2. Resident #38 was admitted to the residence on 3/25/2. The face sheet for Resident #38 read "n/a" (not applicable) for DNR which implied Resident #38 required life saving treatment in the event of an emergency. However, the only care plan the residence provided for Resident #38 was dated 4/18/23, the day of the onsite investigation, and was contradictory to the resident's face sheet. The care plan for read Resident #38, read the resident was a DNR since she was on hospice. On 4/20/23 at 11:30 a.m., the administrator stated that he did not know why Resident #38's face sheet and care plan had differing information. The administrator stated that he would expect both to contain the same information and the health and wellness director and resident care coordinator were responsible for updating face sheets and care plans. 3. Resident #28 was admitted to the residence on 12/23/21, with diagnoses including diabetes and Parkinson's disease. On 4/18/23 at approximately 7:45 a.m., there was a white pill on the floor in the hallway to the left of the medication cart. Staff #41 was observed walking by the medication cart as she administered medications to residents in the area. On 4/18/23 at approximately 8:00 a.m. a white pill was still on the floor in the hallway adjacent to the medication cart. On 4/18/23 at approximately 8:30 a.m., the pill was still on the floor in the hallway adjacent to the medication cart. On 4/18/23 at approximately 8:30 a.m., the licensed practical nurse (LPN) stated the white pill on the floor was, in fact, a medication. On 4/18/23 at 9:20 a.m., the LPN stated the medication on the floor was a controlled substance medication that belonged to a resident whose medications were stored by the residence on a different medication cart and hallway. She added when staff counted controlled substance medications together that one must have fallen on the floor. On 4/20/23 at approximately 11:30 a.m., the administrator stated the residence had conducted increased medications audits and he would expect that medications were accounted for with those audits and not laying unsecured on the hallway floor.

Plan of correction · submitted by the facility

Q1110 The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all Federal and State regulations, the community has taken or will take, the actions set forth in the following plan of correction. Part A Q1110 1. Facesheet for #38 was updated to show correct DNR status on computer on 4/20/23. A MOST form audit was completed on 4/20/23 and updated to ensure that the DNR status match the computer EMR facesheets. Training provided by DON on 9/27/23 to all care staff related to MOST form importance and for carestaff to notify DON/designee of any new MOST forms received or changes made to MOST form. 2. DON/Designee will complete MOST form audits monthly on all residents to ensure MOST form DNR status matches EMR face sheets. DON/Designee will review new admission for MOST form and update in system as MOST form is available or information changes. 3. Any discrepancies will be corrected immediately. Audit results will be filed in POC binder and brought to QAPI for review. Part B Q11101. To address the failure to provide a safe environment for #38 and #28, staff immediately inspected their rooms on 4/20/23 for any environment concerns. Staff have been educated on maintaining a safe and sanitary environment for the residents on 9/26/23 and 9/27/23. Staff training on: Tasks review, Resident care, Incident Reporting also took place on 8/22/23. On 5/10/2023 Pine Grove Crossing switched to Heartland Pharmacy. All medications including narcotics are now in individual cards. We are no longer accepting bottles of narcotics in the facility. The counting of the narcotic in the bottle is how the pill ended up on the floor after they transfer the pills from the tablet to the bottle. Training will be ongoing. 2. ED/designee to complete walking rounds in the interior and exterior of the building and 5 resident rooms weekly for 3 months to ensure a safe and sanitary environment. 3. Audit results will be reviewed at QAPI and filed in the POC Binder. Any concerns related to the audit will be brought to the attention of the ED immediately.

4/18/2023Licensure Complaint · ID B28U1111 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure complaint, prompted by #CO29990, #CO31014, #CO31212 and #CO31566, was completed on 4/20/23. Deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0290LicProc-DeptOvrst-Srvy/Inspct Ensr Cmply-POCS/S B▼

Findings

Based on observations, record review and interview, the residence failed to provide, upon request, personnel files and other residence documents as determined by the department, affecting 108 current residents. Findings include:a. Record ReviewOn 4/18/23 at 8:39 a.m., staff files, policies, medication administration records, orders, and full resident records were requested for all sample residents. On 4/18/23 at 10:32 a.m., resident records were provided. However, no record was provided for former residents #20, #41 and #42. On 4/18/23 at 2:37 p.m., six hours later, resident records were received for former residents #20, #41, and #42. On 4/18/23 at 10:32 a.m., resident records were provided. However, no record was provided for former residents #20, #41 and #42. On 4/18/23 at 11:04 a.m., almost four hours after requested, the health information policy, resident agreement, progress notes for March and April 2023, a face sheet, care plans and assessments, the April medication administration record, incident reports for Resident #33 were requested a second time. Former Resident #20's progress notes, care plans and assessments, and hospital records were requested a second time. Former Resident #41 and #42's last two medication administration records, orders, incident reports and observation notes, care plans and assessments, face sheets, and hospice notes were requested a second time, since none of the above was included when a complete resident record was requested. On 4/18/23 at 12:37 p.m., orders missing for Residents #22, #28, #36, #37 and #38, were requested. On 4/18/23 at 1:00 p.m., two hours after requested for a second time, the above information was provided except for Resident #38's admission assessment, and orders missing for Resident #22 and #28 were provided. On 4/18/23 at 1:02 p.m., the admission assessment was re-requested for Resident #38. However, Resident #38's assessment was not provided until 2:41 p.m., when requested a third time. The care plan/assessment was re-requested for Resident #33. On 4/18/24 at 1:44 p.m., the care plan/assessment was provided for Resident #33. On 4/18/23 at 4:24 p.m., four hours after requested a second time, the missing orders for Resident #37 and #38 were provided. On 4/19/23 at 7:32 a.m., administrator training was requested. At 11:22 a.m., almost four hours later, the administrator training was provided.b. InterviewsOn 4/18/23 at 8:35 a.m., the HWD stated that she would have to go in the old system and was unsure she would be able to retrieve the resident records for Former Residents #20, #41 and #42. On 4/19/23 at 11:33 a.m., the administrator stated that records should have been provided as soon as possible. The administrator stated that the reason there were issues for surveyors receiving the documents requested were due to issues finding it on the current health record and previous, and finding the former resident records in the purge box. The administrator had not known if we got documents timely, but acknowledged there were printing issues too. On 4/20/23 at 1:40 p.m., the RN consultant stated that she did not think the residence was prepared with the change in management; however, the surveyors should have gotten timely documentation especially for the resident records that were not received until almost 3:00 p.m., considering they had two different health record systems and hard copies.

Plan of correction · submitted by the facility

B290The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all Federal and State regulations, the community has taken or will take, the actions set forth in the following plan of correction. 1. Due to the new EMR (rolled out 4/2023), PGC required some assistance to be able to pull reports. Access to the old EMR system was initially unavailable due to the previous management company’s status. All of these issues have been resolved and going forward should no longer be an issue with the community. Printing issues have been resolved with new copiers available throughout the community. PGC management has been trained by Stellar Senior Living on specific reports and accessibility. Ongoing education will be provided to directors to ensure that they are aware of where the resident records (charts) are stored. 2. During the monthly QAPI meeting the resident records will be discussed to ensure that the files have been updated, filing is done timely and records are stored for easy access. A monthly audit by DON/designee will be completed to ensure a minimum of 5 resident records are readily accessible. This monitoring will continue for 3 months. Findings will be discussed and results will be filed in the POC Binder. Any concerns will be addressed during the QAPI meeting for three months and ongoing if any concerns.

0540Admin-Dts RespS/S B▼

Findings

Based on record review and interview, the residence failed to ensure the administrator compliedwith all applicable state laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 108 current residents. Findings include:The Residential Care Facility (RCF) Comprehensive Mitigation Guidance, updated 2/22/23, required residences to keep a current COVID-19 ongoing vaccination and treatment plan and for the plan to be presented for review upon request during health facility inspections. On 4/18/23 at 7:37 a.m., the residence's COVID-19 vaccination and treatment plan was requested from the administrator. On 4/20/23 at 11:33 a.m., after exit, the administrator stated he thought he had a COVID-19 vaccination and treatment plan that was completed in July of 2022. He stated that the primary infection control person was the same but the backup would change since the health and wellness director was new and subsequently stated he would send over a completed plan. The administrator stated that there was so much requested and was unsure as to why this is being recited. On 4/20/23 at approximately 12:00 p.m. after exit, the plan was provided. The plan was dated 4/20/23, and therefore, was not accepted. On 4/20/23 at 1:54 p.m., the registered nurse consultant stated that in larger buildings the clinical team handled more duties and may have been unaware of what all was required for the ongoing vaccination plan. The RN consultant acknowledged that she understood why this deficiency was recited.

Plan of correction · submitted by the facility

Q540The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all Federal and State regulations, the community has taken or will take, the actions set forth in the following plan of correction. 1. EMResource updated with correct information for ICP information immediately. The Covid mitigation plan was updated 4/20/23. ICP was updated for Pine Grove to Betsy Hardy, RN on 4/20/23, who has previously completed both CDC and CoTrain Infection Control requirements. Going forward, any changes in personnel will be updated by the next required reporting by ED/Designee. 2. EMResource will be updated per guidelines monthly and with any changes. The Covid mitigation guidance continues to be updated and changes made with any new guidance. 3. DON/designee will provide documentation of EMResource updates two times a months for 3 months and Covid Mitigation plan will be reviewed if any changes are made. All printed documentation will be filed in the POC Binder and be reviewed at Pine Grove’s monthly QAPI meeting.

0736Stff Rq-First Aid Stff CPR ListS/S B▼

Findings

Based on observation, record review and interview, the residence failed to place in a visible location a list of all staff who had current certification in first aid or CPR (cardiopulmonary resuscitation), so that the information was readily available to staff at all times, affecting 108 current residents. Findings include:Throughout the two day onsite investigation from 4/18-4/19/23, there was no list of all staff who had current certification in first aid or CPR placed in a visible location, so that the information was readily available to all staff at all times. On 4/18/23 at 7:45 a.m., Staff #41 stated the list of all staff who had current certification in first aid or CPR was posted in the wellness office. On 4/18/23 at 8:15 a.m., Staff #19 stated she was unsure where the list of all staff who had current certification in first aid or CPR was posted. She added it might be posted on the wall in the copy room. On 4/18/23 at 8:30 a.m., there was no list of staff who had current certification in first aid or CPR in the residence's copy room and wellness office. On 4/18/23 at 10:51 a.m., the list of all staff with current certification in first aid or CPR was requested. On 4/19/23 at approximately 2:00 p.m., the nurse consultant stated the list of staff who had current certification in first aid or CPR was posted in the wellness office and the copy room. On 4/19/23 at approximately 2:00 p.m., there was no list of staff who had current certification in first aid or CPR in the residence's copy room and wellness office. On 4/19/23 at 2:12 p.m., the health and wellness director (HWD) said the list of staff with first aid or CPR that was provided was not current. On 4/19/23 at approximately 2:15 p.m., the list of all staff who had current certification in first aid or CPR was provided. On 4/19/23 at 2:22 p.m., a list of all staff who had current certification in first aid or CPR was posted in the copy room. On 4/19/23 at 4:02 p.m., a second list that was updated of all staff who had current certification in first aid or CPR was provided. On 4/20/23 at 11:33 a.m., the administrator stated the list of staff who had current certification in first aid or CPR was posted in the staff break room and the daily schedules book and acknowledged he was unsure why it was not updated. He added that the business office manager was responsible for updating the list.

Plan of correction · submitted by the facility

Q0736 CPRThe statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all Federal and State regulations, the community has taken or will take, the actions set forth in the following plan of correction. 1. The staff list indicated all staff with current CPR and First Aid certifications was updated on 4/20/23. The list has been updated and maintained monthly with the last updated on 9/18/23. The updated list includes the current status of staff members #41 and #19. The current list continues to be posted in the visible locations of the staff work room and nurses office. Additional staff training completed on:5/3/23: Section 8.8 CPR/First Aid List- ReviewedWhat is it? What does it mean? And where is it?2. DON/designee will maintain the CPR list monthly and with new changes related to staff education or new hires. 3. DON/designee will sample three staff members that are CPR certified to ensure their card is present in the employee file. This audit will be completed weekly for 12 weeks and filed in the POC Binder. Any issues will be corrected immediately, if card is not present the name will be removed from the list immediately and brought to QAPI for review. 4. CPR classes will be offered monthly in the facility by the DON (CPR instructor certified). Last class offered August 26, 2023

1110Res Care Srvs-Min Srvs Res AgrS/S A▼

Findings

Plan of correction · submitted by the facility

1146Res Care Srvs-Comp Res Asmnt Annl/CICS/S B▼

Findings

Based on observation, record review, and interview, the residence failed to ensure a comprehensive assessment was updated at least annually, or whenever the residents' conditions changed from baseline status, affecting four of five sample residents (#33, #36-#38) and one former resident (#20) who experienced a change in condition. (Cross-reference Q1180 and B0290). 1. References and Residence Policiesa. Chapter VII regulations governing assisted living residences, part 12.7, requires that the comprehensive assessment shall include all the following items:(B) Information regarding the resident's overall health and physical functioning ability;(E) Current diagnoses and any known or anticipated need or impact related to the diagnoses;(J) History and circumstances of recent falls and any known approaches to prevent future falls;(L) Types of physical, mental, and social support required.b. The residence's change in condition policy, dated 2014, read that the residence will monitor and respond to any changes in resident health or mental status. Resident needs will be identified through a nursing assessment, and the care plan will be updated. c. The residence's assessment policy, dated 2/1/23, read that a resident would be reassessed with any change in condition, and periodically in accordance with state regulations. 2. Resident #38 was admitted to the residence on 3/25/23, with no listed diagnoses. On 4/18/23 at 9:49 a.m., Resident #38 was observed laying in bed with tears running down her face. Resident #38 stated that she had felt sick all day. Incident reports revealed since Resident #38's admission to the residence on 3/25/23 (24 days prior to the on-site investigation), the resident had six falls as follows: On 3/27 twice, 3/28, 3/29, 3/30, and 4/6/23. The record for Resident #38 contained a medication administration record dated, April 2023 that read Resident #38 had refused medications on 4/10/23 due to her mouth hurting from a fall. However, the record for Resident #38 reveled no evidence of a fall since 4/6/23. The residence's pre-admission assessment, which was also the residence's care plan, dated 3/9/23, read in part: Resident #38 was at risk for falls, has three or more falls in the last three months and had poor balance when ambulating. The section titled Fall Risk Interventions read in part: Staff to perform frequent safety checks and alert a licensed nurse to any observable changes in resident condition such as weakness, confusion or sign/symptoms of illness. The residence discouraged the use of throw rugs, encouraged keeping her room organized with pathways clear of clutter. If an assistive device was used, staff to encourage safe and appropriate usage. Nurses would assign appropriate staff monitoring to ensure safety in activities of daily living. The residence would ensure appropriate assistive items in use including grab bars, durable medical equipment and assistive devices. Physical therapy evaluation and treatment considered, routine exercise encouraged. Floor mats, low bed and sleep/incontinent ace schedule considered. The assessment contained one resident specific direction which read the resident had tremor that caused weakness and difficulty walking. However, the assessment failed to contain history and circumstances of recent falls and any known approaches to prevent future falls. Additionally, the residence's care plan, dated 4/18/23, which was also the residence's assessment, was completed the day of the onsite investigation and, read that Resident #38 used a walker for ambulation and used a wheelchair for increased tremors. Staff to perform frequent safety checks and alert a licensed nurse to any observable changes in resident condition such as weakness, confusion or sign/symptoms of illness. The residence discouraged the use of throw rugs, encouraged keeping her room organized with pathways clear of clutter. The residence would ensure appropriate assistive items in use including grab bars, durable medical equipment and assistive devices. Physical therapy evaluation and treatment considered, routine exercise encouraged. Floor mats, low bed and sleep/incontinent ace schedule considered. Further, the assessment mirrored the previous assessment, and failed to contain history and circumstances of recent falls and any known approaches to prevent future falls. There were no other assessments in the record for Resident #38. On 4/18/23 at 9:53 a.m., Staff #24 stated that Resident #38 had expressed she had felt under the weather and had wanted to stay in bed later than usual, ever since her infusion on 4/15/23. Staff #24 stated that she had just noticed this change in Resident #38 when she had worked two days prior to the onsite investigation. On 4/19/23 at 8:46 a.m., the family member for Resident #38 stated the resident would visit a neurologist for nerve damage in her legs and would get infusions in her legs every three weeks. The family member stated that although the infusions helped to improve the nerve damage, it also caused Resident #38 pain and reduced coordination, especially immediately after. On 4/19/23 at approximately 2:58 p.m., the health and wellness director (HWD) stated Resident #38 received infusions to help with her shakiness that caused her falls. The HWD further stated Resident #38 had only received one infusion since she was admitted to the residence. 3. Resident #37 was admitted to the residence on 3/1/23, with a diagnosis of cervical spondylosis. The record for Resident #37 revealed the resident had four a falls since 3/24/23 ( in 22 days) on 3/24, 3/27 a fall with skin tears, 3/28 and 4/15/23, Resident #37 had two more falls without injury. A progress note and incident reports revealed the following:A progress note, dated 3/24/23, read Resident #37 was found lying on his right side uninjured, with his walker was nearby. Staff #42 independently stood the resident up with his walker and transferred him back into the recliner. Resident #37's power of attorney (POA) was notified and the resident was advised to use his walker, since he had not used it when he fell. An incident report, dated 3/27/23, read Resident #37 was found on the floor lying on his back. The resident stated that he had hit his head lightly and was not in any pain. There was a slight skin tear on his left arm close to his elbow. The POA for Resident #37 was notified. An incident report, dated 3/28/23, read Resident #37 was found lying between his recliner and television stand with no apparent injuries. An incident report, dated 4/15/23, read Resident #37 slid out of bed and had no apparent injuries. Post-fall assessments were conducted after each of Resident #37's falls on 3/24, 3/27, 3/28 and 4/15/23; however, the post-fall assessments did not include any approaches to prevent future falls, and were only standard yes/no questions. A care plan, dated 4/18/23, which was also the residence's assessment, was completed the day of the onsite investigation and, read that Resident #37 had an otitis externa which caused pain and dizziness and family took to the emergency department (ED) for pain, that Resident #37 was required to use a call pendant for assistance and required regular safety checks. However there was no evidence any comprehensive assessments were completed following the falls sustained and the assessment did not include any known approach to prevent future falls. On 4/19/23 at 8:03 a.m., the family member for Resident #37 stated she had observed skin tears on Resident #37's shoulder and elbow after the fall on 4/15/23. The family member stated Resident #37 had an ear infection that had gotten worse over the last three months, which caused weakness and the subsequent fall on 4/15/23. The family member for Resident #37 stated she opted to send the resident to the ED on 4/16/23 for his ear infection. The family member further stated that as long as Resident #37 had his walker with him, he was unlikely to fall. 4. Resident #33 was admitted to the residence on 10/19/22, with diagnoses including unspecified vascular dementia with behavioral disturbance and major depressive disorder. Resident #33 had four falls on 3/4, 3/6, 4/2 and 4/7/23 without injury. Incident reports and progress notes revealed the following:An incident report, dated 3/4/23, read Resident #33 was found on the floor of the sensory room of the residence with no apparent injuries. An incident report, dated 3/6/23, read in part: "Resident grabbed onto the counter and lost balance/footing stumbled and went down to the floor and laid there. The caregiver was holding onto the resident as she went to the ground."An incident report, dated 4/2/23, read a caregiver heard a loud noise and Resident #33 was found on the ground on her back, no injuries or pain. An observation note, dated 4/7/23, read Resident #33 sustained a witnessed fall. An ED discharge summary, dated 4/2/23, read Resident #33 was seen for a fall and was advised fall management interventions. On 4/19/23 at 9:00 a.m., The family member for Resident #33 stated the resident was holding her arm after the fall on 4/2/23. He stated the practitioner for the resident, requested to have Resident #33 sent to the ED. The family member further stated that the resident was released the same day from the ED as the scans revealed no evidence of injury. The family member stated he was not aware of any fall interventions put in place for Resident #33. He stated that Resident #33's toenails were starting to curl which residence staff thought to be the cause of her falls. A care plan, dated 4/18/23 (the date of the on-site investigation), which was also the residence's assessment, read in part: Resident #33 was independent, required an escort to and from specific locations within the residence, however was able to transfer safely and independently. The care plan/assessment further read that the resident likely to be in the sensory room and liked to be in the chair and it caused her to fall and was removed. The resident had long toenails and on the podiatry list since she had fallen and was sent to the hospital. Further, although it included that Resident #33 had fallen due to long toenails and was hospitalized, it was revealed the care plan/assessment was updated after the record was requested and no other care plans/assessments were provided for Resident #33. On 4/19/23 at approximately 10:12 a.m., the HWD stated that herself and the administrator were responsible for reassessments. The HWD stated that old assessments she would have to find a way to obtain them from the residence's former electronic health record system. On 4/19/23 at approximately 11:08 a.m., the HWD stated she was unsure where it was in the regulations to update assessments whenever a resident was hospitalized or condition changed otherwise. On 4/19/23 at 1:54 p.m., the RN consultant stated that she had noticed the residence had no fall interventions in place for Resident #33. The RN consultant confirmed that Resident #33 did not have an updated assessment after any of her falls or after the incident on 3/6/23. The RN consultant acknowledged that the HWD had just updated her assessment when requested on 4/18/23, because when the RN consultant had looked at her record, she had noticed it had not been updated. On 4/19/23 at 3:02 p.m., the memory care director (MCD) stated Resident #33 had fall interventions of seeing a podiatrist for long toenails, escorts and spending time in the sensory room according to the care plan/assessment in their electronic health record system. On 4/20/23 at 11:33 a.m., the administrator stated that since Resident #33 was sent to the hospital for falls, she would have qualified for a reassessment and acknowledged he was unsure why the care plan/assessment had not been updated until the day of the on-site investigation on 4/18/23. The administrator stated the HWD was responsible for reassessments, however, with the turnover in HWD's, leaned more on practitioner's to reassess over the residence's clinical team. 5. Former Resident #20 was admitted to the residence on 9/27/19 with no listed diagnoses. Progress notes and incident reports for Former Resident #20 revealed the former residence had the following:A progress note, dated 12/6/22, read Former Resident #20 was found on the floor in her bathroom. A progress note, dated 12/27/22, read Former Resident #20 was found on the floor and sent to the hospital. A progress note, dated 12/28/22, read that a hematoma was found on the right side of Former Resident #20's head with suture closed. An external hospice note, dated 1/4/23, read that Former Resident #20 had her staples removed from her fall on 12/27/22. An incident report, dated 1/8/23, read that Former Resident #20 had an unwitnessed fall and was found laying on her stomach on the floor with a skin tear on her left hand. An external hospice note, dated 1/8/23, read that Former Resident #20 was a two person assistance with transfers and had pain in her left wrist. An external hospice note, dated 1/10/23, read that Former Resident #20 had a fall and hit her head. An incident report, dated 2/10/23, read that Former Resident #20 was found on the floor with her oxygen cord wrapped around her ankle and complained of pain in her right knee. An incident report, dated 2/11/23 read that Former Resident #20 was found on the floor next to her bed lying face down and complained that her feet hurt. A care plan which was also the resident's assessment, dated 3/25/21 and updated 12/28/22, read that Former Resident #20 required toileting and spot checks three times daily, a tidy environment to reduce fall risk, use of wheelchair for mobility rather than walker and was on hospice. However, the assessment was not updated since 12/28/22, and Former Resident #20 fell and sustained a skin tear to her left hand on 1/8/23, had three additional falls on 1/10, 2/10, and 2/11/23.6. Resident #36 was admitted to the residence on 3/31/23, with a diagnosis of Parkinson's Disease. Progress notes and incident reports for Resident #36 revealed the resident fell six times as follows:An incident report, dated 4/3/23, read Resident #36 had fallen after she attempted to use the restroom without her walker. An incident report, dated 4/7/23, read Resident #36 had not used her walker and fell. An incident report, dated 4/12/23, read Resident #36 was found on the ground in front of her recliner. A progress note, dated 4/15/23, had an alert of an unwitnessed fall. However, there was no progress note or incident report of the fall. An incident report, dated 4/16/23, read Resident #36 had fallen out of her chair in the dining area and it was reported by another resident that she had hit her head. A progress note, dated 4/17/23, read that Resident #36 was found on the floor. No pain, and vital signs were taken. When asked for the full resident record, the only care plan the residence provided, which was also the residence's assessment, dated 4/18/23, did not include any individualized approaches for falls other than every two hour checks. On 4/18/23 at 9:53 a.m., the HWD stated that care plans and assessments were one in the same. On 4/20/23 at 11:33 a.m., the administrator stated that the HWD was responsible for reassessments, and stated that a reassessment needed to be completed whenever a resident went to the hospital, if there was a cognitive change, a change in sleep patterns, multiple falls in a short amount of time, or signs of infection. The administrator stated that he did not know why Resident #33, #36-#38 and Former Resident #20 stated it had been difficult with the change in HWD's and leaned more on practitioner's to reassess over the residence's clinical team.

Plan of correction · submitted by the facility

Q1146The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all Federal and State regulations, the community has taken or will take, the actions set forth in the following plan of correction. 1. Resident #33 most recent comprehensive resident evaluation was updated 9/20/23, #36 completed 7/3/23, #37 completed 6/23/23 and #38 completed 7/13/23. All current residents continue to have comprehensive resident evaluation every 6 months (memory care) and annually for assisted living residents. Training was completed to care staff related to how to access the current care plan and to notify DON/ designee of any change of conditions timely. Additional training included: 8/22/23 Staff Training - Tasks review, Resident care, Incident Reporting 2. During Pine Grove Crossing’s morning meeting (stand up) all residents with incidents including falls, hospitalizations and changes of conditions are reviewed. DON/ED/designee will review resident records to ensure the care plan and comprehensive evaluations are completed if needed or necessary. Comprehensive assessments will be completed by the DON/ RN timely. 3. DON/designee will provide a list of the comprehensive assessments completed during the month. The updated list will be filed in the POC Binder and reviewed at the monthly QAPI meeting.

1180Res Care Srvs-Fall Mgt PrS/S D▼

Findings

Based on observation, record review and interview, the residence failed to implement a fall management program that included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting four of five sample residents (#33, #36-#38) and one former resident (#20). (Cross-reference Q1146)Specifically, Former Resident #20 sustained a fall on 12/6/22; however, the residence failed to update the care plan for the former resident after the fall and the resident sustained second fall on 12/27/22. The second fall resulted in injury and required sutures at the emergency department (ED). Although the residence updated the care plan on 12/28/22 (the day after the second fall with injury), the former resident fell four more times in which the care plan for the resident was not updated with individualized approaches. Additionally, three of the four additional falls resulted in further injuries. Specifically, Resident #37 had four falls in 24 days (3/24, 3/27, 3/28 and 4/15/23) in which the residence failed to update the care plan with individualized approaches necessary to address fall risks. One fall on 3/27/23 resulted in skin tears. Additionally, on 4/18/23 (the day of the onsite investigation) the residence updated the care plan for Resident #37; however, the residence still failed to include individualized approaches necessary to prevent additional falls. Specifically, Resident #38 had six falls in 12 days (3/27 twice, 3/28, 3/29, 3/30 and 4/6/23), additional evidence in the record revealed the resident experienced pain in her mouth as a result of a fall on an unknown date. However, the record for Resident #38 revealed no evidence of an updated care plan after the falls that contained individualized approaches necessary to address fall risks. Specifically Resident #33 had four falls in 34 days (3/4, 3/6, 4/2 and 4/7/23). However on 4/2/23, Resident #33 had a fall with pain and was sent to the ED. The residence failed to update Resident #33's care plan to include individualized approaches necessary to prevent additional falls, after Resident #33's falls on 3/4, 3/6, 4/2/23 and 4/7/23. Findings include: 1. Residence Policy The residence's undated Fall Management Policy read that the residence was to provide fall management education and materials to residents and family members, update the resident's care plan after each fall with appropriate individualized approaches necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive assessment. The residence would provide staff training related to fall prevention during orientation, as well as during routine staff training and services. Staff were routinely educated on how to identify each resident's individualized fall interventions. 2. Former Resident #20 was admitted to the residence on 9/27/19. A progress note, dated 12/6/22, read Former Resident #20 was found on the floor in her bathroom. A progress note, dated 12/27/22, read Former Resident #20 was found on the floor and sent to the hospital. A progress note, dated 12/28/22, read a hematoma was found on the right side of Former Resident #20's head with suture closed. A care plan, dated 12/28/22 (the day after a fall resulting in injury), read Former Resident #20 required toileting assistance and spot (safety) checks three times daily; a tidy environment to reduce fall risk; use of wheelchair for mobility rather than walker; and received external hospice services. The care plan also read fall risk monitoring as needed. However, the residence failed to include how many staff are required to transfer Former Resident #20 and failed to update the care plan for the former resident with individualized approaches necessary to address fall risk after Former Resident #20 fell four additional times on 1/8, 1/10, 2/10 and 2/11/23. An external hospice note, dated 1/4/23, read Former Resident #20 had her staples removed from her fall on 12/27/22. An incident report, dated 1/8/23, read Former Resident #20 had an unwitnessed fall and was found laying on her stomach on the floor with a skin tear on her left hand. An external hospice note, dated 1/8/23, read Former Resident #20 was a two person assist and had pain in her left wrist. An external hospice note, dated 1/10/23, read Former Resident #20 had a fall and hit her head. An incident report, dated 2/10/23, read Former Resident #20 was found on the floor with her oxygen cord wrapped around her ankle and complained of pain in her right knee. An incident report, dated 2/11/23, read Former Resident #20 was found on the floor next to her bed lying face down and complained that her feet hurt. On 4/18/23 at 12:58 p.m., the health and wellness director (HWD) stated she had no record of ED notes for Former Resident #20 dated 12/27/23. On 4/19/23 at 9:28 a.m., the family member for Former Resident #20 stated the former resident had sustained seven to eight falls over a 14-month period. The family member stated that the former resident had attempted to get staff attention for assistance for transferring and toileting; however, Former Resident #20 had become impatient and got up independently and would then fall. The family member for Former Resident #20 stated the former resident had hit her head on her dresser during one of her falls and and broke her wrist. On 4/19/23 at 12:37 p.m., the practitioner for Former Resident #20 stated the former resident had been weak and remained in bed most of the time. The practitioner further stated the former resident had been unable to independently transfer and had more frequent falls during the end of life. 3. Resident #37 was admitted to the residence on 3/1/23 with diagnoses including a urinary tract infection (UTI) and cervical spondylosis. A progress note, dated 3/24/23, read Resident #37 was found lying on his right side and his walker was nearby and sustained no injuries. One staff person assisted the resident to a standing position with his walker and then into a recliner. Staff advised the resident to use his walker. An incident report, dated 3/27/23, read Resident #37 was found on the floor lying on his back. The resident stated that he had hit his head lightly and was not in any pain. There was a slight skin tear on his left arm close to his elbow. An incident report, dated 3/28/23, read Resident #37 was found lying between his recliner and television stand. An incident report, dated 4/15/23, read Resident #37 slid out of bed and sustained no injuries. Review of the resident record revealed one care plan, dated 4/18/23 (the first day of the onsite investigation). The care plan read in part: Resident #37 had otitis externa, which caused the resident pain and dizziness, so the resident's family transported him to the emergency room. The care plan read Resident #37 was required to use a call pendant for assistance and staff were required to provide regular safety checks. The care plan also read that Resident #37 was independent with ambulation and did not require any assistive devices. Moreover, the care plan for Resident #37 was not updated with detailed individualized approaches necessary to address fall risk related to deficits in strength, or balance after he fell on 3/24, 3/27, and 3/28/23, and did not include that Resident #37 had a walker. On 4/19/23 at 8:03 a.m., the family member for Resident #37 stated although the residence had notified her of Resident #37's falls, the residence had not notified her of the skin tears she herself observed on the resident's shoulder and elbow. The family member stated the resident had an ear infection that had gotten worse over the last three months prior to the onsite investigation. She stated the worsening ear infection made the resident so weak that that it caused his latest fall on 4/15/23, so she had opted to send the resident to the hospital on 4/16/23. Thefamily member for Resident #37 stated the the only fall intervention for Resident #37 was the use of a walker and that as long as Resident #37 had his walker with him, he was unlikely to fall. On 4/19/23 at 9:16 a.m., Staff #39 stated that she had worked at the residence since October 2023 and worked where the resident resided. Staff #39 stated that Resident #37 had a walker and was being treated with ear drops for an ear infection after diagnosed with right otitis externa on 3/28/23. Staff #39 stated that since Resident #37's ear infection started, he has had more frequent falls. Staff #39 stated that she was not aware of any additional fall interventions for Resident #37. On 4/20/23 at 1:00 p.m., the administrator stated that Resident #37 fall risk intervention was for the resident to push his call light and wait for staff assistance. The administrator stated he did not recall if Resident #37 used a walker for mobility since the resident was not listed on the residence's list of residents who frequently fell. The administrator stated residents identified on this list were discussed at the residence's quality assurance meetings. 4. Resident #38 was admitted to the residence on 3/25/23 with no listed diagnoses. On 4/18/23 at 9:49 a.m., a walker, wheelchair, and floor mat was in Resident #38's room. An incident report titled unwitnessed fall read on 3/27/23 at 12:20 a.m., Resident #38 fell while wandering outside of her room, the resident was "clearly confused and distressed" and was very weak. The incident report had no further follow-up or actions taken by staff to address the changing needs. An incident report titled unwitnessed fall read on 3/27/23 at 1:45 p.m., Resident #38 had a fall, no injuries noted and vitals taken. The incident report had no further follow-up or actions taken by staff to address the changing needs. An incident report titled unwitnessed fall read on 3/28/23 at 8:47 p.m., Resident #38 was heard screaming in another resident room, she was found on the floor on her back, no injuries were noted. The incident report had no further follow-up or actions taken by staff to address the changing needs. An incident report titled witnessed fall read on 3/29/23 at 4:30 a.m., Resident #38 was found crawling on the floor trying to exit her room, the resident was subsequently assisted up and assisted back into bed. Resident #38 was checked on between 2:00 and 3:00 a.m. and again at 4:30 a.m., she was found on her back in front of herself under her television. Resident #38 was crying and claimed to be in pain; however, the resident was unable to determine the location of the pain. Resident #38 was subsequently toileted and began to cry in pain once she stood up to use her walker. Resident #38 "proceeded to collapse onto her rear and then assumed a fetal position while crying and screaming. Resident #38 suffered no injuries or wounds from the fall when Resident #38 was assisted into the wheelchair, she proceeded to scream louder. Did not want to be touched. Resident #38 was taken to her recliner where she had fallen asleep from exhaustion. The resident screamed and cried out when transferred to the recliner and continued to flinch and cry out in pain when blankets were placed over her." The incident report had no further follow-up or actions taken by staff to address the changing needs. An incident report titled unwitnessed fall read on 3/30/23 at 5:28 a.m., Resident #38 was found on the floor in her room at 10:50 p.m., caregivers directed to stay near her room and monitor all night with the door open, no injuries. A progress note, dated 4/6/23, Resident #38 had a witnessed fall and was on the floor on her right side in the fetal position with no complaints of injury. Resident #38 was assisted back into her wheelchair. However, the April 2023 medication administration record (MAR), read Resident #38 had refused medication on 4/10/23 due to her mouth hurting from a fall. There were no incident reports or progress notes in therecord for Resident #38 regarding the fall with injury to the mouth. The record for Resident #38 contained one care plan, dated 4/18/23 (the day of the onsite investigation), which read in part: Resident #38 required total assistance with medication administration, bathing, dressing, full assistance with grooming, used a walker and a wheelchair when she had tremors, had moderate communication impairment, liked to be on the floor, had demylination disease that causes her to shake and fall. The care plan further read the resident was a high fall risk, staff to perform frequent checks, alert licensed nurse of any observable changes in condition such as increase in weakness or confusion. "Escort and safety assistance provided per resident need (Physical Therapy) eval(ulation) and treatment considered. Routine exercise encouraged. Floor mats, low bed and sleep/incontinence scheduling encouraged." Safety checks at 9:00 a.m., 12:00 p.m. and 11:00 p.m. Resident has been known to lower herself to the floor and crawl on all fours, she had mentioned she is okay on the floor. On 4/19/23 at 2:48 a.m., Staff #18 stated that Resident #38 required checks every two hours, had a wheelchair, fall mat, and walker. Staff #18 did not list any other fall interventions nor behaviors related to the resident on the floor. On 4/20/23 at 11:33 a.m., the administrator stated that Resident #38 had a note about choosing to ambulate on the floor. Some of it was under behavior management. The administrator stated that Resident #38 was a high fall risk, and required frequent safety checks, alerts, and escorts. 5. Resident #33, was admitted to the residence on 10/19/22 with a diagnosis of unspecified vascular dementia with behavioral disturbance. An incident report, dated 3/4/23, read Resident #33 was found on the floor of the sensory room of the residence and no injuries were noted. An incident report, dated 3/6/23, read in part: "caregivers were doing rounds after lunch and checking residents and taking them to the bathroom, when (Resident #33) was on Emerald side by the television room and bathroom agency caregiver approached the resident to escort her to the bathroom. Resident grabbed onto the counter and lost balance/footing stumbled and went down to the floor and laid there. The caregiver was holding on to the resident as she went to the ground."An incident report, dated 4/2/23, read that a caregiver heard a loud noise and Resident #33 was found on the ground on her back, no injuries or pain. A ED discharge summary, dated 4/2/23, read that Resident #33 was seen for a fall and was advised fall management interventions. An incident report, dated 4/7/23, read Resident #33 slid out of her chair onto the floor and no injuries were noted. The record for Resident #33 contained one care plan, dated 4/18/23 (the day of the onsite investigation), which read in part: Resident #33 was independent,. Resident #33 had long toenails that caused her to fall and was hospitalized. However, the care plan had no evidence of individualized approach necessary to address fall risks. On 4/19/23 at 9:00 a.m., the family member for Resident #33 stated that he only remembered being informed of a fall which occurred on 4/2/23. The family member stated that he decided to send Resident #33 to the ED because she was holding her arm after her fall and the practitioner recommended that she get it checked out. The family member for Resident #33 stated the resident was released the same day after scans were performed and no injury was found. The family member further stated that the residence did not have any fall interventions for Resident #33 that he was aware of. He further stated that Resident #33's toenails were starting to curl which residence staff thought to be the cause of her falls. On 4/19/23 at 1:54 p.m., the RN consultant stated that she had noticed the residence had no fall interventions in place for Resident #33. The RN consultant stated that Resident #33 did not have an updated care plan after her falls or after the incident on 3/6/23. The RN consultant acknowledged that the HWD had just updated her care plan when the department requested it on 4/18/23. On 4/19/23 at 2:50 p.m., Staff #18 stated that there were no fall interventions in place for Resident #33. Staff #18 stated that she had never received any fall management education or learned about any resident specific approaches for Resident #33. On 4/20/23 at 11:33 a.m., the administrator stated that Resident #33 had no specific fall interventions that were documented in place. The administrator stated there were interventions that he could think of for Resident #33, however were not in place. 6. Resident #36 was admitted to the residence on 3/31/23 with a diagnosis of Parkinson's Disease. An incident report, dated 4/3/23, read Resident #36 had fallen after she attempted to use the restroom without her walker. The fall was unwitnessed and no injuries were sustained. An incident report, dated 4/7/23, read Resident #36 had not used her walker and fell. The call lights were down so she was not reached. The fall was unwitnessed and no injuries were sustained. An incident report, dated 4/12/23, read that Resident #36 was found on the ground in front of her recliner. Fall was unwitnessed and no injuries were sustained. A progress note, dated 4/15/23, had an alert of an unwitnessed fall. However, there was no progress note or incident report of the fall. An incident report, dated 4/16/23, read Resident #36 had fallen out of her chair in the dining area and it was reported by another resident that she had hit her head. The report further read no injuries were sustained. A progress note, dated 4/17/23, read Resident #36 was found on the floor, there was no pain, and vital signs were taken. The record for Resident #36 contained one care plan dated 4/18/23 (the day of the onsite investigation), which read that Resident #36 required checks every two hours and was on external hospice. However, the residence had not updated Resident #36's care plan to include individualized approaches necessary to prevent additional falls other than two hour checks. On 4/20/23 at 11:33 a.m., the administrator stated that he was aware that Resident #36 had an ongoing decline with falls and was still sustaining falls. The administrator stated that he was trying to implement new interventions and get her a wheelchair that could recline, since majority of Resident #36's falls were due to her leaning forward. On 4/19/23 at 12:13 p.m., the external hospice provider for Resident #36 stated that the resident was wheelchair bound and required staff assistance to the toilet. The external hospice provider stated that Resident #36 had sustained falls throughout April 2023 with no injuries falling off the toilet and was unsure of any additional interventions. On 4/19/23 at 1:54 p.m., the RN consultant stated that she saw that some residents interventions were not updated after each fall and stated that the care plans the department was provided, may not have revealed all the interventions that were shown on the electronic system. The RN consultant acknowledged that we should have been provided with all care plan updates if applicable, as part of a complete record. The RN consultant acknowledged that fall management had been an ongoing issue for the residence. On 4/20/23 at 11:33 a.m., the administrator stated that the residences fall management program should include risk factors for falls, and new fall interventions. The administrator stated that residence staff were made aware of fall interventions through the electronic health record system on a mobile device or desktop. The administrator stated that every fall is discussed in quality assurance.

Plan of correction · submitted by the facility

1. Deficiency/Resident-Specific CorrectionThe residence will immediately implement corrective action to ensure an effective fall management program, in accordance with the requirements of 6 CCR 1011-1 Chapter 7 Section 12.15. No corrective action can be conducted for former Resident #20, who no longer resides at the facility. For Residents #33, #36, #37, and #38 the administrator, wellness manager, therapy manager and pertinent interdisciplinary team (IDT) members will work collaboratively to:(1) Complete a current, comprehensive fall risk assessment.(2) Conduct a comprehensive review of each fall to identify and address any trends, contributing circumstances (e.g., recent medication changes, footwear choice, unmet needs, potential medical causes) and missed prevention opportunities.(3) Obtain physician evaluation of potential medical causes (e.g., postural hypotension, lower extremity neuropathy, cataracts) that contribute to the resident's repeat falls. Obtain the physician's recommendation for any specialist evaluations and for any information (e.g., blood pressure) that should be gathered post-fall to assist identification of possible medical issues contributing to repetitive falls.(4) Develop and implement a person-centered fall care plan and update any kardex or abbreviated direct care staff care plans to reflect any changes.(5) Educate all staff working with these residents on the fall/injury minimization care plan.(6) As applicable, include these residents in therapy or health promotion programing to aid with increased strength and balance abilities.(7) Obtain a pharmacy review of the residents' medications to ascertain possible medications contributing to falls. Facilitate discussion with the authorized practitioner/physician regarding any medications that may contribute to increased fall risk. 2. Identification of Others Affected or Potentially AffectedThe administrator, wellness manager, therapy manager, and pertinent IDT members will employ the following steps to identify others at risk for falls with injury:(1) Audit the most recent 30 days of new admissions to determine completeness and accuracy of all comprehensive fall risk assessments, fall reduction/injury minimization care plans, and any post-fall investigations. Any incomplete or inaccurate assessments, care plans, or investigations will be corrected. One-to-one education will be given to any staff whose work was incomplete or inaccurate.(2) Audit the most recent 30 days of falls to determine completeness and accuracy of all comprehensive fall risk assessments, fall reduction/injury minimization care plans, any post-fall investigations, and if all applicable were in place at the time of the fall. Any incomplete or inaccurate assessments, care plans or investigations will be corrected. The DON and registered nurse consultant will provide one-to-one education to any nurse whose work was incomplete or inaccurate. One-to-one education will be given to any staff who failed to implement planned approaches. 3. System Changes to Prevent RecurrenceThe administrator, wellness manager, therapy manager, and pertinent IDT members will oversee the development and implementation of a fall management program. This should include but not be limited to:(1) Developing and implementing an effective system for pre-admission assessment to determine necessary resources to prevent falls and minimize injury in newly and readmitted residents.(2) Developing and implementing an interdisciplinary team to establish effective observation and monitoring practices to prevent falls and minimize injuries from falls for those residents with history of and/or high risk for falls.(3) Developing and implementing an interdisciplinary team to implement a consistent post-fall practice that identifies opportunities to reduce recurrence and mitigate injury through investigation into the circumstances of the fall.(1) (4)Developing and implementing a system to investigate resident falls that includes use of a standardized fall investigation tool that ascertains pertinent facts at the time of the fall in order to implement effective fall/injury prevention care plan approaches. The fall investigation tool, at minimum, will determine factors contributing to the fall such as environmental hazards such as pathway obstructions, wet floors, and lighting levels; resident footwear status; time of last staff-to-resident contact; continence at the time of fall; call light status; and presence/absence of care planned safety devices.(2) (5)Developing and implementing a resident-specific, individualized purposeful rounding program for residents at high-risk for falls that is inclusive the “five P’s“ (pain, potty, personal possessions, positioning, path free of clutter) (Telligen Quality Innovation Network National Coordinating Center under contract with U.S. Department of Health and Human Services, Health Quality Innovation Network) with each resident contact. The resident specific plan will use information gathered from the fall investigation to inform the frequency of purposeful rounding contacts.(3) (6)Developing and implementing procedures of medical practitioner/specialist referrals for evaluation of conditions contributing to repeat falls.(4) (7)All wellness/care staff shall be educated on the new systems for fall reduction and injury minimization.(5) (8)Nurses and other applicable wellness staff will be educated on correctly conducting comprehensive falls risk assessments, conducting post-fall investigations, and participating in the person-centered fall reduction and injury minimization care planning process. 4. Monitoring of Corrective ActionThe residence will implement a program of ongoing monitoring to ensure corrective actions are effective and sustained.(1) Weekly, for no less than three months, the wellness manager and pertinent interdisciplinary team members will audit/monitor the residence's compliance with providing a fall management program to ensure the actions taken to correct deficient practice continue and are effective. The monitoring includes:a. Observations of Residents #33, #36, #37, #38, and other residents at high-risk for falls to ensure staff are consistently implementing care planned fall risk mitigation interventions.b. Reviewing incident reports and investigation tools for all falls to determine the steps that can be taken to identify and mitigate the cause(s) of the resident's fall.c. Reviewing fall assessments and care plans for any residents with new or increasing falls to determine if the fall management program is being correctly implemented to mitigate the risk of harm. When monitoring audits demonstrate consistent compliance with the fall management program, the frequency of monitoring audits will reduce from weekly to monthly and will continue for no less than one additional quarter.(2) The administrator/designee shall track and trend the success of all quality assurance performance improvement activities related to the fall management program. Such tracking and trending data will be reported to the quality assurance performance improvement committee monthly for no less than three months and shall continue until all performance plan objectives related to maintaining a timely updated state license is consistently implemented. 5. Correction Date9/23/2023Pine Grove Crossing - Directed Plan of Correction Q1180 - QNJD12 B28U11

1360Res Rts-Inv Ab/Neg Alleg or Inj Unk Org A/NS/S E▼

Findings

Based on interview and record review, the residence failed to investigate all allegations of abuse and neglect, affecting 108 current residents. Specifically, on 3/6/23, staff brought to the health and wellness directors (HWD) attention that an incident occurred with Resident #33. The staff stated an unknown contracted staff was rough with Resident #33 and the resident subsequently fell. The HWD stated she interviewed two staff that were present but not all staff. She stated she did not look into the incident further and did not review the camera footage of the incident. She stated she did not document her interviews and was not aware of what other staff worked on that shift when there was alleged abuse. The incident was identified by the residence as a fall. The residence had no documentation an investigation was completed, no evidence measures were into place to protect Resident #33 or any other resident from additional abuse, and no documentation that the allegation had been reported. This failure created an immediate jeopardy risk for all 108 residents. On 4/19/23, the department directed the residence to submit written evidence that the risk had been removed. Findings include:1. References and Residence Policya. Chapter II regulations governing assisted living residences, part 4.2.2, the following occurrences shall be reported to the Department within one business day after the occurrence or when the licensee becomes aware of the occurrence, in the format required by the Department: (D) Any occurrence involving physical, sexual, or verbal abuse of a client, by another client, an employee of the licensee or a visitor to the facility or agency.b. Chapter II regulations governing assisted living residences, part 1.1, reads "Abuse" means the willful infliction of injury, unreasonable confinement, intimidation, or punishment, with resulting physical harm, pain, or mental anguish.c. Chapter VII regulations governing assisted living residences, part 13.11, requires that the residence investigate all allegations of abuse and neglect of residents, in accordance with Part 5.3 and its written policy. The residence's written policy was required to include the following:(A) Reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator.(B) Notification to legal representatives, of the allegation within 24 hours of the assisted living residence becoming aware of the allegation.(C) The process for investigating such allegations.(D) How the assisted living residence will document the investigation process to evidence the required reporting and that a thorough investigation was conducted.(E) Resident protection from potential future abuse and neglect, while the investigation is being conducted.(F) Appropriate corrective action if the alleged neglect or abuse is verified.(G) Ensure a copy of the report with the investigation findings is retained by the facility and available for Department review.c. The residence's Abuse and Neglect Policy, updated August 2017, read that each resident has the right to be free from physical or mental abuse on involuntary seclusion, and when an allegation of abuse was known by the residence, corrective action was immediately taken and monitored to ensure the problem does not reoccur. Abuse was defined as the non-accidental act of physical mistreatment or injury of a resident through the action of inaction of another individual and any resident involved was protected during the course of the investigation through appropriate means as determined by the administrator. The administrator or designee would initiate the investigation and complete the investigation within 30 days. 2. Inaccurate PolicyThe residence's policy did not include the following and read that investigation should be done in 30 days not 24 hours. The policy did not include and the following actions were not taken by the residence as follows: (A) reporting requirements to the appropriate agencies such as the adult protection services of the appropriate county Department of Social Services, and to the assisted living residence administrator; (B) Notification to legal representatives, of the allegation within 24 hours of the assisted living residence becoming aware of the allegation; (C) The process for investigating such allegations; (D) How the assisted living residence would document the investigation process to evidence the required reporting and that a thorough investigation was conducted; (E) Resident protection from potential future abuse and neglect, while the investigation is being conducted; (F) Appropriate corrective action if the alleged neglect or abuse is verified and (G) Ensure a copy of the report with the investigation findings was retained by the facility and available for Department review. 2. Resident #33 was admitted to the residence on 10/19/22, with diagnoses including anemia, unspecified vascular dementia with behavioral disturbance and major depressive disorder. A staff schedule dated 3/6/23 read as follows:Contracted Staff #36 worked from 6:00 a.m.-10:00 p.m. in the secured environment. An unknown contracted staff member and Staff #38 worked at the residence from 6:00 a.m.-2:00 p.m. in the secured environment. An incident report, dated 3/6/23, read in part: "caregivers were doing rounds after lunch and checking residents and taking them to the bathroom, when (Resident #33) was on Emerald side by the television room and bathroom agency caregiver approached the resident to escort her to the bathroom. Resident grabbed onto the counter and lost balance/footing stumbled and went down to the floor and laid there. The caregiver was holding on to the resident as she went to the ground." The incident report revealed it was written by Staff #38 and reviewed by the maintenance director (MD). However, the incident report did not specify who the caregiver was, and there was no documentation for the investigation of the alleged physical abuse in Resident #33's record. On 4/18/23 at 7:54 a.m., contrary to what the incident report read, Contracted Staff #36 stated that on 3/6/23, Resident #33 was pulling herself along the countertop between the television and bathroom in the secure environment and a contracted staff member grabbed Resident #33 by the arm in an aggressive and forceful mannerism. Resident #33 buckled her knees and the contracted staff member pulled Resident #33 down and "dragged her across the floor." Contracted Staff #36 stated that herself and Staff #38 reported the incident to both the memory care director (MCD) and the HWD the day the incident occurred on 3/6/23. Contracted Staff #36 stated that the assailant of the abuse was another contracted staff member; however, the contracted staff had not worked with her before and did not know her name. Contracted Staff #36 further stated she considered the incident on 3/6/23 as abuse. On 4/18/23 at 8:06 a.m., the MCD stated that Resident #33 was resistive to care and a staff member tried to help her to the bathroom and Resident #33 grabbed the counter and buckled her knees. The MCD stated the staff member whose name she did not know, held on to Resident #33 and sat her on the floor. The MCD stated that nothing was reported to her personally since she was still in training at the time since she had just assumed her position on 3/1/23. On 4/18/23 at 11:51 a.m., similarly to Staff #36's statement, and contrary to the MCD's statement, Confidential Staff #43 stated that on 3/6/23, Resident #33 had soiled her brief and a contracted staff member whose last name she did not know; however, first name was that of Contracted Staff #37, had grabbed #33's hand and forcefully pulled her to the ground when Resident #33 grabbed the counter and held onto it in opposition. Confidential Staff #43 that s/he felt the incident was abuse; although, the contracted staff member reported to theHWD that Resident #33 fell on her own and stated the incident report was altered to reflect the contracted staff member's statement. Confidential Staff #43 stated the incident report had not reflected what was originally written and had been altered after submission. Confidential Staff #43 further stated the MD was also there during the incident. Confidential Staff #43 stated abuse had reported to both the MD and the HWD, who stated that she would handle the situation. On 4/18/23 at 12:08 p.m., the MD stated contrary to the staff member who wished to remain anonymous and Staff #36's statement, that a contracted staff member was trying to change Resident #33's brief and she fell to the floor. The MD stated that the contracted staff member was unable to communicate with Resident #33 due to a language barrier and tried to pick her back up after. The MD stated that he did not see the whole incident from start to finish and stated he did not see any misconduct. On 4/18/23 at at 4:25 p.m., Contracted Staff #37 stated that she did not know of an incident that occurred on 3/6/23, or any fall with Resident #33. Contracted Staff #37 stated that she still worked at the residence and had worked at the residence in March 2023 in the secure environment; however, was unsure when she had last worked. On 4/19/23 at 9:00 a.m., the family member for Resident #33 stated that he had not been made aware of any allegations of abuse. On 4/19/23 at 12:48 p.m., contrary to what the staff member who wished to remain anonymous reported and Contracted Staff #36, the HWD stated she finalized and saved incident reports and denied modifying the report. The HWD stated what was reported to her regarding the incident with Resident #33 on 3/6/23, was that a staff was rough and herself and the administrator talked about it with residence staff in a quality assurance meeting. However, the HWD stated she did not feel there was intent, because it was not like "she was dragged down the hallway." The HWD further stated that Resident #33 was only lowered to the ground. On 4/19/23 at 1:51 p.m., the RN consultant stated that the day of the onsite investigation on 4/19/23, was the first time she had heard about an allegation of abuse for Resident #33 on 3/6/23. The consultant stated the incident report, dated 3/6/23, was not completed until 4/15/23 (four days prior to the onsite investigation). The consultant stated the incident should have been investigated when the word "rough" was reported to the HWD. The consultant also stated that the residence's protocol was to evaluate each fall and further stated it should have been done for Resident #33. On 4/19/23 at 2:12 p.m., during a second interview, the HWD stated that she was not aware of any allegation of abuse. She stated it reported by Contracted Staff #36 that a staff member was rough with Resident #33 when she fell. However, the HWD stated that "(Staff #36) was dramatic and came down right away and reported to her what had happened." The HWD further stated that the fall did not meet the criteria for abuse based on her interview with Contracted Staff #36. The HWD stated that Resident #33 had soiled her brief on 3/6/23, and a unknown staff member subsequently tried to assist Resident #33 to the bathroom. She stated the resident then grabbed onto the counter and refused the care. The HWD stated she had cameras; however, she did not review the footage or interview any other staff members other than, Staff #36 who reported the incident to her. The HWD stated after speaking with Staff #36, she did not feel that the staff had intent to harm, and a staff member being rough with a resident did not sound like abuse. On 4/19/23 at 3:46 p.m., Confidential Staff #44 stated that s/he had not witnessed the incident on 3/6/23; however, s/he heard that Resident #33 needed to be changed a contracted staff member pulled Resident #33 which resulted in the resident falling and stated at that point the MD yelled out "what is going on?" Confidential Staff #44 stated that the contracted staff member "grabbed (Resident #33) like a kid and dragged to the floor" and contracted Staff #36 and Staff #38 were there and were upset by the situation. Confidential Staff #44 stated that she believed the HWD modified the incident report to cover up the incident, and believed what happened to Resident #33 was abuse. On 4/19/23 at 4:04 p.m., the administrator stated that if there was alleged abuse, the process was to inform the HWD then the HWD would initiate an investigation and inform the administrator and the investigation would consist of interviews, assessments, and potential review of camera footage. The administrator stated that once it was determined abuse occurred, family would be notified, and law enforcement. The administrator stated the the HWD had not reported to him any concerns higher than a fall and had just found out on 4/18/23 about the allegation. 5. Immediate Jeopardy Risk - Written Evidence, Immediate Correction The investigation established that the findings above placed the 108 current residents at immediate jeopardy risk for abuse since the residence failed to investigate when an allegation of abuse was brought to their attention on 3/6/23. The residence was directed to provide the department with written evidence that the risk had been removed. Part 13.11 of the Chapter VII regulations require residences to immediately correct the circumstances that gave rise to the immediate jeopardy situation. On 4/19/23 at 4:48 p.m., the administrator submitted written evidence that read in pertinent part: "On 4/19/23 administrator to start investigation into alleged occurrence on 3/6/23. This will include but not limited to review of camera footage, interviews with staff and residents, review of relevant documents. On 4/19/23 administrator to file initial report through CDPHE portal of occurrence. On 4/19/23 administrator to notify legal representative of alleged victim. On 4/19/23 effective immediately, all agency staff will need to be partnered with a residence permanent staff member during all resident care."However, the written evidence did not contain a monitoring element or how the risk would be removed. On 4/19/23 at 4:52 p.m., the administrator submitted a second attempt with written evidence that read in pertinent part: "On 4/19/23 administrator to start investigation into alleged to occurrence on 3/6/23. This will include but not limited to review of camera footage, interviews with staff and residents, review of relevant documents. 4/19/23 administrator to file initial report through CDPHE portal of occurrence. 4/19/23 administrator to notify legal representative of alleged victim. 4/19/23 effective immediately, all contracted staff will need to be partnered with a (residence) associate during all resident care. Assignments will be noted on a daily chore schedule, (residence) staff to sign off on confirmation of partnership and report to management any contracted staff that is non compliant. Contracted partnership to be discontinued upon verification of individual alleged occurrence. Alleged individual would be banned from working at the (residence) and occurrence will be reported to the (contracted) agency. On 4/24/23, all staff members will be retrained on mandatory reporting protocol. All staff to be retrained by 4/26/23. Training to be documented in employee's personnel file. All staff to be retrained on Mandatory Reporting Protocols every other month for the next 6 months."However, the written evidence did not state that staff would be trained prior to each shift. On 4/19/23 at 5:02 p.m., the administrator submitted a third and final attempt with written evidence that read in pertinent part: "On 4/20/23 all staff members will be retrained by management on mandatory reporting protocol. All staff to be retrained prior to the beginning of their shifts. Business Office Director to confirm that all training is completed and documented in each employee's personnel file. All staff to be retrained on Mandatory Reporting Protocols every other month for the next 6 months.

Plan of correction · submitted by the facility

Q1360 Abuse/NegThe statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all Federal and State regulations, the community has taken or will take, the actions set forth in the following plan of correction. 1. IJ action plan was provided to survey team on 4/19/23 and accepted. 4/19/23 Administrator to start investigation into alleged Occurrence on 3/6/2023. This will include but not limited to review of camera footage, interviews with staff and residents, review of relevant documents. The Investigation was completed, police and family were notified of investigation. Allegation was reported to the state through the portal as unsubstantiated. The allegation was deactivated by state. HWD was provided education on 4/19/2023 on abuse/neglect and all items that must be completed during an investigation. The abuse/neglect policy was updated on4/19 Administrator or designee (Business Office Director) will identify alleged individual before leaving.• 4/19/23 Administrator to File initial report through CDPHE portal of occurrence, including mandatory reporting. 4/19/23 Administrator to notify legal representative of alleged victim. 4/19/23 Effective immediately, all Agency staff will need to be partnered with a Pine Grove Associate during all resident care. All community and agency staff will be trained on this protocol and mandatory reporting protocols prior to their shift starting. Assignments will be noted on Daily Care SchedulePine Grove Staff to sign off on confirmation of partnership and report to management any agency staff that is non-compliant.o Agency Partnering to be discontinued upon verification of individual alleged of occurrence. Alleged individual will be banned from working at community and occurrence will be reported to individual’s agency.o 4/19 All staff members will be retrained on mandatory reporting protocol. All staff to be retrained prior to the beginning of their shifts. Business OfficeDirector to confirm that all training is completed and documented in each Employee's personnel file.o All staff are to be retrained on Mandatory Reporting Protocols every other month for the next 6 months.o Administrator to complete weekly check ins with a minimum of 3 staff members and keep record to ensure staff understands mandatory reporting protocols and there has not been any new events that are reportable by definition, this will be done for 6 weeks. Addendum:IJ action plan was provided to survey team on 4/19/23 and accepted. 4/19/23 Administrator to start investigation into alleged Occurrence on 3/6/2023. This will include but not limited to review of camera footage, interviews with staff and residents, review of relevant documents. The Investigation was completed, police and family were notified of investigation. Allegation was reported to the state through the portal as unsubstantiated. The allegation was deactivated by state. HWD was provided education on 4/19/2023 and again on 10/11/2023 on abuse/neglect and all items that must be completed during an investigation. The abuse/neglect policy was updated on 8/2/2023.

1430Med/Med Adm-Gen Rq Pract OrdrS/S A▼

Findings

Based on record review and interview, the residence failed to prepare or administer only medication that has been ordered by an authorized practitioner, affecting one sample resident (#36). Findings include:1. Residence PolicyThe residence's medication policy, dated 7/26/16, read in part: Any medication received by the residence was checked against a practitioner's order. 2. Resident #36 was admitted to the residence on 3/31/23, with a diagnosis of Parkinson's Disease.a. AtropineThe April 2023 medication administration record (MAR) read Resident #36 was administered atropine 1% in the morning and evening from 4/16-4/17/23 both doses and 4/18/23 in the morning for a total of five doses. However, the residence was unable to provide a written practitioner's order for the medication. 3. InterviewsOn 4/20/23 at 11:33 a.m., the administrator stated that it was never acceptable to administer medications without an order. The administrator stated that he was not aware that Resident #36's atropine 1% order was never provided. On 4/20/23 at 1:54 p.m., the RN consultant stated that medications had been a concern for the residence. On 4/20/23 at 2:50 p.m., the health and wellness director stated that she had an atropine 1% order and acknowledged that she understood when we requested a complete resident record, we were requesting for all corresponding orders to the MAR. However, no order was provided.

Plan of correction · submitted by the facility

Q1430The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all Federal and State regulations, the community has taken or will take, the actions set forth in the following plan of correction. 1. Pine Grove Crossing changed to Heartland Pharmacy on 5/10/23. Heartland Pharmacy puts all orders in to ECP and DON/designee confirms the orders. Heartland provided a website that has all of the active orders they are providing medication for and they profile the medication lists for resident that are not using PGC for medication administration. Medication order for #36 was provided on 4/20/23Ongoing training to Qmap care staff related to medication administration including:-9/26/23 Medication rights, holes in MARS, notifying family and physician for any missed or refused medications, importance of giving medication as prescribed and possible negative effects if missed.-8/22/23 Staff Training on Medication Orders, Carts, Processes (Refusal),Alert Charting, Parameters for PRN, and more medication related topics.-6/15/2023 Pine Grove Crossing had a staff meeting that reviewed QMAP job responsibilities and requirements-5/3/23 r/t Medication Management-A. Qmaps can have no holes in MARSB. Do not document a refusal for other issues. C. Notify nurse/RCD/DON immediately of any meds not available. 1. Fill out form at end of each shift and put in RCC box. 2. Notify if any medication is different from orders. 3. Check Incompletes before you leave your shift. 2. DON/Designee completes a monthly audit on all resident’s medications in which PGC is administering. When the pharmacy provides PGC a new 30- day supply of medication, DON/Designee ensures the following following:-All current medications match the current orders in the EMR-Subsequently, all current orders math what PGC is administeringThis audit will continue every 30 days as part of PGC’s standard monthly medication audit. 3. Any medication discrepancies that are noted are immediately corrected with the pharmacy and active order. All medication, including orders, discrepancies, or other medication concerns are documented and brought to the monthly QAPI meeting for review. Copies of the monthly audit will be filed in the POC binder for a minimum of 3 months.

1468Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼

Findings

Based on observation, record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting six of six sample residents (#22, #28, #34-#35, and #37-#38). Findings include: 1. Residence PolicyThe residence's medication administration policy, dated 7/26/16, read the residence was to assist with medication administration and all medication administrations unless the resident could self-administer. Staff were to assist residents with the administration of prescribed medication. 2. Resident #37 was admitted to the residence on 3/1/23, with diagnoses including a urinary tract infection (UTI), cervical spondylosis, diabetic kidney disease, and endocarditis. a. Hydrocortisone CreamA written practitioner's order, dated 2/23/23, directed the residence to administer hydrocortisone cream 0.2% topically to the affected area twice daily. However, the April 2023 electronic medication administration records (eMAR) for Resident #37 read the medication was not administered on 3/3/23 and 3/11/23 in the evening, due to the area needing to be specific, and 3/30/23 in the morning, for a total of three missed doses. b. Triamcinolone ointmentA written practitioner's order, dated 2/23/23, directed the residence to administer triamcinolone ointment 0.05% to face, neck, and groin area twice daily. However, the March and April 2023 eMAR for Resident #37 read the medication was not administered on 3/3 and 3/11/23 in the evening due to the area not specified, for a total of two missed doses. c. MeloxicamA written practitioner's order, dated 3/30/23, directed the residence to administer meloxicam 7.5 mg daily. However, the April 2023 eMAR for Resident #37 read the medication was not administered on 4/10 and 4/14/23 due to meloxicam being unavailable, for a total of two missed doses. d. FosfomycinA written practitioner's order, dated 2/23/23, directed the residence to administer fosfomycin powder 3 grams weekly on Thursdays. However, the March 2023 eMAR for Resident #37 read the medication was not administered on 3/16 and 3/30/23 due to medication unavailable, for a total of two missed doses.e. TramadolA written practitioner's order, dated 3/28/23, directed the residence to administer tramadol 0.5 mg every 12 hours. However, the March 2023 eMAR for Resident #37 read the medication was not administered on 3/29/23 due to medication unavailable, for a total of one missed dose.f. Terbinafine CreamA written practitioner's order, dated 2/23/23, directed the residence to administer terbinafine cream 1% to Resident #37's toenails twice daily. However, the April 2023 eMAR for Resident #37 read the medication was not administered on 4/14/23 in the evening due to medication unavailable, for a total of one missed dose. g. CiprodexA written practitioner's order, dated 4/13/23, directed the residence to instill four drops of ciprodex 0.2% in Resident #37's affected ear twice daily for 14 days. However, the April 2023 eMAR for Resident #37 read the medication was not administered on 4/14/23, for a total of one missed dose. On 4/18/23 at 3:10 p.m., the health and wellness director (HWD) stated that she was unsure why Resident #37 had missed medications. However, she stated he had seen an outside provider numerous times over the past two months and he kept having orders changed due to his ear infection. 3. Resident #35 was admitted to the residence on 11/2/22 with diagnoses including hyperlipidemia and anxiety.a. FurosemideA written practitioner's order, dated 11/15/22, directed the residence to administer furosemide 20 mg daily. However, the March and April 2023 eMARs revealed that furosemide was not administered 3/18-3/21/23, 3/23-3/25/23, and 3/27-4/18/23, due to waiting on family to deliver, for a total of thirty-five missed doses.b. AcetaminophenA written practitioner's order, dated 11/15/22, directed the residence to administer acetaminophen 500 mg two tablets every eight hours. However, the March and April 2023 eMARs revealed that acetaminophen was not administered 3/15/23 in the morning and afternoon, 3/14-3/18 all three doses, 3/19 in the morning and afternoon, 3/20 all three doses, 3/21 in the afternoon and evening and 3/22/23 in the morning, due to waiting on family to provide, for a total of nineteen misses doses.c. MeloxicamA written practitioner's order, dated 11/15/22, directed the residence to administer meloxicam 7.5 mg once daily. However, the March and April 2023 eMARs revealed that meloxicam was not administered 3/9, 3/11, 3/15-3/21, 3/23-3/25, and 3/27-4/1/23, due to waiting on family to deliver, for a total of eighteen missed doses. d. AspirinA written practitioner's order, dated 11/15/22, directed the residence to administer aspirin 81 mg daily. However, the March and April 2023 eMARs revealed that aspirin was not administered 3/28-4/5/23 for a total of nine missed doses.e. Potassium chlorideA written practitioner's order, dated 11/15/22, directed the residence to administer potassium chloride 10 meq once daily. However, the March 2023 eMAR revealed that potassium chloride was not administered 3/24-3/25, and 3/27-3/31/23 for a total of seven missed doses. 4. Resident #22 was admitted to the residence on 11/10/21, with diagnoses including hypothyroidism, hypertension, and congestive heart failure. a. TramadolA written practitioner's order, dated 1/24/23, directed the residence to administer tramadol 50 mg three times daily. However, the April 2023 eMAR revealed that tramadol was not administered 4/14-4/17/23 for a total of twelve missed doses.b. AcidophilusA written practitioner's order, dated 3/17/23, directed the residence to administer acidophilus every 12 hours for fifteen days. However, the March 2023 eMAR revealed that acidophilus was not administered on 3/17/23 in the evening or 3/18/23 in the morning due to waiting on pharmacy for delivery, for a total of two missed doses.c. CiprofloxacinA written practitioner's order, dated 3/17/23, directed the residence to administer ciprofloxacin 250 mg twice daily for ten days. However, the March 2023 eMAR revealed that ciprofloxacin was not administered on 3/17/23 in the evening or 3/18/23 in the morning due to waiting on pharmacy for delivery, for a total of two missed doses.d. LevothyroxineA written practitioner's order, dated 3/4/23, directed the residence to administer levothyroxine 125 mcg once daily. However, the March 2023 eMAR revealed that levothyroxine was not administered on 3/15/23, due to medication unavailable, for a total of one missed dose.e. TorsemideA written practitioner's order, dated 2/22/23, directed the residence to administer torsemide 10 mg once daily. However, the March 2023 eMAR revealed the torsemide was not administered 3/9/23 for a total of one missed dose, due to waiting on the pharmacy to deliver. 5. Resident #28 was admitted to the residence on 12/23/21, with diagnoses including diabetes and Parkinson's disease.a. Salonpas padA written practitioner's order, dated 2/28/23, directed the residence to administer Salonpas pad 3.1- 6-10 apply for 12 hours then remove for 12 hours. However, the April 2023 MAR read the medication was not administered on 4/3 and 4/4/23 as the medication was out of stock, for a total of two missed administrations. b. Metformin A written practitioner's order, dated 2/28/23, directed the residence to administer Metformin 500 mg twice daily. However, the March 2023 MAR read the medication was not administered on 3/2/23 evening dose as the medication was not available, for a total of one missed dose. c. PioglitazoneA written practitioner's order, dated 2/28/23, directed the residence to administer pioglitazone 15 mg once daily at bedtime. However, the April 2023 MAR read the medication was not administered on 4/6/23 as it was out of stock, for a total of one missed dose. 6. Resident #38 was admitted to the residence on 3/25/23, with no listed diagnoses.a. Docusate SodiumA written practitioner's order,dated 2/1/23, directed the residence to administer docusate sodium 100 mg once daily. However, the MAR 2023 eMAR revealed no evidence the medication was administered because it was not transcribed on the eMAR from 3/26-3/28/23. b. AspirinA written practitioner's order, dated 2/1/23, directed the residence to administer aspirin 81 mg once daily. However, the April 2023 eMAR read the medication was not administered on 4/2/23 as the medication was out of stock, for a total of one missed dose.c. RisperidoneA written practitioner's order, dated 3/30/23, directed the residence to administer risperidone 0.5 mg twice daily at 8:00 a.m. and 8:00 p.m. However, the March and April 2023 eMARs read that the medication was administered once on 3/31/23 at 8:00 p.m., and was administered at 8:00 a.m. and 4:00 p.m. on 4/4 and 4/5/23 for a total of one missed medication administration and two inaccurate medication administrations. 7. Resident #34 was admitted to the residence on 4/17/23 with no listed diagnoses. a. SenexonA written practitioner's order, dated 4/11/23, directed the residence to administer senexon 8.6-50 mg twice daily. However, the April 2023 eMAR revealed that senexon was not administered 4/18/23 due to the medication being unavailable, for a total of one missed dose.b. Slow MagnesiumA written practitioner's order, dated 4/11/23, directed the residence to administer slow magnesium 75.5-119 mg once daily. However, the April 2023 eMAR revealed that slow magnesium was not administered 4/18/23 due to the medication being unavailable, for a total of one missed dose.c. Florastor A written practitioner's order, dated 4/11/23, directed the residence to administer florastor 250 mg once daily. However, the April 2023 eMAR revealed that slow magnesium was not administered 4/18/23 due to the medication being unavailable, for a total of one missed dose. On 4/18/23 at 7:45 a.m., Staff #41 stated that Resident #34's family was to provide his medication. 8. InterviewsOn 4/20/23 at 11:33 a.m., the administrator stated that overs are sent to the pharmacy and some are filled by providers or resident family members. The administrator stated that he expected the residence to comply with practitioner's orders, and stated the whole clinical team was responsible for medication management. On 4/20/23 at 1:54 p.m., the RN consultant stated that medications had been disastrous since before the HWD started at the residence and she was hopeful for when the residence would switch pharmacies on 5/1/23.

Plan of correction · submitted by the facility

The residence will immediately implement corrective action to ensure the residence complies with authorized practitioner orders for those medications administer by the residence, in accordance with the requirements of 6 CCR 1011-1 Chapter 7 Section 14.21. The qualified medication administration person (QMAP) supervisor and applicable members of the interdisciplinary team (IDT), will complete the following for Residents #22, #28, #34, #35, #37, and #38:(1) Audit current medication administration record (MAR) and practitioner orders to ensure the authorized practitioner order for each medication the resident is presently receiving is accurately reflected on the current MAR. Any medications identified with a discrepancy will be reported to the authorized practitioner for resolution of the discrepancy.(2) Audit all current authorized practitioner orders to ensure a sufficient (not less than seven days) supply of each medication is on hand for administration to the resident. Any medication with less than a seven-day supply will be reordered immediately. Any medication without an authorized practitioner order will be removed from the medication cart/storage area and returned to the resident or disposed of, in accordance with residence policy.(3) Identify the staff members involved in these residents' medications errors. Provide these staff with education on how to address discrepancies in authorized practitioner orders and preventing and addressing out-of-stock medications, in accordance with residence policy. 2. Identification of Others Affected or Potentially AffectedThe QMAP supervisor and applicable members of the IDT shall employ the following steps to identify other residents for whom the residence failed to administer medications per authorized practitioner orders:(1) Audit the medication regimens for all residents receiving medication assistance to determine if each authorized practitioner order matches the current MAR. The residence will contact the residents authorized practitioner for resolution of any ongoing discrepancy identified during the medication regimen audit.(2) Audit all current authorized practitioner orders for residents receiving medication assistance to ensure a sufficient (not less than seven days) supply of each medication is on hand for administration to the resident. Any medication with less than a seven-day supply will be reordered immediately. Any medication without an authorized practitioner order will be removed from the medication cart/storage area and returned to the resident or disposed of, in accordance with residence policy.(3) Identify any staff members involved in any newly identified failures to administer medications per authorized practitioner orders. Provide these staff with education on how to prevent and mitigate such failures, in accordance with residence policy. 3. System Changes to Prevent RecurrenceThe QMAP supervisor and applicable members of the IDT, shall oversee the development and implementation of procedures to ensure staff administer medications per authorized practitioner orders. This should include but not be limited to:(1) Developing and implementing an effective action plan to ensure each medication order is accurately and timely transcribed to the MAR. This plan must also include timely discontinuing medications, as ordered by the authorized practitioner.(2) Developing and implementing an effective action plan to ensure the residence maintains a minimum par level of each medication administered by the residence on hand to prevent each medication's being out of stock.(3) Educating all nurses and QMAPs on: a. The seven rights of medication administration - right patient, right drug, right dose, right time, right route, right reason, and right documentation.b. Each staff's role in implementing the action plans for administering medications in accordance with authorized practitioner orders and ensuring sufficient and accurate stock of each ordered/discontinued medication in the resident's medication regimen.c. Educating staff on the potential outcomes that could experienced by Residents #22, #28, #34, #35, #37 and #38 as a result of not administering medications per practitioner orders. 4. Monitoring of Corrective ActionThe residence will implement a program of ongoing monitoring to ensure corrective actions are effective and sustained.(1) Weekly, for no less than three months, the QMAP supervisor and pertinent interdisciplinary team members will audit/monitor the residence's compliance with administering medication per authorized practitioner orders to ensure the actions taken to correct deficient practice continue and are effective. The monitoring includes:a. Auditing MARs and authorized practitioner orders for Residents #22, #28, #34, #35, #37, #38 and at least one other resident on each unit/floor/neighborhood to ensure medications are administered per authorized practitioner orders.b. Auditing authorized practitioner orders with medication storage/carts for Residents #22, #28, #34, #35, #37, #38 and at least one other resident on each unit/floor/neighborhood to ensure medications are maintained in sufficient amounts to administer medications per authorized practitioner orders. When monitoring audits demonstrate consistent compliance with administering medications per authorized practitioner orders the frequency of monitoring audits will reduce from weekly to monthly and will continue for no less three months.(2) The administrator/designee shall track and trend the success of all quality assurance performance improvement activities related to administering medications per authorized practitioner orders. Such tracking and trending data will be reported to the quality assurance performance improvement committee monthly for no less than three months and shall continue until all performance plan objectives related to maintaining a timely updated state license is consistently implemented. 5. Correction Date9/23/2023Pine Grove Crossing - Directed Plan of Correction Q1468 - QNJD12 B28U11

1510Med/Med Adm-Rcrd Kpng MARS/S B▼

Findings

Based on record review and interview, the residence failed to accurately document each medication administration at the time the event was completed for each resident, affecting four of six sample residents (#28, #35, #37 and #38). Findings include:1. Resident #35 was admitted to the residence on 11/2/22 with diagnoses including hyperlipidemia and anxiety.a. MeloxicamA written practitioner's order, dated 11/15/22, directed the residence to administer meloxicam 7.5 mg daily. However, the March 2023 MAR and April 2023 electronic medication administration records (eMAR) revealed no evidence of documentation on 3/22, 3/24, 3/26, and 4/2/23.b. FurosemideA written practitioner's order, dated 11/15/22, directed the residence to administer furosemide 20 mg daily. However, the March 2023 MAR revealed no evidence of documentation on 3/22 and 3/26/23.c. Potassium chlorideA written practitioner's order, dated 11/15/22, directed the residence to administer potassium chloride 10 meq once daily. However, the March 2023 MAR and April 2023 eMAR revealed no evidence of documentation on 3/26/23 and 4/2/23.d. FinasterideA written practitioner's order, dated 11/15/22, directed the residence to administer finasteride 5 mg once daily. However, the April 2023 eMAR revealed no evidence of documentation on 4/2/23.e. IpratropiumA written practitioner's order, dated 11/15/22, directed the residence to instill two sprays of ipratropium 0.03 % in each nostril twice daily. However, the April 2023 eMAR revealed no evidence of documentation on 4/2/23 in the morning.f. OmeprazoleA written practitioner's order, dated 11/15/22, directed the residence to administer omeprazole 40 mg once daily. However, the April 2023 eMAR revealed no evidence of documentation on 4/2/23.g. Vitamin b12A written practitioner's order, dated 11/15/22, directed the residence to administer vitamin b12 1000 mcg once daily. However, the April 2023 eMAR revealed no evidence of documentation on 4/2/23.2. Resident #28 was admitted to the residence on 12/23/21, with diagnoses including diabetes and parkinson's disease.a. Salonpas padA written practitioner's order, dated 2/28/23, directed the residence to administer Salonpas pad 3.1- 6-10 apply for 12 hours then remove for 12 hours. However, the March 2023 MAR revealed no evidence of documentation in the evening on 3/1 and 3/6/23. b. AcetaminophenA written practitioner's order, dated 2/28/23, directed the residence to administer acetaminophen 325 three times daily. However, the March 2023 MAR revealed no evidence of documentation on 3/20/23 noon dose.c. Carbidopa/LevodopaA written practitioner's order, dated 2/28/23, directed the residence to administer Carbidopa/ Levodopa 25/100 mg four times a day. However, the March 2023 MAR revealed no evidence of documentation on 3/20/23 noon dose.d. LevothyroxineA written practitioner's order, dated 2/28/23, directed the residence to administer levothyroxine 50 mcgs once daily. However, the March 2023 MAR revealed no evidence of documentation on 3/3/23.e. SennaA written practitioner's order, dated 2/28/23, directed the residence to administer Senna 8.6 mg once daily. However, the March 2023 MAR revealed no evidence of documentation on 3/6/23.3. Resident #37 was admitted to the residence on 3/1/23, with diagnoses including a urinary tract infection (UTI), cervical spondylosis, diabetic kidney disease, and endocarditis. a. HumulinA written practitioner's order, dated 12/4/22, directed the residence to administer 24 units of humulin before breakfast, and 10 units of humulin before dinner. However, the March 2023 paper MAR for Resident #37 had no evidence of documentation on 3/6/23 before dinner. Additionally, between the April 2023 eMAR and March 2023 paper MAR, it read that humulin was given twice in the morning from 3/6-3/9/23, and given three times in the evening on 3/7-3/9/23. On 4/18/23 at 3:32 p.m., the HWD stated that staff would not have given Resident #37's humulin three times, and was just documented more than once. The HWD stated that the MARS had it documented more than once because it was when they changed to a new electronic health system from 3/1/23. On 4/19/23 at 10:53 a.m., the LPN stated that Resident #37's humulin was only given as ordered, and some medications would show up on the new electronic MAR after 3/1/23, and others would not, so she had documented in both the electronic MAR and the old paper MAR to be safe.b. Triamcinolone ointmentA written practitioner's order, dated 2/23/23, directed the residence to administer 0.05% triamcinolone ointment to face, neck, and groin area twice daily. However, the March 2023 MAR read that triamcinolone ointment was refused when the MAR notation notes read the medication was not available, on 4/10/23 in the morning.c. AcetaminophenA written practitioner's order, dated 3/28/23, directed the residence to administer two tablets of 500 mg acetaminophen twice daily. However, the April 2023 eMAR revealed no evidence of documentation on 4/9/23 in the afternoon. 4. Resident #38 was admitted to the residence on 3/25/23, with no listed diagnoses.a. AcetaminophenA written practitioner's order, dated 3/28/23, directed the residence to administer acetaminophen 1000 mg three times daily. However, the March 2023 MAR revealed no evidence of documentation on 3/31/23 a.m. and p.m. doses.b. RisperdalA written practitioner's order, dated 3/30/23, directed the residence to administer Risperdal 0.5 mg twice daily at 8:00 a.m. and 8:00 p.m. However, the April 2023 MAR read the 0.25 mg was administered 4/9-4/14/23 at 8:00 p.m. Additionally, the MAR read the medication was not administered at 8:00 a.m. from 4/10- 4/18/23. c. RisperdalA written practitioner's order, dated 3/30/23, directed the residence to administer Risperdal 0.5 mg twice daily at 8:00 a.m. and 8:00 p.m. However, the April 2023 MAR read the medication was administered twice at 8:00 a.m. on 4/6/23. 5. InterviewsOn 4/18/23 at 3:32 p.m., the HWD stated that empty spaces in the MAR meant a medication was not given or refused, and she expected staff to document refused if a medication was refused. The HWD acknowledged that each box should not just be left blank. The HWD stated that some staff would document refused when they should have marked "other" due to medication not available, and it was a preference for some people. On 4/20/23 at 11:33 a.m., the administrator stated that a blank space in the MAR meant it was not documented, and would expect staff to initial according to whether a medication was given, refused, unavailable or something else. On 4/20/23 at 1:54 p.m., the RN consultant stated that staff were trained on how to document appropriately on the medication administration records.

Plan of correction · submitted by the facility

Q1510The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all Federal and State regulations, the community has taken or will take, the actions set forth in the following plan of correction. 1. Upon identifying 6 sample residents that had holes in the MARS, PGC staff was immediately educated to notify PCP and families of any missing medication. Staff were reeducated on using the new EMR system and proper documentation for missing or unavailable medications. Immediate training on 4/20/23 to review new EMR system, documentation for EMR administration. QMAP training will continue to be provided to discuss any concerns, review medication rights, and overall QMAP medication process and procedures. Recent trainings since survey occurred includes:-9/26/23 Medication rights, holes in MARS, notifying family and physician for any missed or refused medications, importance of giving medication as prescribed and possible negative effects if missed. -8/22/23 Staff Training on Medication Orders, Carts, Processes (Refusal), Alert Charting, Parameters for PRN, and more medication related topics.-6/15/2023 Pine Grove Crossing had a staff meeting that reviewed QMAP job responsibilities and requirements-5/3/23 r/t Medication Management-A. Qmaps can have no holes in MARSB. Do not document a refusal for other issues. C. Notify nurse/RCD/DON immediately of any meds not available. 1. Fill out form at end of each shift and put in RCC box. 2. Notify if any medication is different from orders. 3. Check Incompletes before you leave your shift. 2. DON/designee reviews the MAR for missing or unavailable medications during the daily stand up meeting each weekday morning. Any missed medications are addressed immediately. A full month review of any issues or concerns will be documented and brought to QAPI meetings. Findings will be discussed and results will be filed in the POC Binder. This process is ongoing and incorporated into PGC daily standard practices.

2130HIR-Cntnt IncldS/S B▼

Findings

Based on record review and interview, the residence failed to ensure resident records contained progress notes regarding any out-of-the-ordinary event or issue that affected 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 four of four sample residents who experienced out of the ordinary events (#33, #37, #38, #40) and one former resident (#20). Findings include:1. Resident #33 was admitted to the residence on 10/19/22, with diagnoses including vitamin B12 deficiency, anemia, unspecified vascular dementia with behavioral disturbance and major depressive disorder. Progress notes read the resident had falls on the following dates: 3/6, 3/7, 4/2 and 4/7/23. However, incident reports revealed the resident sustained falls on the following dates as follows as follows: 3/4, 3/6 and 4/2/23. Therefore, there was no progress note of a fall on 3/4/23. An incident report, dated 3/4/23, read Resident #33 was found on the floor of the sensory room of the residence with no injuries. An incident report, dated 3/6/23, read in part: "caregivers were doing rounds after lunch and checking residents and taking them to the bathroom, when Resident #33 was on Emerald side by the television room and bathroom agency caregiver approached the resident to escort her to the bathroom. Resident grabbed onto the counter and lost balance/footing stumbled and went down to the floor and laid there. The caregiver was holding on to the resident as she went to the ground."An incident report, dated 4/2/23, read a caregiver heard a loud noise and Resident #33 was found on the ground on her back, no injuries or pain were noted. A emergency department (Ed) discharge summary, dated 4/2/23, read that Resident #33 was seen for a fall and was advised fall management interventions. However, in addition to the progess notes and incident reports having different dates of incidents, the progress notes in Resident #33's record did not include actions taken by staff for out of the ordinary events such as what occurred on 3/6/23 where the resident went to the emergency room for all fall. On 4/18/23 at 7:54 a.m., Staff #36 stated on 3/6/23, Resident #33 was pulling herself along the counter between the television and bathroom in the secure environment and a contracted staff member grabbed Resident #33 by the arm in an aggressive and forceful mannerism. Resident #33 buckled her knees and the contracted staff member pulled Resident #33 down and "dragged her across the floor." On 4/18/23 at 11:51 a.m., Confidential Staff #1, stated on 3/6/23, Resident #33 had soiled her brief and a contracted staff member whose name s/he did not know, grabbed #33's hand and forcefully pulled her to the ground when Resident #33 grabbed the counter and held onto it in opposition. Confidential Staff #1 that s/he felt the incident was abuse. On 4/19/23 at 9:00 a.m., the family member forResident #33 stated that he only remembered being informed of Resident #33's fall on 4/2/23. The family member stated that he decided to send Resident #33 to the ED because she was holding her arm after her fall and the practitioner recommended that she get it checked out. The family member of Resident #33 stated that Resident #33 was released the same day after scans. On 4/20/23 at 1:54 p.m., the RN consultant stated that she had reviewed Resident #33's record and had noticed there were auto-generated flags. However, there was no evidence of a progress note for Resident #33's falls including the incident on 3/6/23. The RN consultant stated that they should have been a progress note for the incident on 3/6/23 and for her falls, and not just a follow-up. 2. Resident #38 was admitted to the residence on 3/25/23, with no listed diagnoses. Incident reports read the resident had falls on the following dates: twice on 3/27 and once on 3/29 and 3/30/23. An incident report titled unwitnessed fall read on 3/27/23, Resident #38 fell while wandering outside of her room, the resident was "clearly confused and distressed" and was very weak. The incident report had no further follow-up or actions taken by staff to address the changing needs. An incident report titled unwitnessed fall read on 3/27/23, Resident #38 had a fall, no injuries noted and vitals taken. The incident report had no further follow-up or actions taken by staff to address the changing needs. An incident report titled unwitnessed fall read on 3/28/23, Resident #38 was heard screaming in another resident room, she was found on the floor on her back, no injuries were noted. The incident report had no further follow-up or actions taken by staff to address the changing needs. An incident report titled witnessed fall read on 3/29/23, Resident #38 "proceeded to collapse onto her rear and then assumed a fetal position while crying and screaming. Resident #38 suffered no injuries or wounds from the fall When Resident #38 was assisted into the wheelchair, she proceeded to scream louder. Did not want to be touched. Resident #38 was taken to her recliner where she had fallen asleep from exhaustion. The resident screamed and cried out when transferred to the recliner and continued to flinch and cry out in pain when blankets were placed over her." The incident report had no further follow-up or actions taken by staff to address the changing needs. An incident report titled unwitnessed fall read on 3/30/23, Resident #38 was found on the floor in her room at 10:50 p.m., caregivers directed to stay near her room and monitor all night with the door open, no injuries. However, there were no progress notes of any of these incidents. The April 2023 medication administration record (MAR), read that Resident #38 had refused medication on 4/10/23 due to her mouth hurting from a fall. However, there was no progress note of any fall with injury in Resident #38's record. On 4/18/23 at 9:53 a.m., Staff #40 stated that Resident #38 had expressed she had felt under the weather and had wanted to stay in bed later than usual, ever since her infusion on 4/15/23. Staff #40 stated that she had just noticed that Resident #38 wanted to stay in bed two days prior to the onsite investigation. However, there were no progress notes about Resident #38's infusions. 3. Resident #37 was admitted to the residence on 3/1/23, with a diagnosis of cervical spondylosis. Incident reports read the resident had falls on the following dates: 3/27, 3/28 and 4/15/23. An incident report, dated 3/27/23, read that Resident #37 was found on the floor lying on his back. The resident stated that he had hit his head lightly and was not in any pain. There was a slight skin tear on his left arm close to his elbow. An incident report, dated 3/28/23, read Resident #37 was found lying between his recliner and television stand. An incident report, dated 4/15/23, read Resident #37 slid out of bed and sustained no injuries. However, review of Resident #37's record revealed that there were no progress notes for Resident #37's fall with injury on 3/27/23, Resident #37's falls on 3/28, and 4/15/23. 4. Former Resident #20 was admitted to the residence on 9/27/19 with no listed diagnoses. A progress note, dated 12/27/22, read Former Resident #20 was found on the floor and sent to the hospital. A progress note, dated 12/28/22, read a hematoma was found on the right side of Former Resident #20's head with suture closed. However, no hospital documentation was provided by the residence. An external hospice note, dated 1/10/23, read Former Resident #20 had a fall and hit her head. However, there were no progress notes or incident reports provided by the residence of this incident. 5. Resident #40 was admitted to the residence on 12/22/21, with diagnoses including hypokalemia, major depressive disorder, chronic obstructive pulmonary disease, gastro-esophageal reflux disease, and difficulty walking. On 4/18/23 at 7:30 a.m., Staff #18 stated on 4/17/23 Resident #40 was choking on toast and needed the heimlich maneuver. On 4/19/23 at 12:53 p.m., the health and wellness director (HWD) stated that she observed Resident #40's choking incident. However, there was no progress notes about any choking incident with Resident #40.6. InterviewsOn 4/20/23 at 11:33 a.m., the administrator stated that he would expect lab diagnostic reports, notes from outside providers, and hospital discharge paperwork to all be a part of a resident record. The administrator stated that he would not consider incident reports to be progress notes, however, their observation notes were. The administrator acknowledged progress notes should contain actions taken by staff to address a resident's changing needs. The administrator stated that there was a disconnect with the new electronic system, because the observation notes generate a note whenever an incident report was submitted and then a follow up to the incident. On 4/20/23 at 1:54 p.m., the RN consultant stated that the HWD must have misunderstood what was required in a resident record. The RN consultant stated she explained to te HWD Chapter VII regulations, however, remembered something from Chapter 2 regarding resident records where services completed offsite were not required to be included. The RN consultant stated she may have given the HWD inappropriate information. The RN consultant acknowledged that all out of the ordinary events should be detailed in progress notes per the regulation. However, the residence used incident reports and observations notes did not always detail events.

Plan of correction · submitted by the facility

Q2130The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all Federal and State regulations, the community has taken or will take, the actions set forth in the following plan of correction. 1. Due to the new EMR (rolled out 4/2023) and the new system of documenting out of the ordinary events, staff were immediately educated on how to document alert charting and observations. Due to the length of time from the occurrence backdating the observations was not recommended. Staff will continue to be educated on appropriate documentation, change of conditions, required documentation for an out of the ordinary event.-8/22/23 Staff Training - Tasks review, Resident care, Incident Reporting-9/26/23 Staff Training- incident reporting, interventions, change of conditions, documentation. 2. Incidents and observations (Progress Notes) are reviewed every weekday morning at stand up to ensure information regarding the out of the ordinary event was documented and any necessary follow up is addressed. 3. Any discrepancies will be documented and reviewed in QAPI on a monthly basis. Any audits or findings will be filed in the POC Binder. This process is ongoing and incorporated into PGC daily standard practices.

9999Final ObservationsSurveyor note▼

Findings

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. Q1514 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.

Plan of correction

The state did not require a plan of correction for this citation.

4/18/2023Revisit: Licensure Complaint · ID ERDJ131 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A licensure revisit was completed on 4/20/23 for the previous deficiency cited on 8/11/22. A deficiencies were cited.

Plan of correction

The state did not require a plan of correction for this citation.

1110Res Care Srvs-Min Srvs Res AgrS/S A▼

Findings

Plan of correction · submitted by the facility

Q1110 The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all Federal and State regulations, the community has taken or will take, the actions set forth in the following plan of correction. Part A Q11101. Facesheet for #38 was updated to show correct DNR status on computer on 4/20/23. A MOST form audit was completed on 4/20/23 and updated to ensure that the DNR status match the computer EMR facesheets. Training provided by DON on 9/27/23 to all care staff related to MOST form importance and for carestaff to notify DON/designee of any new MOST forms received or changes made to MOST form. 2. DON/Designee will complete MOST form audits monthly on all residents to ensure MOST form DNR status matches EMR face sheets. DON/Designee will review new admission for MOST form and update in system as MOST form is available or information changes. 3. Any discrepancies will be corrected immediately. Audit results will be filed in POC binder and brought to QAPI for review. Part B Q11101. To address the failure to provide a safe environment for #38 and #28, staff immediately inspected their rooms on 4/20/23 for any environment concerns. Staff have been educated on maintaining a safe and sanitary environment for the residents on 9/26/23 and 9/27/23. Staff training on: Tasks review, Resident care, Incident Reporting also took place on 8/22/23. On 5/10/2023 Pine Grove Crossing switched to Heartland Pharmacy. All medications including narcotics are now in individual cards. We are no longer accepting bottles of narcotics in the facility. The counting of the narcotic in the bottle is how the pill ended up on the floor after they transfer the pills from the tablet to the bottle. Training will be ongoing. 2. ED/designee to complete walking rounds in the interior and exterior of the building and 5 resident rooms weekly for 3 months to ensure a safe and sanitary environment. 3. Audit results will be reviewed at QAPI and filed in the POC Binder. Any concerns related to the audit will be brought to the attention of the ED immediately.

4/18/2023Revisit: Licensure Complaint · ID QNJD125 deficiencies▼

0000Initial CommentsSurveyor note▼

Findings

A licensure revisit was completed on 4/20/23 for all previous deficiencies cited on 8/11/22. Deficiences were cited.

Plan of correction

The state did not require a plan of correction for this citation.

0540Admin-Dts RespS/S B▼

Findings

Plan of correction · submitted by the facility

Q540The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all Federal and State regulations, the community has taken or will take, the actions set forth in the following plan of correction. EMResource updated with correct information for ICP information immediately. The Covid mitigation plan was updated 4/20/23. ICP was updated for Pine Grove to Betsy Hardy, RN on 4/20/23, who has previously completed both CDC and CoTrain Infection Control requirements. Going forward, any changes in personnel will be updated by the next required reporting by ED/DesigneeEMResource will be updated per guidelines monthly and with any changes. The Covid mitigation guidance continues to be updated and changes made with any new guidance. DON/designee will provide documentation of EMResource updates two times a months for 3 months and Covid Mitigation plan will be reviewed if any changes are made. All printed documentation will be filed in the POC Binder and be reviewed at Pine Grove’s monthly QAPI meeting.

0736Stff Rq-First Aid Stff CPR ListS/S B▼

Findings

Based on observation, record review and interview, the residence failed to place in a visible location a list of all staff who had current certification in first aid or CPR (cardiopulmonary resuscitation), so that the information was readily available to staff at all times, affecting 108 current residents. This deficiency was cited previously during a licensure complaint on 8/11/22. Although the residence corrected the deficiency, the residence has not maintained compliance with this regulatory requirement. Findings include:Throughout the two day onsite investigation from 4/18-4/19/23, there was no list of all staff who had current certification in first aid or CPR placed in a visible location, so that the information was readily available to all staff at all times. On 4/18/23 at 7:45 a.m., Staff #41 stated the list of all staff who had current certification in first aid or CPR was posted in the wellness office. On 4/18/23 at 8:15 a.m., Staff #19 stated she was unsure where the list of all staff who had current certification in first aid or CPR was posted. She added it might be posted on the wall in the copy room. On 4/18/23 at 8:30 a.m., there was no list of staff who had current certification in first aid or CPR in the residence's copy room and wellness office. On 4/18/23 at 10:51 a.m., the list of all staff with current certification in first aid or CPR was requested. On 4/19/23 at approximately 2:00 p.m., the nurse consultant stated the list of staff who had current certification in first aid or CPR was posted in the wellness office and the copy room. On 4/19/23 at approximately 2:00 p.m., there was no list of staff who had current certification in first aid or CPR in the residence's copy room and wellness office. On 4/19/23 at 2:12 p.m., the health and wellness director (HWD) said the list of staff with first aid or CPR that was provided was not current. On 4/19/23 at approximately 2:15 p.m., the list of all staff who had current certification in first aid or CPR was provided. On 4/19/23 at 2:22 p.m., a list of all staff who had current certification in first aid or CPR was posted in the copy room. On 4/19/23 at 4:02 p.m., a second list that was updated of all staff who had current certification in first aid or CPR was provided. On 4/20/23 at 11:33 a.m., the administrator stated the list of staff who had current certification in first aid or CPR was posted in the staff break room and the daily schedules book and acknowledged he was unsure why it was not updated. He added that the business office manager was responsible for updating the list.

Plan of correction · submitted by the facility

Q0736 CPRThe statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all Federal and State regulations, the community has taken or will take, the actions set forth in the following plan of correction. 1. The staff list indicated all staff with current CPR and First Aid certifications was updated on 4/20/23. The list has been updated and maintained monthly with the last updated on 9/18/23. The updated list includes the current status of staff members #41 and #19. The current list continues to be posted in the visible locations of the staff work room and nurses office. Additional staff training completed on:5/3/23:Section 8.8 CPR/First Aid List- ReviewedWhat is it? What does it mean? And where is it?2. DON/designee will maintain the CPR list monthly and with new changes related to staff education or new hires. 3. DON/designee will sample three staff members that are CPR certified to ensure their card is present in the employee file. This audit will be completed weekly for 12 weeks and filed in the POC Binder. Any issues will be corrected immediately, if card is not present the name will be removed from the list immediately and brought to QAPI for review. 4. CPR classes will be offered monthly in the facility by the DON (CPR instructor certified). Last class offered August 26, 2023

1110Res Care Srvs-Min Srvs Res AgrS/S A▼

Findings

Plan of correction · submitted by the facility

1180Res Care Srvs-Fall Mgt PrS/S D▼

Findings

Based on observation, record review and interview, the residence failed to implement a fall management program that included detailing in each resident's care plan the individualized approach necessary to address fall risks related to deficits in strength and balance, affecting four of five sample residents (#33, #36-#38) and one former resident (#20). This deficiency was cited previously during a licensure complaint on 8/11/22. Although the residence corrected the deficiency, the residence has not maintained compliance with this regulatory requirement. Specifically, Former Resident #20 sustained a fall on 12/6/22; however, the residence failed to update the care plan for the former resident after the fall and the resident sustained second fall on 12/27/22. The second fall resulted in injury and required sutures at the emergency department (ED). Although the residence updated the care plan on 12/28/22 (the day after the second fall with injury), the former resident fell four more times in which the care plan for the resident was not updated with individualized approaches. Additionally, three of the four additional falls resulted in further injuries. Specifically, Resident #37 had four falls in 24 days (3/24, 3/27, 3/28 and 4/15/23) in which the residence failed to update the care plan with individualized approaches necessary to address fall risks. One fall on 3/27/23 resulted in skin tears. Additionally, on 4/18/23 (the day of the onsite investigation) the residence updated the care plan for Resident #37; however, the residence still failed to include individualized approaches necessary to prevent additional falls. Specifically, Resident #38 had six falls in 12 days (3/27 twice, 3/28, 3/29, 3/30 and 4/6/23), additional evidence in the record revealed the resident experienced pain in her mouth as a result of a fall on an unknown date. However, the record for Resident #38 revealed no evidence of an updated care plan after the falls that contained individualized approaches necessary to address fall risks. Specifically Resident #33 had four falls in 34 days (3/4, 3/6, 4/2 and 4/7/23). However on 4/2/23, Resident #33 had a fall with pain and was sent to the ED. The residence failed to update Resident #33's care plan to include individualized approaches necessary to prevent additional falls, after Resident #33's falls on 3/4, 3/6, 4/2/23 and 4/7/23. Findings include: 1. Residence Policy The residence's undated Fall Management Policy read that the residence was to provide fall management education and materials to residents and family members, update the resident's care plan after each fall with appropriate individualized approaches necessary to address fall risk related to deficits in strength, balance, and eyesight, or effects of medication as identified during the comprehensive assessment. The residence would provide staff training related to fall prevention during orientation, as well as during routine staff training and services. Staff were routinely educated on how to identify each resident's individualized fall interventions. 2. Former Resident #20 was admitted to the residence on 9/27/19. A progress note, dated 12/6/22, read Former Resident #20 was found on the floor in her bathroom. A progress note, dated 12/27/22, read Former Resident #20 was found on the floor and sent to the hospital. A progress note, dated 12/28/22, read a hematoma was found on the right side of Former Resident #20's head with suture closed. A care plan, dated 12/28/22 (the day after a fall resulting in injury), read Former Resident #20 required toileting assistance and spot (safety) checks three times daily; a tidy environment to reduce fall risk; use of wheelchair for mobility rather than walker; and received external hospice services. The care plan also read fall risk monitoring as needed. However, the residence failed to include how many staff are required to transfer Former Resident #20 and failed to update the care plan for the former resident with individualized approaches necessary to address fall risk after Former Resident #20 fell four additional times on 1/8, 1/10, 2/10 and 2/11/23. An external hospice note, dated 1/4/23, read Former Resident #20 had her staples removed from her fall on 12/27/22. An incident report, dated 1/8/23, read Former Resident #20 had an unwitnessed fall and was found laying on her stomach on the floor with a skin tear on her left hand. An external hospice note, dated 1/8/23, read Former Resident #20 was a two person assist and had pain in her left wrist. An external hospice note, dated 1/10/23, read Former Resident #20 had a fall and hit her head. An incident report, dated 2/10/23, read Former Resident #20 was found on the floor with her oxygen cord wrapped around her ankle and complained of pain in her right knee. An incident report, dated 2/11/23, read Former Resident #20 was found on the floor next to her bed lying face down and complained that her feet hurt. On 4/18/23 at 12:58 p.m., the health and wellness director (HWD) stated she had no record of ED notes for Former Resident #20 dated 12/27/23. On 4/19/23 at 9:28 a.m., the family member for Former Resident #20 stated the former resident had sustained seven to eight falls over a 14-month period. The family member stated that the former resident had attempted to get staff attention for assistance for transferring and toileting; however, Former Resident #20 had become impatient and got up independently and would then fall. The family member for Former Resident #20 stated the former resident had hit her head on her dresser during one of her falls and and broke her wrist. On 4/19/23 at 12:37 p.m., the practitioner for Former Resident #20 stated the former resident had been weak and remained in bed most of the time. The practitioner further stated the former resident had been unable to independently transfer and had more frequent falls during the end of life. 3. Resident #37 was admitted to the residence on 3/1/23 with diagnoses including a urinary tract infection (UTI) and cervical spondylosis. A progress note, dated 3/24/23, read Resident #37 was found lying on his right side and his walker was nearby and sustained no injuries. One staff person assisted the resident to a standing position with his walker and then into a recliner. Staff advised the resident to use his walker. An incident report, dated 3/27/23, read Resident #37 was found on the floor lying on his back. The resident stated that he had hit his head lightly and was not in any pain. There was a slight skin tear on his left arm close to his elbow. An incident report, dated 3/28/23, read Resident #37 was found lying between his recliner and television stand. An incident report, dated 4/15/23, read Resident #37 slid out of bed and sustained no injuries. Review of the resident record revealed one care plan, dated 4/18/23 (the first day of the onsite investigation). The care plan read in part: Resident #37 had otitis externa, which caused the resident pain and dizziness, so the resident's family transported him to the emergency room. The care plan read Resident #37 was required to use a call pendant for assistance and staff were required to provide regular safety checks. The care plan also read that Resident #37 was independent with ambulation and did not require any assistive devices. Moreover, the care plan for Resident #37 was not updated with detailed individualized approaches necessary to address fall risk related to deficits in strength, or balance after he fell on 3/24, 3/27, and 3/28/23, and did not include that Resident #37 had a walker. On 4/19/23 at 8:03 a.m., the family member for Resident #37 stated although the residence had notified her of Resident #37's falls, the residence had not notified her of the skin tears she herself observed on the resident's shoulder and elbow. The family member stated the resident had an ear infection that had gotten worse over the last three months prior to the onsite investigation. She stated the worsening ear infection made the resident so weak that that it caused his latest fall on 4/15/23, so she had opted to send the resident to the hospital on 4/16/23. The family member for Resident #37 stated the the only fall intervention for Resident #37 was the use of a walker and that as long as Resident #37 had his walker with him, he was unlikely to fall. On 4/19/23 at 9:16 a.m., Staff #39 stated that she had worked at the residence since October 2023 and worked where the resident resided. Staff #39 stated that Resident #37 had a walker and was being treated with ear drops for an ear infection after diagnosed with right otitis externa on 3/28/23. Staff #39 stated that since Resident #37's ear infection started, he has had more frequent falls. Staff #39 stated that she was not aware of any additional fall interventions for Resident #37. On 4/20/23 at 1:00 p.m., the administrator stated that Resident #37 fall risk intervention was for the resident to push his call light and wait for staff assistance. The administrator stated he did not recall if Resident #37 used a walker for mobility since the resident was not listed on the residence's list of residents who frequently fell. The administrator stated residents identified on this list were discussed at the residence's quality assurance meetings. 4. Resident #38 was admitted to the residence on 3/25/23 with no listed diagnoses. On 4/18/23 at 9:49 a.m., a walker, wheelchair, and floor mat was in Resident #38's room. An incident report titled unwitnessed fall read on 3/27/23 at 12:20 a.m., Resident #38 fell while wandering outside of her room, the resident was "clearly confused and distressed" and was very weak. The incident report had no further follow-up or actions taken by staff to address the changing needs. An incident report titled unwitnessed fall read on 3/27/23 at 1:45 p.m., Resident #38 had a fall, no injuries noted and vitals taken. The incident report had no further follow-up or actions taken by staff to address the changing needs. An incident report titled unwitnessed fall read on 3/28/23 at 8:47 p.m., Resident #38 was heard screaming in another resident room, she was found on the floor on her back, no injuries were noted. The incident report had no further follow-up or actions taken by staff to address the changing needs. An incident report titled witnessed fall read on 3/29/23 at 4:30 a.m., Resident #38 was found crawling on the floor trying to exit her room, the resident was subsequently assisted up and assisted back into bed. Resident #38 was checked on between 2:00 and 3:00 a.m. and again at 4:30 a.m., she was found on her back in front of herself under her television. Resident #38 was crying and claimed to be in pain; however, the resident was unable to determine the location of the pain. Resident #38 was subsequently toileted and began to cry in pain once she stood up to use her walker. Resident #38 "proceeded to collapse onto her rear and then assumed a fetal position while crying and screaming. Resident #38 suffered no injuries or wounds from the fall when Resident #38 was assisted into the wheelchair, she proceeded to scream louder. Did not want to be touched. Resident #38 was taken to her recliner where she had fallen asleep from exhaustion. The resident screamed and cried out when transferred to the recliner and continued to flinch and cry out in pain when blankets were placed over her." The incident report had no further follow-up or actions taken by staff to address the changing needs. An incident report titled unwitnessed fall read on 3/30/23 at 5:28 a.m., Resident #38 was found on the floor in her room at 10:50 p.m., caregivers directed to stay near her room and monitor all night with the door open, no injuries. A progress note, dated 4/6/23, Resident #38 had a witnessed fall and was on the floor on her right side in the fetal position with no complaints of injury. Resident #38 was assisted back into her wheelchair. However, the April 2023 medication administration record (MAR), read Resident #38 had refused medication on 4/10/23 due to her mouth hurting from a fall. There were no incident reports or progress notes in the record for Resident #38 regarding the fall with injury to the mouth. The record for Resident #38 contained one care plan, dated 4/18/23 (the day of the onsite investigation), which read in part: Resident #38 required total assistance with medication administration, bathing, dressing, full assistance with grooming, used a walker and a wheelchair when she had tremors, had moderate communication impairment, liked to be on the floor, had demylination disease that causes her to shake and fall. The care plan further read the resident was a high fall risk, staff to perform frequent checks, alert licensed nurse of any observable changes in condition such as increase in weakness or confusion. "Escort and safety assistance provided per resident need (Physical Therapy) eval(ulation) and treatment considered. Routine exercise encouraged. Floor mats, low bed and sleep/incontinence scheduling encouraged." Safety checks at 9:00 a.m., 12:00 p.m. and 11:00 p.m. Resident has been known to lower herself to the floor and crawl on all fours, she had mentioned she is okay on the floor. On 4/19/23 at 2:48 a.m., Staff #18 stated that Resident #38 required checks every two hours, had a wheelchair, fall mat, and walker. Staff #18 did not list any other fall interventions nor behaviors related to the resident on the floor. On 4/20/23 at 11:33 a.m., the administrator stated that Resident #38 had a note about choosing to ambulate on the floor. Some of it was under behavior management. The administrator stated that Resident #38 was a high fall risk, and required frequent safety checks, alerts, and escorts. 5. Resident #33, was admitted to the residence on 10/19/22 with a diagnosis of unspecified vascular dementia with behavioral disturbance. An incident report, dated 3/4/23, read Resident #33 was found on the floor of the sensory room of the residence and no injuries were noted. An incident report, dated 3/6/23, read in part: "caregivers were doing rounds after lunch and checking residents and taking them to the bathroom, when (Resident #33) was on Emerald side by the television room and bathroom agency caregiver approached the resident to escort her to the bathroom. Resident grabbed onto the counter and lost balance/footing stumbled and went down to the floor and laid there. The caregiver was holding on to the resident as she went to the ground."An incident report, dated 4/2/23, read that a caregiver heard a loud noise and Resident #33 was found on the ground on her back, no injuries or pain. A ED discharge summary, dated 4/2/23, read that Resident #33 was seen for a fall and was advised fall management interventions. An incident report, dated 4/7/23, read Resident #33 slid out of her chair onto the floor and no injuries were noted. The record for Resident #33 contained one care plan, dated 4/18/23 (the day of the onsite investigation), which read in part: Resident #33 was independent,. Resident #33 had long toenails that caused her to fall and was hospitalized. However, the care plan had no evidence of individualized approach necessary to address fall risks. On 4/19/23 at 9:00 a.m., the family member for Resident #33 stated that he only remembered being informed of a fall which occurred on 4/2/23. The family member stated that he decided to send Resident #33 to the ED because she was holding her arm after her fall and the practitioner recommended that she get it checked out. The family member for Resident #33 stated the resident was released the same day after scans were performed and no injury was found. The family member further stated that the residence did not have any fall interventions for Resident #33 that he was aware of. He further stated that Resident #33's toenails were starting to curl which residence staff thought to be the cause of her falls. On 4/19/23 at 1:54 p.m., the RN consultant stated that she had noticed the residence had no fall interventions in place for Resident #33. The RN consultant stated that Resident #33 did not have an updated care plan after her falls or after the incident on 3/6/23. The RN consultant acknowledged that the HWD had just updated her care plan when the department requested it on 4/18/23. On 4/19/23 at 2:50 p.m., Staff #18 stated that there were no fall interventions in place for Resident #33. Staff #18 stated that she had never received any fall management education or learned about any resident specific approaches for Resident #33. On 4/20/23 at 11:33 a.m., the administrator stated that Resident #33 had no specific fall interventions that were documented in place. The administrator stated there were interventions that he could think of for Resident #33, however were not in place. 6. Resident #36 was admitted to the residence on 3/31/23 with a diagnosis of Parkinson's Disease. An incident report, dated 4/3/23, read Resident #36 had fallen after she attempted to use the restroom without her walker. The fall was unwitnessed and no injuries were sustained. An incident report, dated 4/7/23, read Resident #36 had not used her walker and fell. The call lights were down so she was not reached. The fall was unwitnessed and no injuries were sustained. An incident report, dated 4/12/23, read that Resident #36 was found on the ground in front of her recliner. Fall was unwitnessed and no injuries were sustained. A progress note, dated 4/15/23, had an alert of an unwitnessed fall. However, there was no progress note or incident report of the fall. An incident report, dated 4/16/23, read Resident #36 had fallen out of her chair in the dining area and it was reported by another resident that she had hit her head. The report further read no injuries were sustained. A progress note, dated 4/17/23, read Resident #36 was found on the floor, there was no pain, and vital signs were taken. The record for Resident #36 contained one care plan dated 4/18/23 (the day of the onsite investigation), which read that Resident #36 required checks every two hours and was on external hospice. However, the residence had not updated Resident #36's care plan to include individualized approaches necessary to prevent additional falls other than two hour checks. On 4/20/23 at 11:33 a.m., the administrator stated that he was aware that Resident #36 had an ongoing decline with falls and was still sustaining falls. The administrator stated that he was trying to implement new interventions and get her a wheelchair that could recline, since majority of Resident #36's falls were due to her leaning forward. On 4/19/23 at 12:13 p.m., the external hospice provider for Resident #36 stated that the resident was wheelchair bound and required staff assistance to the toilet. The external hospice provider stated that Resident #36 had sustained falls throughout April 2023 with no injuries falling off the toilet and was unsure of any additional interventions. On 4/19/23 at 1:54 p.m., the RN consultant stated that she saw that some residents interventions were not updated after each fall and stated that the care plans the department was provided, may not have revealed all the interventions that were shown on the electronic system. The RN consultant acknowledged that we should have been provided with all care plan updates if applicable, as part of a complete record. The RN consultant acknowledged that fall management had been an ongoing issue for the residence. On 4/20/23 at 11:33 a.m., the administrator stated that the residences fall management program should include risk factors for falls, and new fall interventions. The administrator stated that residence staff were made aware of fall interventions through the electronic health record system on a mobile device or desktop. The administrator stated that every fall is discussed in quality assurance.

Plan of correction · submitted by the facility

1. Deficiency/Resident-Specific CorrectionThe residence will immediately implement corrective action to ensure an effective fall management program, in accordance with the requirements of 6 CCR 1011-1 Chapter 7 Section 12.15. No corrective action can be conducted for former Resident #20, who no longer resides at the facility. For Residents #33, #36, #37, and #38 the administrator, wellness manager, therapy manager and pertinent interdisciplinary team (IDT) members will work collaboratively to:(1) Complete a current, comprehensive fall risk assessment.(2) Conduct a comprehensive review of each fall to identify and address any trends, contributing circumstances (e.g., recent medication changes, footwear choice, unmet needs, potential medical causes) and missed prevention opportunities.(3) Obtain physician evaluation of potential medical causes (e.g., postural hypotension, lower extremity neuropathy, cataracts) that contribute to the resident's repeat falls. Obtain the physician's recommendation for any specialist evaluations and for any information (e.g., blood pressure) that should be gathered post-fall to assist identification of possible medical issues contributing to repetitive falls.(4) Develop and implement a person-centered fall care plan and update any kardex or abbreviated direct care staff care plans to reflect any changes.(5) Educate all staff working with these residents on the fall/injury minimization care plan.(6) As applicable, include these residents in therapy or health promotion programing to aid with increased strength and balance abilities.(7) Obtain a pharmacy review of the residents' medications to ascertain possible medications contributing to falls. Facilitate discussion with the authorized practitioner/physician regarding any medications that may contribute to increased fall risk. 2. Identification of Others Affected or Potentially AffectedThe administrator, wellness manager, therapy manager, and pertinent IDT members will employ the following steps to identify others at risk for falls with injury:(1) Audit the most recent 30 days of new admissions to determine completeness and accuracy of all comprehensive fall risk assessments, fall reduction/injury minimization care plans, and any post-fall investigations. Any incomplete or inaccurate assessments, care plans, or investigations will be corrected. One-to-one education will be given to any staff whose work was incomplete or inaccurate.(2) Audit the most recent 30 days of falls to determine completeness and accuracy of all comprehensive fall risk assessments, fall reduction/injury minimization care plans, any post-fall investigations, and if all applicable were in place at the time of the fall. Any incomplete or inaccurate assessments, care plans or investigations will be corrected. The DON and registered nurse consultant will provide one-to-one education to any nurse whose work was incomplete or inaccurate. One-to-one education will be given to any staff who failed to implement planned approaches. 3. System Changes to Prevent RecurrenceThe administrator, wellness manager, therapy manager, and pertinent IDT members will oversee the development and implementation of a fall management program. This should include but not be limited to:(1) Developing and implementing an effective system for pre-admission assessment to determine necessary resources to prevent falls and minimize injury in newly and readmitted residents.(2) Developing and implementing an interdisciplinary team to establish effective observation and monitoring practices to prevent falls and minimize injuries from falls for those residents with history of and/or high risk for falls.(3) Developing and implementing an interdisciplinary team to implement a consistent post-fall practice that identifies opportunities to reduce recurrence and mitigate injury through investigation into the circumstances of the fall.(4) Developing and implementing procedures of medical practitioner/specialist referrals forevaluation of conditions contributing to repeat falls.(5) Developing and implementing an hourly purposeful rounding program for residents at high-risk for falls that is inclusive the "four P's" (pain, potty, personal possessions, positioning, path free of clutter).(6) All wellness/care staff shall be educated on the new systems for fall reduction and injury minimization.(7) Nurses and other applicable wellness staff will be educated on correctly conducting comprehensive falls risk assessments, conducting post-fall investigations, and participating in the person-centered fall reduction and injury minimization care planning process. 4. Monitoring of Corrective ActionThe residence will implement a program of ongoing monitoring to ensure corrective actions are effective and sustained.(1) Weekly, for no less than three months, the wellness manager and pertinent interdisciplinary team members will audit/monitor the residence's compliance with providing a fall management program to ensure the actions taken to correct deficient practice continue and are effective. The monitoring includes:a. Observations of Residents #33, #36, #37, #38, and other residents at high-risk for falls to ensure staff are consistently implementing care planned fall risk mitigation interventions.b. Reviewing incident reports for all falls to determine the steps that can be taken to identify and mitigate the cause(s) of the resident's fall.c. Reviewing fall assessments and care plans for any residents with new or increasing falls to determine if the fall management program is being correctly implemented to mitigate the risk of harm. When monitoring audits demonstrate consistent compliance with the fall management program, the frequency of monitoring audits will reduce from weekly to monthly and will continue for no less than one additional quarter.(2) The administrator/designee shall track and trend the success of all quality assurance performance improvement activities related to the fall management program. Such tracking and trending data will be reported to the quality assurance performance improvement committee monthly for no less than three months and shall continue until all performance plan objectives related to maintaining a timely updated state license is consistently implemented. 5. Correction Date9/23/2023Pine Grove Crossing - Directed Plan of Correction Q1180 - QNJD12 B28U11

1468Med/Med Adm-Ordrs Cmpy w/OrdrsS/S B▼

Findings

Based on observation, record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting 6 of 6 sample residents (#22, #28, #34-#35, and #37-#38). Findings include: 1. Residence PolicyThe residence's medication administration policy, dated 7/26/16, read the residence was to assist with medication administration and all medication administrations unless the resident could self-administer. Staff were to assist residents with the administration of prescribed medication. 2. Resident #37 was admitted to the residence on 3/1/23, with diagnoses including a urinary tract infection (UTI), cervical spondylosis, diabetic kidney disease, and endocarditis. a. Hydrocortisone CreamA written practitioner's order, dated 2/23/23, directed the residence to administer hydrocortisone cream 0.2% topically to the affected area twice daily. However, the April 2023 electronic medication administration records (eMAR) for Resident #37 read the medication was not administered on 3/3/23 and 3/11/23 in the evening, due to the area needing to be specific, and 3/30/23 in the morning, for a total of three missed doses. b. Triamcinolone ointmentA written practitioner's order, dated 2/23/23, directed the residence to administer triamcinolone ointment 0.05% to face, neck, and groin area twice daily. However, the March and April 2023 eMAR for Resident #37 read the medication was not administered on 3/3 and 3/11/23 in the evening due to the area not specified, for a total of two missed doses. c. MeloxicamA written practitioner's order, dated 3/30/23, directed the residence to administer meloxicam 7.5 mg daily. However, the April 2023 eMAR for Resident #37 read the medication was not administered on 4/10 and 4/14/23 due to meloxicam being unavailable, for a total of two missed doses. d. FosfomycinA written practitioner's order, dated 2/23/23, directed the residence to administer fosfomycin powder 3 grams weekly on Thursdays. However, the March 2023 eMAR for Resident #37 read the medication was not administered on 3/16 and 3/30/23 due to medication unavailable, for a total of two missed doses.e. TramadolA written practitioner's order, dated 3/28/23, directed the residence to administer tramadol 0.5 mg every 12 hours. However, the March 2023 eMAR for Resident #37 read the medication was not administered on 3/29/23 due to medication unavailable, for a total of one missed dose.f. Terbinafine CreamA written practitioner's order, dated 2/23/23, directed the residence to administer terbinafine cream 1% to Resident #37's toenails twice daily. However, the April 2023 eMAR for Resident #37 read the medication was not administered on 4/14/23 in the evening due to medication unavailable, for a total of one missed dose. g. CiprodexA written practitioner's order, dated 4/13/23, directed the residence to instill four drops of ciprodex 0.2% in Resident #37's affected ear twice daily for 14 days. However, the April 2023 eMAR for Resident #37 read the medication was not administered on 4/14/23, for a total of one missed dose. On 4/18/23 at 3:10 p.m., the health and wellness director (HWD) stated that she was unsure why Resident #37 had missed medications. However, she stated he had seen an outside provider numerous times over the past two months and he kept having orders changed due to his ear infection. 3. Resident #35 was admitted to the residence on 11/2/22 with diagnoses including hyperlipidemia and anxiety.a. FurosemideA written practitioner's order, dated 11/15/22, directed the residence to administer furosemide 20 mg daily. However, the March and April 2023 eMARs revealed that furosemide was not administered 3/18-3/21/23, 3/23-3/25/23, and 3/27-4/18/23, due to waiting on family to deliver, for a total of thirty-five missed doses.b. AcetaminophenA written practitioner's order, dated 11/15/22, directed the residence to administer acetaminophen 500 mg two tablets every eight hours. However, the Marchand April 2023 eMARs revealed that acetaminophen was not administered 3/15/23 in the morning and afternoon, 3/14-3/18 all three doses, 3/19 in the morning and afternoon, 3/20 all three doses, 3/21 in the afternoon and evening and 3/22/23 in the morning, due to waiting on family to provide, for a total of nineteen misses doses.c. MeloxicamA written practitioner's order, dated 11/15/22, directed the residence to administer meloxicam 7.5 mg once daily. However, the March and April 2023 eMARs revealed that meloxicam was not administered 3/9, 3/11, 3/15-3/21, 3/23-3/25, and 3/27-4/1/23, due to waiting on family to deliver, for a total of eighteen missed doses. d. AspirinA written practitioner's order, dated 11/15/22, directed the residence to administer aspirin 81 mg daily. However, the March and April 2023 eMARs revealed that aspirin was not administered 3/28-4/5/23 for a total of nine missed doses.e. Potassium chlorideA written practitioner's order, dated 11/15/22, directed the residence to administer potassium chloride 10 meq once daily. However, the March 2023 eMAR revealed that potassium chloride was not administered 3/24-3/25, and 3/27-3/31/23 for a total of seven missed doses. 4. Resident #22 was admitted to the residence on 11/10/21, with diagnoses including hypothyroidism, hypertension, and congestive heart failure. a. TramadolA written practitioner's order, dated 1/24/23, directed the residence to administer tramadol 50 mg three times daily. However, the April 2023 eMAR revealed that tramadol was not administered 4/14-4/17/23 for a total of twelve missed doses.b. AcidophilusA written practitioner's order, dated 3/17/23, directed the residence to administer acidophilus every 12 hours for fifteen days. However, the March 2023 eMAR revealed that acidophilus was not administered on 3/17/23 in the evening or 3/18/23 in the morning due to waiting on pharmacy for delivery, for a total of two missed doses.c. CiprofloxacinA written practitioner's order, dated 3/17/23, directed the residence to administer ciprofloxacin 250 mg twice daily for ten days. However, the March 2023 eMAR revealed that ciprofloxacin was not administered on 3/17/23 in the evening or 3/18/23 in the morning due to waiting on pharmacy for delivery, for a total of two missed doses.d. LevothyroxineA written practitioner's order, dated 3/4/23, directed the residence to administer levothyroxine 125 mcg once daily. However, the March 2023 eMAR revealed that levothyroxine was not administered on 3/15/23, due to medication unavailable, for a total of one missed dose.e. TorsemideA written practitioner's order, dated 2/22/23, directed the residence to administer torsemide 10 mg once daily. However, the March 2023 eMAR revealed the torsemide was not administered 3/9/23 for a total of one missed dose, due to waiting on the pharmacy to deliver. 5. Resident #28 was admitted to the residence on 12/23/21, with diagnoses including diabetes and Parkinson's disease.a. Salonpas padA written practitioner's order, dated 2/28/23, directed the residence to administer Salonpas pad 3.1- 6-10 apply for 12 hours then remove for 12 hours. However, the April 2023 MAR read the medication was not administered on 4/3 and 4/4/23 as the medication was out of stock, for a total of two missed administrations. b. Metformin A written practitioner's order, dated 2/28/23, directed the residence to administer Metformin 500 mg twice daily. However, the March 2023 MAR read the medication was not administered on 3/2/23 evening dose as the medication was not available, for a total of one missed dose. c. PioglitazoneA written practitioner's order, dated 2/28/23, directed the residence to administer pioglitazone 15 mg once daily at bedtime. However, the April 2023 MAR read the medication was not administered on 4/6/23 as it was out of stock, for a total of one missed dose. 6. Resident #38 was admitted to the residence on 3/25/23, with no listed diagnoses.a. Docusate SodiumA written practitioner's order, dated 2/1/23, directed the residence to administer docusate sodium 100 mg once daily. However, the MAR 2023 eMAR revealed no evidence the medication was administered because it was not transcribed on the eMAR from 3/26-3/28/23. b. AspirinA written practitioner's order, dated 2/1/23, directed the residence to administer aspirin 81 mg once daily. However, the April 2023 eMAR read the medication was not administered on 4/2/23 as the medication was out of stock, for a total of one missed dose.c. RisperidoneA written practitioner's order, dated 3/30/23, directed the residence to administer risperidone 0.5 mg twice daily at 8:00 a.m. and 8:00 p.m. However, the March and April 2023 eMARs read that the medication was administered once on 3/31/23 at 8:00 p.m., and was administered at 8:00 a.m. and 4:00 p.m. on 4/4 and 4/5/23 for a total of one missed medication administration and two inaccurate medication administrations. 7. Resident #34 was admitted to the residence on 4/17/23 with no listed diagnoses. a. SenexonA written practitioner's order, dated 4/11/23, directed the residence to administer senexon 8.6-50 mg twice daily. However, the April 2023 eMAR revealed that senexon was not administered 4/18/23 due to the medication being unavailable, for a total of one missed dose.b. Slow MagnesiumA written practitioner's order, dated 4/11/23, directed the residence to administer slow magnesium 75.5-119 mg once daily. However, the April 2023 eMAR revealed that slow magnesium was not administered 4/18/23 due to the medication being unavailable, for a total of one missed dose.c. Florastor A written practitioner's order, dated 4/11/23, directed the residence to administer florastor 250 mg once daily. However, the April 2023 eMAR revealed that slow magnesium was not administered 4/18/23 due to the medication being unavailable, for a total of one missed dose. On 4/18/23 at 7:45 a.m., Staff #41 stated that Resident #34's family was to provide his medication. 8. InterviewsOn 4/20/23 at 11:33 a.m., the administrator stated that overs are sent to the pharmacy and some are filled by providers or resident family members. The administrator stated that he expected the residence to comply with practitioner's orders, and stated the whole clinical team was responsible for medication management. On 4/20/23 at 1:54 p.m., the RN consultant stated that medications had been disastrous since before the HWD started at the residence and she was hopeful for when the residence would switch pharmacies on 5/1/23.

Plan of correction · submitted by the facility

9999Final ObservationsSurveyor note▼

Findings

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

Plan of correction

The state did not require a plan of correction for this citation.

4/18/2023Revisit: Licensure Complaint · ID ZIBB121 deficiency▼

0000Initial CommentsSurveyor note▼

Findings

A licensure revisit was completed on 4/20/23 the previous deficiency cited on 9/1/22. A deficiency was cited.

Plan of correction

The state did not require a plan of correction for this citation.

0540Admin-Dts RespS/S B▼

Findings

Based on record review and interview, the residence failed to ensure the administrator compliedwith all applicable state laws to help prevent the possible development and transmission of coronavirus (COVID-19), affecting 108 current residents. Findings include:The Residential Care Facility (RCF) Comprehensive Mitigation Guidance, updated 2/22/23, required residences to keep a current COVID-19 ongoing vaccination and treatment plan and for the plan to be presented for review upon request during health facility inspections. On 4/18/23 at 7:37 a.m., the residence's COVID-19 vaccination and treatment plan was requested from the administrator. On 4/20/23 at 11:33 a.m., after exit, the administrator stated he thought he had a COVID-19 vaccination and treatment plan that was completed in July of 2022. He stated that the primary infection control person was the same but the backup would change since the health and wellness director was new and subsequently stated he would send over a completed plan. On 4/20/23 at approximately 12:00 p.m. after exit, the plan was provided. The plan was dated 4/20/23, and therefore, was not accepted. On 4/20/23 at 1:54 p.m., the registered nurse consultant stated that in larger buildings the clinical team handled more duties and may have been unaware of what all was required for the ongoing vaccination plan. The RN consultant acknowledged that she understood why this deficiency was recited.

Plan of correction · submitted by the facility

Q540The statements made on this plan of correction are not an admission to and do not constitute an agreement with the alleged deficiencies herein. To remain in compliance with all Federal and State regulations, the community has taken or will take, the actions set forth in the following plan of correction. 1. EMResource updated with correct information for ICP information immediately. The Covid mitigation plan was updated 4/20/23. ICP was updated for Pine Grove to Betsy Hardy, RN on 4/20/23, who has previously completed both CDC and CoTrain Infection Control requirements. Going forward, any changes in personnel will be updated by the next required reporting by ED/Designee2. EMResource will be updated per guidelines monthly and with any changes. The Covid mitigation guidance continues to be updated and changes made with any new guidance. 3. DON/designee will provide documentation of EMResource updates two times a months for 3 months and Covid Mitigation plan will be reviewed if any changes are made. All printed documentation will be filed in the POC Binder and be reviewed at Pine Grove’s monthly QAPI meeting.

Reportable Occurrences

60 records

5/5/2026Death · ID 2623N138007Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 5/5/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported the death of a client. Client (A)'s family member discovered them on the floor unresponsive and notified staff. During the course of the investigation, the healthcare entity contacted medical providers and the police, conducted interviews, and reviewed records. Staff followed client (A)'s medical directives and performed cardiopulmonary resuscitation. The incident was not reported to the coroner as unexplained or suspicious. Client (A) did not receive hospice services and was independent with cares. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/24/2026 · released to the public 7/31/2026.

5/1/2026Brain Injury · ID 2623N138005Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 5/5/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a brain injury of a client. Client (A) was found on the floor by staff after they had an unwitnessed fall. The client indicated they were reaching for something and fell backwards. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client was diagnosed with a brain injury at the hospital, and returned to the facility in a wheelchair. The client’s care plan was updated to reflect safety interventions to include: escorts to meals, supportive assistance, and encouragement to participate with therapy. Staff will also provide frequent safety checks, and remind the client to use their pendant to call for assistance. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/23/2026 · released to the public 6/30/2026.

4/14/2026Verbal Abuse · ID 2623N138004Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/15/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported verbal abuse of a client. Client (A) alleged staff (1) was abusive when administering their medications and requested that staff (1) no longer administer them. During the course of the investigation, the healthcare entity suspended staff (1), ensured client (A) felt safe, contacted police, and conducted interviews. Staff did not assess client (A). Client (A) explained they questioned one of their medications and wanted to save it for later, and then staff (1) took the medication cup away from them and stated they would mark the medication as refused. Staff (1) denied the allegation. The facility terminated staff (1)'s employment. The facility trained staff on abuse and mandatory reporting. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/17/2026 · released to the public 6/24/2026.

3/21/2026Neglect · ID 2623N138003Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/21/26, the healthcare entity investigated a reportable event of neglect of a client. This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 3/26/26, Event ID LFW011. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/15/2026 · released to the public 5/22/2026.

12/29/2025Misappropriation of Property · ID 2523N138018Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/31/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported misappropriation of client property. Client (A) lost their wallet on an outing, and it was returned to the facility by a visitor who found it in the parking lot. Client (A) reported that two $50 bills were missing from the wallet and confirmed they were in the wallet before losing it. During the course of the investigation, the healthcare entity conducted interviews and reminded clients to lock their valuables. The facility was unable to identify any alleged assailants and were unable to determine if the items were lost or stolen. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/2/2026 · released to the public 4/9/2026.

12/19/2025Neglect · ID 2523N138017Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 12/16/26, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported neglect of a client. A medical provider allegedly did not provide care to a client, potentially leading to a significant change in condition requiring a higher level of care. During the course of the investigation, the healthcare entity assessed the client, notified the client’s guardians, and conducted interviews. The client was assessed after appearing in distress, and the provider reported no significant findings. The client continued to exhibit difficulties with mobility over the next few days. The facility reported staff deviated from policy on changes of condition and did not send the client to a higher level of care for assessment. When the client was sent to the hospital at a later date, diagnostic imaging showed a fracture. The client moved to another facility due to their increased level of care needs. All staff were trained on documenting and reporting changes in condition to reduce the risk of recurrence. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/16/2026 · released to the public 4/23/2026.

11/25/2025Misappropriation of Property · ID 2523N138015Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 11/28/25, the healthcare entity investigated a reportable event of misappropriation of a client. This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 11/25/25, Event ID PZP911. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was not submitted within the required timeframe.

Publication

Sent to facility 1/26/2026 · released to the public 2/2/2026.

11/15/2025Neglect · ID 2523N138016Reported on time: No▼

Occurrence summary

SUMMARY OF FINDINGS:On 11/15/25, the healthcare entity investigated a reportable event of neglect of a client. This occurrence has been identified for further investigation by the Department. An onsite investigation was conducted by a representative from the State agency. For results of that on-site investigation, please reference https://cdphe.colorado.gov/find-and-compare-facilities, specifically the inspection dated 11/25/25, Event ID PZP911. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. The department investigation of this occurrence was also conducted offsite. The healthcare entity occurrence report was not submitted within the required timeframe.

Publication

Sent to facility 2/24/2026 · released to the public 3/3/2026.

9/30/2025Physical Abuse · ID 2523N138014Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 9/30/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported physical abuse of two clients. Client (C) struck client (A) and then client (B). During the course of the investigation, the healthcare entity separated both clients, contacted police, conducted interviews, and reviewed records. No visible injuries for clients (A), (B), and (C) were indicated when assessed by emergency medical services (EMS). Due to cognitive impairment, clients (A), (B), and (C) were unable to provide detailed information about the event. The facility implemented environmental changes to help deter others from wandering into client (A)'s room. The following interventions were added: Client (C)'s medications were adjusted, and staff were instructed to provide consistent monitoring. Staff witnessed the incident. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/31/2026 · released to the public 4/7/2026.

7/6/2025Sexual Abuse · ID 2523N138011Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/6/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to help prevent a future recurrence. The healthcare entity reported sexual abuse of a client. The client alleged they were sexually assaulted during the night by an unknown man. During the course of the investigation, the healthcare entity notified law enforcement, reviewed video footage, and conducted an assessment and interviews. The client , who reported no pain, had no physical signs of injury or trauma and later reported they were not sexually assaulted but rather pushed out of bed and kicked. Video footage did not show any males entering the room during the time in question, and documentation review showed a decline in the client’s cognitive status related to dementia. The facility continued with the current care plan. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 11/23/2025 · released to the public 12/3/2025.

7/6/2025Misappropriation of Property · ID 2523N138012Reported on time: No▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/7/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported misappropriation of client property. The client alleged $40.00 was stolen from their night stand on the night of 7/5/25. During the course of the investigation the healthcare entity conducted a search, and interviews. No staff or other clients were aware of missing items. The client's family indicated the client did not have any money and had a history of misplacing things that were later found. The police were notified and no assailant was identified. The facility will install a lock on a drawer if the client agrees to one. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 9/23/2025 · released to the public 9/30/2025.

7/1/2025Misappropriation of Property · ID 2523N138010Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 6/30/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported misappropriation of client property. The client alleged $120,000.00 was taken from their bank. The client could not provide any proof. During the course of the investigation the healthcare entity conducted interviews. The police were notified and no assailant was identified. The client has a history of false allegations. They are not at risk for being discharged. All staff have been made aware of these allegations. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 8/27/2025 · released to the public 9/3/2025.

6/7/2025Physical Abuse · ID 2523N138009Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 6/1/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Staff witnessed Client (B) push Client (A) after becoming inpatient from Client (A) blocking them from exiting the elevator. Client (A) fell and was able to get up on their own. Client (A) did not recall the event. Client (B) will be escorted by staff when using the elevator and will be supervised in the common areas. The staff will keep the two clients apart and monitor for Client (B) having bullying behavior. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 11/19/2025 · released to the public 11/26/2025.

5/10/2025Brain Injury · ID 2523N138008Reported on time: No▼

Occurrence summary

SUMMARY OF FINDINGS:On 5/12/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a brain injury of a client. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client was diagnosed with a brain injury at the hospital. The client’s care plan was updated to reflect safety interventions to include; staff increased safety checks, and provided escorts. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was not submitted within the required timeframe.

Publication

Sent to facility 8/14/2025 · released to the public 8/21/2025.

4/23/2025Physical Abuse · ID 2523N138007Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/23/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the was safe before the police were notified. Client (A) alleged four individuals came into the facility and sprayed something in their eye while they slept that caused irritation. The client was assessed without injury and the camera footage did not show evidence of the allegation occurring. Client (A)’s allegation is a direct result of their diagnoses of dementia. Eye drops were added to the clients medication list in case they were experiencing any discomfort. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 9/29/2025 · released to the public 10/6/2025.

3/14/2025Misappropriation of Property · ID 2523N138005Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/14/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported misappropriation of client property. During the course of the investigation the healthcare entity conducted interviews. The client alleged they were missing $150.00 from their purse and refused staff to assist with searching for the money. A family member indicated giving the client a different amount of money weeks ago. The police were notified and no assailant was identified. The client had a history of hiding money, no unwanted visitors were seen and could be forgetful at times. The client was educated to use their locked cabinet and to lock their door. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/29/2025 · released to the public 5/6/2025.

3/13/2025Misappropriation of Property · ID 2523N138004Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/14/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported misappropriation of client property. During the course of the investigation the healthcare entity conducted a search, and interviews. The client alleged a small bottle of shampoo was stolen from them. The family member indicated it was a bottle of hair oil and was almost certain it had been used. The client was reminded of using the locked cabinet for their things and to lock their apartment when not inside. The police were notified and no assailant was identified. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/29/2025 · released to the public 5/6/2025.

3/7/2025Misappropriation of Property · ID 2523N138002Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/7/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported misappropriation of client property. During the course of the investigation the healthcare entity conducted a search, and interviews. Client (A) alleged Client (B)(husband) stole their check book and cell phone. Both Clients have cognitive impairment and did not recall the incident later on. The police were notified. Client (A) was reminded of their locking options and chose to use the cabinet in the bathroom. That cabinet had a lock installed on it. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/29/2025 · released to the public 5/6/2025.

3/7/2025Misappropriation of Property · ID 2523N138003Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 3/7/25, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported misappropriation of client property. During the course of the investigation the healthcare entity conducted a search, and interviews. The client alleged $200.00 was taken from them but acknowledged having memory concerns. The family stated they did give the client money, however the client had a history of gifting money and that last time the money was seen or accounted for was about four weeks prior. A locked cabinet was offered to the client. The police were notified and no assailant was identified. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/29/2025 · released to the public 5/6/2025.

12/25/2024Missing Person · ID 2423N138038Reported on time: Yes▼

Occurrence summary

SUMMARY FINDINGS: On 12/25/24 the facility was notified that Resident (A) who resided in the memory care unit was at an apartment complex. The resident was returned to the facility and placed on monitoring by staff. The facility investigation concluded Resident (A) went out the door left open by a family member, and tried to get back in, but could not. Resident (A) was out of the facility for about an hour. No staff was aware Resident (A) had left the facility as they reset the alarm believing it was a false alarm. To help prevent a recurrence, Resident (A) was placed on frequent checks and signage was placed by the exit doors for resident safety. Resident (A)’s care plan has been updated, and staff were educated on how to respond to the door alarms. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 1/17/2025 · released to the public 1/24/2025.

11/4/2024Brain Injury · ID 2423N138037Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 11/4/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported a brain injury of a client. During the course of the investigation the healthcare entity did an assessment, and obtained medical treatment for the client. The client’s care plan was updated to reflect safety interventions should the client return. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/11/2025 · released to the public 2/18/2025.

10/21/2024Physical Abuse · ID 2423N138035Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 10/21/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured Client (A) and the alleged assailant Family member #1 were separated before the police were notified. Client (A) stated they were attached by Family member #1. Family member #1 denied the allegation and stated they held Client (A) due to Client (A) becoming aggressive towards their spouse. Client (A) sustained a skin tear that was treated by staff. The facility concluded Family member #1 was preventing Client (A) from becoming physical. Client (A) was taken home by family. Client (A) was transferred to memory care for increased services. The police asked Family member #1 to stay away from Client (A) for a little while to de-escalate the situation. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 6/18/2025 · released to the public 6/25/2025.

10/15/2024Neglect · ID 2423N138034Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 10/15/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported neglect of a client. Emergency services reported to a family member of Client (A), that Client (A) had been sitting in their own feces for two days when they arrived to take the client to the hospital. During the course of the investigation the healthcare entity assessed the client, conducted interviews and reviewed documentation. Hospice staff, family of the client, and the facility all indicated they did not see any findings to prove the allegation that was made. The client did not return to the facility. Staff were educated in observing and reporting changes even though neglect was not identified. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 7/5/2025 · released to the public 7/12/2025.

10/9/2024Misappropriation of Property · ID 2423N138032Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 10/11/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported misappropriation of client property. During the course of the investigation the healthcare entity conducted a search, and interviews. The police were notified and no assailant was identified. The client was encouraged to secure their valuables. The client may have spent the money on an outing with a friend. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 3/24/2025 · released to the public 4/1/2025.

10/6/2024Physical Abuse · ID 2423N138031Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 10/6/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured Client (A) was safe before the police were notified. Client (A) alleged they were hit the night before by someone with a frying pan. The area was assessed and the client was complaining of an area that has a recurrent skin concern. During the interviews it was identified the client had a history of making this statement without any proof of occurring. The clients care plan was updated to reflect this allegation so staff were aware and continued with their skin treatments. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/30/2025 · released to the public 6/9/2025.

9/25/2024Physical Abuse · ID 2423N138030Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 9/25/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Staff witnessed two clients seated next to each other who began slapping each other's hands. The physicians of both clients reviewed their medications for any necessary changes. Frequent monitoring of the clients was implemented. Contact was made, however no injuries were seen. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/28/2025 · released to the public 6/4/2025.

9/1/2024Physical Abuse · ID 2423N138027Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 9/1/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured Client (A) and the alleged assailant (staff member 1) were separated before the police were notified. Client (A) alleged they were pushed onto the bed by staff member (1) and complained of leg pain. Client (A) was assessed in the hospital without injuries. The client later stated they appreciated Staff member (1) pushing them onto the bed to avoid a fall as they had become weaker and it was not rough treatment. Staff member (1) stated the same. Client (A) was evaluated for therapy and pain management. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 5/7/2025 · released to the public 5/14/2025.

7/31/2024Misappropriation of Property · ID 2423N138025Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 7/31/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported misappropriation of client property. During the course of the investigation the healthcare entity educated the client to use a lock box, lock their door and possibly utilize a locking drawer. The event was not substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 2/6/2025 · released to the public 2/13/2025.

7/10/2024Misappropriation of Property · ID 2423N138023Reported on time: Yes▼

Occurrence summary

SUMMARY FINDINGS: On 7/10/24 Resident (A) reported missing his wallet, and staff assisted him with a search, with his permission. The wallet was found, however, $225.00 was missing when the wallet was found in the back of Resident (A)’s closet. The family confirmed Resident (A) had money in his wallet. The facility investigation concluded no assailant was identified. Based on interviews no staff were aware Resident (A) had any money or concerns regarding misappropriation. To help prevent a recurrence, Resident (A) was encouraged to lock his door, use a lockbox in his room and potentially a locked drawer. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 1/30/2025 · released to the public 2/6/2025.

6/27/2024Physical Abuse · ID 2423N138021Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 6/28/24, the healthcare entity investigated a reportable event. The facility acted appropriately to protect their clients by taking immediate protective actions, investigating the event, and implementing a plan to prevent a future recurrence. The healthcare entity reported physical abuse of a client. During the course of the investigation the healthcare entity ensured the clients were separated before the police were notified. Client (A) hit two other clients before staff could intervene due to agitation. Staff kept Client (A) within eye sight. Client (A) also had their medications changed to assist with unwanted behaviors. Possible triggers were removed from the Client (B)’s plan of care. The event was witnessed by staff. The event was substantiated. This public occurrence summary was provided in accordance with 25-1-124, C.R.S., and was based on the report and investigation provided by the licensed healthcare entity. Department investigation of this occurrence was conducted off-site. The healthcare entity occurrence report was submitted within the required timeframe.

Publication

Sent to facility 4/9/2025 · released to the public 4/16/2025.

5/30/2024Death · ID 2423N138024Reported on time: No▼

Occurrence summary

SUMMARY FINDINGS: On 7/23/24 the facility received an email with a death certificate referenced in it for Resident (A). The family had sent the email to the facility stating Resident (A)’s death was a result of a fall that occurred in the facility back on May 30, 2024. The facility investigation concluded based on documentation Resident (A) went to the hospital for five days after her fall in May 2024 and then returned to the facility on 6/4/24 under hospice services. Resident (A) passed away in the facility on 6/15/24, however, the facility was not made aware the resident's cause of death was due to the fall she sustained almost two months prior. To help prevent a recurrence, the facility will continue to assist residents with supportive measures who were identified as a fall risk to mitigate residents from falling. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 1/20/2025 · released to the public 1/27/2025.

5/16/2024Misappropriation of Property · ID 2423N138017Reported on time: Yes▼

Occurrence summary

SUMMARY FINDINGS: On 5/16/24 a family member of resident (A) reported allegedly resident (A) was missing $400.00 from their wallet in the last three days. The money was last seen before the resident moved into the facility. Interviews were conducted and camera footage was reviewed and did not identify an assailant. No staff members were ever aware of the resident having a purse or money. The facility investigation concluded the allegation was unsubstantiated as there was no evidence the money entered into the facility with the resident. To help prevent a recurrence, residents were encouraged to lock their doors as well as use safes for their valuables. Staff will assist residents in pairs to make her feel safe. Resident (A) was offered a locking drawer if she desired to use one. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 11/27/2024 · released to the public 12/9/2024.

4/29/2024Physical Abuse · ID 2423N138014Reported on time: Yes▼

Occurrence summary

SUMMARY OF FINDINGS:On 4/29/24, male resident (A) witnessed female resident (B) wander into his room. He entered the room, grabbed her shirt/arm to try to redirect her out of the room. However, she resisted and ended up falling to the ground. Staff intervened to separate the residents. No visible injuries were observed with resident (B), and she had no current complaint of pain. With a diagnosis of a severe cognitive impairment, she was unable to participate in a follow up interview about the incident. She frequently wandered. Resident (A) was sent to the hospital for a mental health evaluation due to his aggression. The facility indicated they were unaware of the hospital findings, but when he returned, medication changes were made and direct staff monitoring was implemented. The facility substantiated the allegation of resident (A) physically handling resident (B) in an effort to remove her from his room, which resulted in a fall. Resident (B)’s medications were also adjusted to decrease wandering habits and intrusive behavior. Staff then implemented 15-minute safety checks. New locks were installed on resident (A)’s door that automatically locks when he leaves the room, so no other residents could enter without consent. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 1/20/2025 · released to the public 1/27/2025.

4/28/2024Verbal Abuse · ID 2423N138013Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE:On 4/28/24, resident (A), who had a diagnosis of significant cognitive impairment, followed staff #1 in the dining area. Staff #1 went to the table of resident (B) and resident (A) followed them. Resident (B) threatened resident (A) and advised them to walk away or s/he was going to physically force resident (A) back to their seat and make them stay there. The incident was witnessed by staff #1. FACILITY / AGENCY ACTION:The facility conducted an internal investigation and notified the police, family/guardians, ombudsman and physicians. Staff #1 directed resident (A) to go to their table and sit and resident (A) complied with this directive. The residents were checked every 15 minutes by staff. Resident (A) was not interviewed due to nonsensical and nonverbal responses. Resident (B) stated s/he just wanted resident (A) to get away from them. The facility reviewed video surveillance, which verified the findings above. From the findings, the facility recognized an incident had taken place between the two residents. To help prevent a recurrence, the facility monitored the residents by continuing 15-minute checks. Staff redirected resident (A) away from resident (B) and a practitioner was asked to evaluate resident (A). DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/15/2024 · released to the public 11/25/2024.

4/23/2024Misappropriation of Property · ID 2423N138015Reported on time: Yes▼

Occurrence summary

SUMMARY FINDINGS: On 4/23/24, resident (A) alleged money was missing from his wallet to his family. The family did not contact the facility until 4/30/24 after a second amount of money went missing. The money was last seen between 4/16/24-4/23/24 totaling $145.00. Staff weren't aware of the resident's money and no staff saw any suspicious person. The facility investigation concluded no assailant was identified and the money was not found. To help prevent a recurrence, the resident was reminded to use his lock box for valuables. The staff will provide care in pairs to make this resident feels safe and to witness services provided. The family will only provide the amount of money resident (A) will use at any given time. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 11/21/2024 · released to the public 11/28/2024.

4/12/2024Diverted Drugs · ID 2423N138012Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 4/12/24 qualified medication administration person (QMAP) (1) alleged one Tramadol 50 mg (milligram) pill from a blister pack was not the same as the others. The card had been tapped. This medication blister pack was removed from the medication cart. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, the physician. The concern was identified before the resident received their medication. All other narcotic blister packs were audited, and no other concerns were identified. All documentation was correct. No concerns were identified during staff interviews. The facility investigation concluded it could not determine intentional diversion as it appeared someone had accidentally punched out two pills instead of one and tried to put one back. The blister pack was replaced however. To help prevent a recurrence, education on medication administration and narcotics was provided to QMAPs along with competencies. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 12/2/2024 · released to the public 12/9/2024.

2/23/2024Physical Abuse · ID 2423N138010Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE:On 2/23/24 resident (B) alleged that resident (A) walked up to them in the hallway and grabbed their arm. The incident was not witnessed. FACILITY / AGENCY ACTION:The facility conducted an internal investigation and notified the police, family/guardians, ombudsman, physicians and Adult Protective Services (APS). The staff frequently monitored resident (A) and resident (B) was assessed and evaluated by staff #1 and emergency room staff. During this assessment and evaluation, there were no markings or redness found on resident (B);s arm and they denied any pain. During the interview, resident (B) did not recall the incident and stated s/he was not fearful of anyone. Resident (A) was unable to answer questions due to advanced confusion. Staff stated resident (A) was upset on the day of the incident, however; no one had witnessed the incident. From the investigation, the facility concluded the allegation of abuse was unsubstantiated. To help prevent a recurrence, the facility continued to check on resident (A) more frequently and her physician reviewed her medications and made some changes. DEPARTMENT FINDINGS:In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The facility/agency complied with licensing standards for conducting an internal investigation of this Occurrence event and submitting a report of the findings to the Department. However, the licensing standard for timely reporting was not met.

Publication

Sent to facility 11/13/2024 · released to the public 11/20/2024.

1/29/2024Sexual Abuse · ID 2423N138007Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 1/29/24 a female resident (A) pointed to her private areas, front and back and stated someone touched her down there. Resident (A) could not give any further information. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, ombudsman, Adult Protective Services and physician. Resident (A) was assessed and her family was spoken to about the allegation. A medical concern was found with resident (A)’s private area that was not of connection to the allegation that would indicate pressure and resident (A) being aware something is different with her private area. The family indicated resident (A) had things happen to her in the past that she will perseverate on. The facility investigation concluded the allegation was not substantiated and a pressure sensation in her groin area may trigger memories for resident (A). To help prevent a recurrence, resident (A)’s care plan was updated to include trauma so staff knew how to handle concerns. Resident (A) will be supported with two staff members at a time. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/26/2024 · released to the public 12/3/2024.

1/27/2024Physical Abuse · ID 2423N138006Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 1/29/24, resident (A)'s guardian alleged resident (A) was attacked by another resident which resulted in skin tears to resident (A)’s arms. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, ombudsman, Adult Protective Services and physician. Documentation revealed on 1/27/24, resident (A) had a witnessed fall and obtained skin tears. Resident (A) was unable to recall the incident due to her cognitive impairment. The alleged assailant was placed on frequent checks. Camera footage was reviewed and revealed the assailant was not near resident (A) when she fell. The facility investigation concluded the allegation of abuse was not substantiated. Resident (A)’s injuries were from her witnessed fall. To help prevent a recurrence, resident (A)'s guardian agreed to move resident (A) to the other side of the facility for continued safety. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/25/2024 · released to the public 12/2/2024.

1/24/2024Misappropriation of Property · ID 2423N138005Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 1/26/24, a female resident (A) in her 80s reported someone stole approximately $65.00 to $85.00 from her wallet the night before. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, ombudsman, Adult Protective Services and physician. Resident (A)’s possessions were searched with her consent. She was unable to state the last time she had money in her wallet. The resident's family said a family member did give resident (A) money in the amount of $50.00. The family thinks resident (A) may have hid the money in her room. A review of documentation revealed $10.00 was placed in the resident's wallet, without the time or date provided. The facility investigation concluded it was unclear what amount of money resident (A) had, if she hid it and no assailant was identified. To help prevent a recurrence, staff will assist resident (A) in pairs. Resident (A) was educated and reminded to lock her door. Her hospice provider identified active hallucinations and adjusted her medications. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/19/2024 · released to the public 11/26/2024.

1/21/2024Physical Abuse · ID 2423N138004Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 1/21/24, caregiver (1) witnessed two residents get into a physical altercation resulting in resident (A) going to the hospital for an evaluation. Resident (A) had a bruise to her right upper arm. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, ombudsman and physician. Resident (A) has cognitive impairment and did not recall the event. Resident (B) stated they were grabbed by resident (A). The facility investigation concluded throught video footage, both were involved in the physical altercation. To help prevent a recurrence, both residents were seen by their physicians and had medication adjustments made. Both residents were placed on safety checks and their behaviors were monitored. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/25/2024 · released to the public 12/3/2024.

1/19/2024Physical Abuse · ID 2423N138003Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 1/19/24 resident (C) held two different residents (A) and (B) against their will at different times after being redirected by staff. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, ombudsman and physician. The residents were all separated. Resident (C) was redirected and their physician made medication adjustments. Neither resident had any visible injuries. The facility investigation concluded the incident was witnessed and confirmed by video footage. To help prevent a recurrence, staff increased safety checks for the residents involved. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/26/2024 · released to the public 12/3/2024.

1/8/2024Physical Abuse · ID 2423N138001Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 1/8/24, a visitor witnessed male resident (B) in his 80s bite the left hand fingers of a female resident (A) in her 60s. The visitor indicated resident (B) was irritated when resident (A) came up behind him and placed her hand on his shoulder. Resident (B) told resident (A) to move her hand closer so he could bite it. Resident (A) moved her hand closer and resident (B) bit it. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families, ombudsman and physician. The residents were separated. Resident (A) was assessed without any break in her skin. Resident (B) was sent to the hospital for an evaluation and treatment for agitation and behaviors. Both residents have cognitive impairment and did not recall the incident. The facility investigation concluded the incident was witnessed. Resident (B) returned to the facility with additional medications. To help prevent a recurrence, resident (B) was administered medications and his behaviors towards other residents were monitored. Staff monitored resident (A) for any residual effects from being bitten. All staff will increase safety checks and redirection for resident (B). DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/25/2024 · released to the public 12/2/2024.

12/26/2023Physical Abuse · ID 2323N138026Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 12/27/23, the facility was notified during a survey yesterday 12/26/23 that a male resident (B) in their 70s placed their hands aggressively on another memory care, female resident (A) in her 80s as she attempted to go into his room. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, ombudsman, Adult Protective Services and physician. Staff monitored resident (B) for safety during the investigation. Resident (A) did not have any visible injuries when assessed. The staff indicated they did not see resident (B) get into any physical altercation. The camera footage was reviewed and did not reveal any physical altercation between the two residents. The facility investigation concluded abuse could not be substantiated. To help prevent a recurrence, resident (B)’s plan of care was updated to reflect he does not like others in his personal space and staff to monitor and intervene when necessary. Resident (A)’s plan of care was updated to reflect her intrusive behaviors into others spaces and for staff to intervene. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/6/2024 · released to the public 11/13/2024.

12/11/2023Physical Abuse · ID 2323N138025Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 12/11/23, the facility received a letter from the legal representative for Resident A. The legal representative alleged staff #1 had been rough when working with Resident A, who was in her 90s. There was another allegation of staff #1 leaving the resident on the toilet for 1.5 hours the weekend before (12/9, 12/10/23). FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian and physician. Staff #1 was suspended until the investigation was completed. A facility licensed practical nurse conducted an assessment of Resident A and found no issues. During a follow up interview, Resident A stated she loved the staff member #1 and had only been left on the toilet for fifteen minutes. Staff #1 reported when transferring the resident this weekend, they both lost their balance and fell to the bed. Staff #1 said Resident A did not turn herself as she normally did and it caused his/her feet to catch and trip. Resident A typically transferred independently with stand by assistance or with the assistance of one person, based on her cognitive ability on a given date and time. Staff #1 confirmed s/he had placed Resident A on the toilet when another staff member yelled for help in an emergent situation. Staff #1 left to assist and returned to help Resident A in approximately seven minutes. Additional residents stated they had no concerns regarding Staff #1, other than saying s/he could be fast when providing care. The legal representative stated they did not believe Staff #1’s actions were intentional, and s/he did good job most of the time. They requested staff #1 needed some education and reminders about care approach. From the investigation, the facility did not substantiate that abuse had occurred. To help prevent a recurrence, the facility educated Staff #1 on the provision of care, call light response and to slow down when providing care. The staff member returned to work. In addition, Resident A continued to receive therapy services to help work on her transfer abilities. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 12/29/2023 · released to the public 12/29/2023.

11/28/2023Death · ID 2323N138024Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 11/19/23 as witnessed by a qualified medication administration person (QMAP) (1), a male resident (A) in his 80s was involved in a physical altercation with another male resident (B) in his 70s. Both residents were trying to get through a door at the same time. Resident (B) pushed resident (A) in the chest to step back, and resident (A) stepped forward and took a big swing at resident (A). Resident (B) blocked resident (A)’s arm and this caused him to fall backwards and hit his head. Resident (A) was assessed and the paramedics were called. Resident (A) was sent to the hospital for an evaluation and was diagnosed with brain injury which included a temporal fracture and small brain bleed and was placed on hospice care. The family chose not to do further treatments or interventions. Resident (A) subsequently passed away on 11/28/23. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families, ombudsman and physicians. Both residents were immediately separated. Both residents had a severe cognitive impairment with communication difficulties and neither remembered the incident. Resident (B) had a one-to-one staff member assigned to him immediately to keep other residents safe. Residents (A) and (B) had a history of aggressiveness towards others. The facility investigation concluded the physical abuse was witnessed by QMAP (1) and was caught on camera footage. The facility indicated both residents had an involvement in the physical altercation with each other and both residents instigated the physical altercation. To help prevent a recurrence, resident (A) was monitored in his room as he did not ambulate after the altercation and was provided additional support and services until his passing. Resident (B) continued with the one-to-one staff member and had his medications adjusted until his emergency move out date of 12/5/23 to a higher level of care. Approximately two weeks earlier, these same two residents were involved in another physical altercation. Refer to event #2323N138022 for further details. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/6/2024 · released to the public 11/13/2024.

11/19/2023Physical Abuse · ID 2323N138022Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 11/19/23, Resident (A) in his 60’s was trying to go through a door at the same time as Resident (B) in his 80’s. They exchanged words and Resident (A) pushed Resident (B) in the chest. Resident (B) swung at Resident (A)’s head, which was blocked by Resident (A)’s arm. Resident (A) pushed Resident (B) and he fell. Resident (B) was injured during the physical altercation. Staff called 911 and Resident (B) was transferred to the hospital for further evaluation. The hospital evaluated Resident (B) and diagnostic findings showed he suffered a closed fracture of the temporal bone and a small brain bleed. He was admitted for treatment and monitoring. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardians, ombudsman and physicians. Resident (A) was monitored on a 1:1 basis. The family of Resident (B) chose to place the resident under hospice care, and he was transferred back to the facility. During interviews, Resident (B) was unable to formulate words when attempting to interview him about the incident. The facility reported Resident (A) did not have any understanding of the altercation when interviewed by the police. From the investigation, the facility concluded the investigation supported a physical altercation had taken place between the two residents, resulting in injury to Resident (B). Resident (B) expired on 11/28/23. To help prevent a recurrence, the facility continued with 1:1 monitoring of Resident (A) and medication changes were made to help manage his aggression. The facility began the process of conducting an emergency eviction and retained a placement agency to assist in placing Resident (A) in a facility that provided a higher level of care. Resident (A) received hospital evaluations on 11/26 and 12/1/23, and was subsequently discharged from the facility on 12/5/23. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the facility/agency acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 1/19/2024 · released to the public 1/19/2024.

11/9/2023Physical Abuse · ID 2323N138021Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 11/9/23, Resident A in his 70’s and Resident B in his 80’s were swearing at each other during the lunch meal. External agency staff #1 stepped between the two residents, to separate and redirect them away from each other. Resident A slightly pushed Resident B and he fell to the floor on his buttocks. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardians and physicians. Resident A went to his room and remained there the rest of the day. A nurse assessed Resident B and found no bruising and the resident was able to stand and ambulate. Subsequently, the family member of resident B came to visit and found he was not eating and ambulating, and requested a physician assessment. The family reported resident B appeared more withdrawn and required more than normal assistance. Resident B was assessed at an emergency room and x-rays were negative for fractures. Resident B then returned to his baseline status and ambulated without any difficulty. Resident A stated he had pushed Resident B to have him get away. Resident B was unable to remember or state what had transpired. From the investigation, the facility concluded Resident A had pushed Resident B to the floor, following an altercation. To help prevent a recurrence, the nurse practitioner evaluated Resident B to determine if any medication changes needed to be made. The care plan of Resident B was updated to include more frequent checks and to include more activity engagement to keep him from being in other resident’s personal space and out in the open more frequently. The nurse practitioner assessed Resident A and reviewed medications. The care plan of Resident A was updated to include more frequent checks. The residents ate on opposite sides of the unit. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 2/8/2024 · released to the public 2/8/2024.

10/15/2023Brain Injury · ID 2323N138018Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 10/15/23, a female resident (A) in her 80s was found on the floor next to her toilet and was bleeding and vomiting presently when staff entered her room. Resident (A) had pressed her call pendant for assistance. Resident (A) had a large bump over her left eye and a cut over her left eye brow that was bleeding. First aid applied and emergency services called. Resident (A) was diagnosed with a brain injury. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the family and physician. Resident (A) was also diagnosed and treated in the hospital for a urinary tract infection and given antibiotics. Resident (A) was independent with care and had been working with therapy on balance and has high anxiety. The facility investigation concluded resident (A) did use her call light pendant and attempted to use the bathroom on her own likely due to urgency from the urinary tract infection causing her to fall and hit her head on the toilet. To help prevent a recurrence, resident (A) will continue working with therapy when she returns to the facility. Increased services will be provided until she returns to her previous status. Care conferences will continue to determine the best interventions to keep resident (A) as independent as possible. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 9/27/2024 · released to the public 10/4/2024.

10/14/2023Verbal Abuse · ID 2323N138017Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 10/14/23, a family member reported they overheard male resident (B) in his 80s and staff member (1) yelling at each other. Resident (B) yelled to get your hands off me and staff member (1) yelled to get your hands off me. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian, ombudsman and physician. Staff member (1) was removed from the facility and suspended. Resident (A) was assessed and no injuries seen. Resident (A) did not recall the incident due to cognitive impairment. The family member stated staff member (1) yelled at resident multiple times as they left and came back in the room to assist resident (A) until they were asked to leave at which time alcohol could be smelt. Another staff member helped the family member with resident (A). Staff member (1) stated they did not recall what happened and went in to give resident (A) coffee and he was fine. Staff member (1) repeated this statement and mentioned drinking the night before. The facility investigation concluded the allegation was substantiated. To help prevent a recurrence, staff member (1)’s employment was terminated. Staff were educated on the appropriate way to approach residents. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 9/27/2024 · released to the public 10/4/2024.

9/20/2023Missing Person · ID 2323N138015Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 9/20/23, a male resident (A) in his 70s was not in the facility and had not signed out. After a search was conducted his whereabouts were unknown. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family, ombudsman, Adult Protective Services and physician. Resident (A) was last seen around 5:30 p.m. Around 7:30 p.m., the police located resident (A) in the community. He had fallen. He had a business card with the facility location on it, which the police used to notify the facility. Resident (A) was taken to the hospital for an evaluation and had some swelling and bruises. The hospital advised the responsible party of resident (A) that a memory care unit would be appropriate for resident (A). The facility investigation concluded resident (A) left the facility without staff being aware, fell and was confused. To help prevent a recurrence, with permission of resident (A)’s responsible party, resident (A) returned and was admitted to memory care section. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 8/28/2024 · released to the public 8/29/2024.

9/12/2023Misappropriation of Property · ID 2323N138014Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 9/12/23, the police department called the facility to report a male resident (A) in his 80s was an alleged victim of fraud. Resident (A) had reported a fraud credit card claim with his bank. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the family. Resident (A) stated his credit card was never lost and the transaction was online in the month of June 2023. The credit card was canceled after he noticed the transaction on his statement. Resident (A) did not suspect anyone close to him. The facility investigation concluded, according to the police department, resident (A) experienced credit card fraud. No assailant was identified. To help prevent a recurrence, the credit card was canceled so no more charges could be made. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site review of this reportable event submitted by the agency/facility. This public summary is based on investigative findings provided by the licensed entity to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence event will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 8/26/2024 · released to the public 8/26/2024.

8/2/2023Physical Abuse · ID 2323N138013Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 8/3/23, one staff member witnessed resident (B) push resident (A) away as they attempted to sit down on the couch. Resident (A) returned to the same location and resident (B) pushed resident (A) on the chest, which caused him to lose his balance and fall onto the couch. Resident (B) then grabbed resident (A)’s arms, pulled the resident off the couch and pushed the resident away. Resident (A) sustained three skin tears to their right forearm and left hand. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families/guardians, and physician. The facility separated the residents immediately. Staff reported resident (B) was agitated following the event and a staff member provided direct 1:1 monitoring until he calmed down. Resident (A)’s skin tears were treated. Both residents have cognitive impairments and they were unable to recall and/or describe the incident. However, resident (B) demonstrated how they had pulled the arms of resident (A). The facility investigation concluded the resident-to-resident abuse was witnessed. To help prevent a recurrence, resident (B)’s medications were adjusted to help with agitation. Staff continued to monitor the residents to help redirect them when needed. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 6/24/2024 · released to the public 6/25/2024.

7/27/2023Neglect · ID 2323N138012Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 7/27/23, a resident reported telling a staff member (staff #1) that he was experiencing pain and felt his catheter was not draining properly. He requested to see the nurse. Staff #1 did not check on the resident’s status and did not call the nurse. He ended up taking care of the issue himself, which helped resolve his pain. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, family/guardian, and physician. A representative from his home care agency came out to check and change his Foley catheter. Management suspended the staff member #1 pending investigation. From the findings, the facility determined an allegation of staff neglect was unsubstantiated. However, the facility concluded staff #1 failed to follow facility policies to ensure they report any concerns of resident pain to a nurse. Staff #1 received a final written warning. Further education was provided to staff on the expectations of notifying the nurse. In addition, new processes were implemented regarding nursing communication. Staff #1 returned to work. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence section of the Department. The provider reports the information submitted to the Department is accurate and complete. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed by the State Agency. The occurrence report was submitted within the required timeframe. The facility/agency complied with licensing standards for conducting an internal investigation of this occurrence event and submitting a report of the findings to the Department.

Publication

Sent to facility 6/4/2024 · released to the public 6/11/2024.

4/30/2023Brain Injury · ID 2323N138009Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 4/30/23, a resident, in her 80s, had a bowel accident causing her to slip and fall in the bathroom. She hit her head on the floor causing a laceration. A family member had been present in the room and summoned staff assistance. Upon staff’s arrival to the room, they noted she was bleeding from the laceration on the right side of her head. First aid treatment was provided to address the bleeding. Per family request, they transported her to the hospital for an evaluation. Diagnostic test results showed the findings of an acute brain bleed. AGENCY/FACILITY ACTION: The facility conducted an internal investigation and notified the physician and family/guardian. She was admitted to the hospital and underwent emergency surgery to treat the brain bleed. With her medical history, she took antiplatelet medications. The facility concluded the resident experienced an unfortunate fall with injury and serious outcome. The patient subsequently passed away at the hospital a few days after the surgery. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the facility/agency acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 1/15/2024 · released to the public 1/15/2024.

4/10/2023Misappropriation of Property · ID 2323N138006Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 4/10/23 a family member of a female resident (A) in her 80s reported that a couple pairs of paints were missing and some blouses and he believed they were stolen. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, and families/guardians. Resident (A) stated the items were in her apartment before she went on leave from the facility and when she returned about three weeks ago she discovered they were missing. The staff indicated they had not seen the items alleged to be missing as the resident is independent and staff did not go into her apartment often. Resident (A) decided not to file an official police report. The facility investigation concluded at the time of this report there was no evidence that would lead towards theft. The facility staff will continue to search the community for these items. To help prevent a recurrence resident (A) was encouraged to lock her door at night and if she was going to be out of the facility for an extended period of time. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 9/21/2023 · released to the public 9/28/2023.

4/3/2023Physical Abuse · ID 2323N138005Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 4/2/23, the facility received an email from a family member of a female resident, in her 90s. The family member alleged a staff member might have injured the resident's foot when transferring her with her walker. The family member said she watched a video showing the staff member coaxing the resident to walk from the bedroom to the living room. The family member stated she heard the resident cry out twice that she was hurt. The resident was assisted to sit in a chair. Upon removing her shoes and socks, the foot appeared swollen. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, physician and family/guardian. The staff member was suspended during the investigation. The resident was assessed and had redness and pain to her left big toe and pain to the right big toe. The resident was given Tylenol. An x-ray was taken which was negative for any fracture. The staff member denied the allegation. The staff member stated the resident was walking slowly like something hurt so she took off her socks and saw the redness to her toes. The staff member notified the nurse. The facility reported the resident's Power of Attorney viewed the same video and did not have the same concerns as the other family member expressed. The family member was contacted and denied she had implied the staff member had purposefully tried to hurt the resident. The allegation of a staff member hurting the resident was not substantiated. The source of the resident's injury could not be determined. The staff member was educated to slow down when providing care. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 11/3/2023 · released to the public 11/3/2023.

3/15/2023Physical Abuse · ID 2323N138003Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 03/15/23 male resident (A), in his 90s, grabbed female resident (B) by her wrists and held on saying she had broken into his shop and stole from him. Resident (B) was in her 80s. Both residents had significant cognitive impairment. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police and families/guardians. Resident (A) was standing his room when resident (B) walked past him. Resident (A) grabbed resident (B)'s wrists. Staff separated them and put both residents on staff monitoring. Resident (B) was assessed and had slight bruising to her left wrist. Resident (B) could not be interviewed due to her cognitive status. Resident (A)'s medications were reviewed and adjusted. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the facility/agency acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 8/14/2023 · released to the public 8/14/2023.

1/4/2023Misappropriation of Property · ID 2323N138002Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 1/4/23 a female resident (A) in her 90s reported that her necklace had been stolen. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, families/guardians. Resident (A) stated that she believed someone on the overnight staff had taken her necklace. She gave a brief description of the necklace but did not know how long it had been missing, possibly around Christmas time. The family member of resident (A) stated they brought the necklace to the facility because resident (A) had requested it. The family member stated resident (A) had a history of hiding her jewelry even before living at the facility and may have misplaced it. The facility investigation concluded no assailant was identified. It was undetermined if the necklace was misplaced by resident (A) or was stolen. To help prevent a recurrence the facility would continue working with the family and resident (A) regarding paranoias as the family member was confident resident (A)’s accounts of what occurred were inaccurate. The facility would monitor for patterns or increased behaviors from resident (A). The facility will continue to monitor the security cameras in the facility and educate staff on resident’s rights. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 6/16/2023 · released to the public 6/16/2023.

1/3/2023Misappropriation of Property · ID 2323N138001Reported on time: Yes▼

Occurrence summary

DESCRIPTION OF OCCURRENCE: On 1/3/23 a family member of a female resident (A) in her 80s reported that resident (A) was missing two bottles of nail polish and believed someone stole them. FACILITY / AGENCY ACTION: The facility conducted an internal investigation and notified the police, and families/guardians. Resident (A) could not recall when the nail polish was last seen, but stated she believed they were taken on two different occasions. The staff that were interviewed were unaware of the missing items and where the nail polish was normally stored. The facility investigation concluded no assailant was identified and the results were inconclusive. To help prevent a recurrence, resident (A) was educated on timely reports and understood. Staff were educated on resident rights and protecting resident’s property and the reporting of as well. DEPARTMENT FINDINGS: In accordance with Colorado Revised Statute 25-1-124, the Department conducted an off-site investigation of this reportable event and investigative findings submitted by the agency/facility. This public summary is based on information provided by the agency/facility to the Occurrence Section of the Department and is accurate and complete at this time. Prior to the next onsite investigation of the agency/facility, this occurrence will be reviewed. The occurrence report indicated the agency/facility acted appropriately in response to this occurrence by complying with licensing standards of reporting and investigating this occurrence.

Publication

Sent to facility 6/14/2023 · released to the public 6/14/2023.