CHELSEA PLACE

An administrative relicensure survey was completed on 4/1/26. No deficiencies were cited. A change of ownership occurred on 4/1/26.

A revisit survey was completed on 4/7/25 for all previous deficiencies cited on 12/10/24. The facility is in compliance with all deficiencies that were cited.

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

A relicensure survey was completed on 12/10/24. A deficiency was cited.

Based on observation, record review, and interview, the residence failed to maintain a fall management program which included detailing in each resident's care plan the individualized approaches necessary to address fall risks, affecting three of three sample residents (#3-#5) who required individualized approaches. Findings include:1. ObservationOn 12/10/24, Resident #5 was seated in a high back wheelchair. 2. Record ReviewThe resident face sheet read Resident #5 was admitted to the residence on 2/20/23. A progress note, dated 9/22/24, read the resident had an unwitnessed fall and was found sitting on the floor beside her bed. A progress note, dated 9/28/24, read the resident had an unwitnessed fall near the lobby door. A progress note, dated 10/3/24, read the resident was sitting on a chair and slid to the floor. A progress note, dated 10/7/24, read late entry: the resident had a witnessed fall in the hallway. A progress note, dated 10/9/24, read the resident care plan had been updated with fall interventions after falls on 10/3/24 and 10/6/24. However there was no evidence the care plan had been updated. A progress note, dated 10/25/24, read the resident care plan had been updated with fall interventions after fall on 10/18. However, there was no evidence the residence updated the care plan or documented in a progress note that the residence sustained a fall. A progress note, dated 10/26/24, read that the external hospice nurse (EHN) and clinical services director (CSD) called the resident's spouse to discuss the use of a wheelchair. The EHN also explained that a wheelchair with footrests would have been beneficial to mitigate falls. The CSD also offered to apply a non-slip material to the seat of the wheelchair to prevent sliding out of the wheelchair. The CSD also recommended another type of footwear. The note also read a wheelchair was ordered by the external hospice provider. A progress note, dated 10/29/24, read that a certified nurse assistant from the external service provider was going to give the resident a shower when she lost her balance and fell back in the bathroom. A progress note, dated 10/29/24, read that a care conference was held and it was discussed that the external hospice nurse had ordered a high back wheelchair with a pommel cushion and would use a non-slip material if needed. Review of the care plan revealed the care plan was updated 6/14/24 and not again until 11/10/24. On 11/10/24, the care plan was updated with the following: Needs physical assist of 1:1 transfers; Resident will experience safe and comfortable transfers through staff assist. Requires fall risk safety checks; Resident will remain in a safe environment. Falls; Staff will minimize risk of falls by keeping resident in common areas. Staff will monitor for safety to minimize falls or injury. Staff to monitor the environment for safety. Ambulation: Needs physical assist of one for mobility; To maintain ability to ambulate with physical assistance of 1. The care plan failed to address the individualized approaches used, including the use of a high back wheelchair, a pommel cushion, foot rests, a non-slip material, or shoes for safety. 3. InterviewsOn 12/10/24 at 2:10 p.m., the administrator acknowledged the care plan did not include individualized approaches to address fall risk. On 12/10/24 at 2:55 p.m., the CSD stated that she was fairly new at her position and understood the care plans did not include individualized approaches or interventions to address fall risk. 4. Evidence revealed similar deficient practice for Residents #3 and #4.

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 7.8.8 Each assisted living residence shall place in a visible location a list of all staff who have current certification in first aid or CPR so that the information is readily available to staff at all times. The list shall be kept up to date and indicate by staff person whether the certification is in first aid or CPR or both. 9.3 The assisted living residence shall have an involuntary discharge grievance policy that complies with Section 25-27-104.3, C.R.S., and includes, at a minimum:(A) The individual designated by the assisted living residence to receive involuntary discharge grievances.(B) The ability for any of the persons the assisted living residence is required to notify in accordance with Part 11.16 to file a grievance challenging the involuntary discharge and/or reasons for the discharge with the individual designated in subpart (A), above, within 14 calendar days after written notice of the involuntary discharge is provided by the assisted living residence.(C) The ability for the resident, or other person allowed to file a grievance to receive assistance in preparing and filing a grievance without interference from the assisted living residence.(D) A requirement that grievances related to involuntary discharge be submitted to the individual designated by the facility in accordance with subpart (A) as follows:(1) In writing, or(2) Orally submitted to the individual designated in accordance with subpart (A), above. In the case of an oral submission, the assisted living residence shall ensure the individual submitting the grievance retains proof of the oral submission through a witness or other evidence.(a) If the grievance is orally submitted and witnessed, the assisted living residence shall ensure that the resident or other person filing the grievance has the witness's name and contact information, and shall keep that information as part of the grievance documentation.(E) A requirement that no later than 5 business days after the submission of a grievance in accordance with subpart (D), above, the individual designated by the assisted living residence to receive involuntary discharge grievances shall provide a response to the grievance as follows:(1) A written response shall be provided to the individuals required to receive notice in Part 11.16, the state long-term care ombudsman, and the designated local ombudsman.(2) An oral explanation of the written response shall be provided to the resident and/or person filing the grievance, as appropriate.(3) The written response shall include the following statement regarding the filing of an appeal: "If the resident, or other person that submitted this grievance is dissatisfied with this response, they may file an appeal to the executive director of the Colorado Department of Public Health and Environment within 5 business days after receiving this written response. The appeal must include the original grievance, the original notice of involuntary discharge and supporting documentation given to the resident as part of that notification, and any additional information or documentation."(F) Acknowledgement that if the resident, the individual filing the grievance, or the assisted living residence is dissatisfied with the findings and recommendations of the Department related to an appeal, they may request a hearing conducted by the Department pursuant to Section 24-4-105, C.R.S.(G) A requirement that the assisted living residence not take any punitive or retaliatory action against a resident due to the resident filing a grievance or appeal pursuant to this Part.(H) A requirement that the assisted living residence continue to assist with planning a discharge or transfer of the resident while the grievance or appeal to the Department is pending.(I) A requirement that the resident be allowed to return to the assisted living residence if all of the following apply:(1) The stated reason for the involuntary discharge in the notice of involuntary discharge provided in accordance with Part 11.17 is nonpayment of monthly services or room and board,(2) The assisted living residence discharged the resident on or after the 31st day after the written notice of involuntary discharge was provided to the resident, and(3) The resident substantially complied with payments due to the residence, as determined through the grievance and appeal process. 10.6 Each assisted living residence's emergency policies shall address, at a minimum, all of the following items:(A) Written instructions for each identified risk that includes persons to be notified and steps to be taken. The instructions shall be readily available 24 hours a day in more than one location with all staff aware of the locations;(B) A schematic plan of the building or portions thereof placed visibly in a central location and throughout the building, as needed, showing evacuation routes, smoke stop and fire doors, exit doors, and the location of fire extinguishers and fire alarm boxes;(C) When to evacuate the premises and the procedure for doing so;(D) A pre-determined means of communicating with residents, families, staff and other providers;(E) A plan that ensures the availability of, or access to, emergency power for essential functions and all resident-required medical devices or auxiliary aids;(F) Storage and preservation of medications;(G) Assignment of specific tasks and responsibilities to the staff members on each shift including use of a triage system to assess the needs of the most vulnerable residents first;(H) Protection and transfer of health information as needed to meet the care needs of residents; and(I) In the event relocation of residents becomes necessary, written agreements with other health facilities and/or community agencies.

A revisit survey was completed on 3/12/24 for all previous deficiencies cited on 7/25/23. The facility is in compliance with all deficiencies that were cited.

A licensure revisit was completed on 7/25/23 for all previous deficiencies cited on 2/22/23. The residence is in compliance with all regulations surveyed.

A licensure complaint, prompted by #CO31466, was completed on 7/25/23. A deficiency was cited.

Based on record review and interview, the residence failed to comply with authorized practitioner orders associated with medication administration, affecting three of three sample residents (#2, #5, #6). 1. Residence Policy The residence's Medication Refill policy, dated May 2017, read in part; "Medication refills will be obtained in a timely manner to ensure residents have all physician (practitioner) ordered medications available ... Medications are never allowed to run out unless directed to by the physician ..."The residence's Medications are Permanently Discontinued policy, dated May 2017, read in part; "Permanently discontinued medication will not be retained in the community (residence) ..." 2. Resident #5 was admitted to the residence on 2/16/23 with diagnoses that included unspecified dementia, depression and hip fracture. a. Acetaminophen A written practitioner's order, dated 2/15/23, directed the residence to administer Acetaminophen 500 mg three times daily. However, the July 2023 medication administration record (MAR) read the medication had not been administered as ordered for the morning dose on 7/3/23 due to the keys to the medication cart being lock in the cart, for a total of one missed dose.b. Senexon PlusA written practitioner's order, dated 2/15/23 , directed the residence to administer senexon plus 8.6-50 mg one tab daily. However, the July 2023 MAR read the medication had not been administered as ordered on 7/3/23 due to the keys to the medication cart being lock in the cart, for a total of one missed dose.c. Sertraline A written practitioner's order, dated 2/15/23, directed the residence to administer sertraline 50 mg one tab daily. However, the July 2023 MAR read the medication had not been administered as ordered on 7/3/23 due to the keys to the medication cart being lock in the cart, for a total of one missed dose.d. Spiriva A written practitioner's order, dated 2/15/23, directed the residence to administer spiriva 2.5 mcg two puffs once daily. However, the July 2023 MAR read the medication had not been administered as ordered on 7/3/23 due to the keys to the medication cart being lock in the cart, for a total of one missed dose.e. Ascorbic Acid (Vitamin C)A written practitioner's order, dated 2/15/23, directed the residence to administer Ascorbic Acid 500 mg one tab daily. However, the July 2023 MAR read the medication had not been administered as ordered on 7/3/23 due to the keys to the medication cart being lock in the cart, for a total of one missed dose.f. Vitamin D A written practitioner's order, dated 2/15/23, directed the residence to administer Vitamin D3 5000 units one tab daily. However, the July 2023 MAR read the medication had not been administered as ordered on 7/3/23 due to the keys to the medication cart being lock in the cart, for a total of one missed dose. On 7/25/23 at approximately 2:51 p.m., the clinical services director stated the keys to the medication cart were locked inside the medication cart and the staff were unable to administer the medications. She stated Resident #5 should have received his practitioner ordered medications. On 7/25/23 at approximately 2:51 p.m., the administrator confirmed the keys to the medication cart had been locked in the medication cart. She stated the medication was unable to be administered during that time. The administrator stated the medication should have been administered to Resident #5. 3. Resident #2 was admitted to the residence on 4/18/19 with diagnoses that included dementia, hypothyroidism, major depression, hypertension and chronic kidney failure. a. Acetaminophen A written practitioner's order, dated 2/4/23, directed the residence to administer acetaminophen 500 mg two tablets three times daily. However, the July 2023 MAR read the medication was not administered for the morning dose on 7/3/23 due to the keys being locked in the medication cart, for a total of one missed dose.b. Aspirin A written practitioner's order, dated 12/12/22, directed the residence to administer aspirin 81 mg once daily. However, the July 2023 MAR read the medication was not administered on 7/3/23 due to the keys being locked in the medication cart, for a total of one missed dose.c. Biotene A written practitioner's order, dated 12/12/22, directed the residence to administer Biotene dry spray three sprays in the mouth three times daily. However, the July 2023 MAR read the medication was not administered for the morning dose on 7/3/23 due to the keys being locked in the medication cart, for a total of one missed dose.d. Escitalopram A written practitioner's order, dated 12/12/22, directed the residence to administer escitalopram 20 mg once daily. However, the July 2023 MAR read the medication was not administered on 7/3/23 due to the keys being locked in the medication cart, for a total of one missed dose.e. Levothyroxine A written practitioner's order, dated 1/28/23, directed the residence to administer levothyroxine 75 mcg once daily. However, the July 2023 MAR read the medication was not administered on 7/3/23 due to the keys being locked in the medication cart, for a total of one missed dose.f. Oyster Shell Calcium A written practitioner's order, dated 12/12/22, directed the residence to administer oyster shell calcium 500/200 mg once daily. However, the July 2023 MAR read the medication was not administered on 7/3/23 due to the keys being locked in the medication cart, for a total of one missed dose.g. Potassium Chloride A written practitioner's order, dated 2/4/23, directed the residence to administer- potassium chloride 8 mcg once daily. However, the July 2023 MAR read the medication was not administered on 7/3/23 due to the keys being locked in the medication cart, for a total of one missed dose. On 7/25/23 at approximately 2:51 p.m., the clinical services director stated the keys to the medication cart were locked inside the medication cart and the staff were unable to administer the medications. She stated Resident #2 should have received her practitioner ordered medications. On 7/25/23 at approximately 2:51 p.m., the administrator confirmed the keys to the medication cart had been locked in the medication cart. She stated the medication was unable to be administered during that time. The administrator stated the medication should have been administered to Resident #2. 4. Resident #6 was admitted to the residence on 1/17/22 with diagnoses that included dementia. A written practitioner's order, dated 2/1/23, directed the residence to discontinue florastor 250 mg once daily. However, the July 2023 MAR read the medication was administered from 7/1-7/24/23, for a total of 24 additional doses. On 7/25/23 at 11:11 a.m., the family member of Resident #6 stated she was unaware of what medications had been discontinued. She stated the external hospice provider had made medication changes and discontinued multiple medications recently. On 7/25/23 at approximately 2:51 p.m., the clinical services director stated the florastor for Resident #6 should have been discontinued and removed from the MAR on 2/1/23. On 7/25/23 at approximately 2:51 p.m., the administrator confirmed the florastor for Resident #6 should have been removed from the MAR and no longer administered after the discontinue order was received.

A licensure complaint, prompted by #CO30250, was completed on 2/22/23. Deficiencies were cited.

Based on observation, record review and interview, the residence failed to provide personal services, including a system for identifying and reporting resident concerns that required an immediate individualized approach and/or on-going monitoring, affecting two of two sample residents (#5, #6) who used oxygen. Findings include: 1. Referencesa. Chapter VII regulations governing assisted living residences, part 2.3, defines "Activities of daily living (ADLs)" as those personal functional activities required by an individual for continued well-being, health and safety. As used in this Chapter 7, activities of daily living include, but are not limited to, accompaniment, eating, dressing, grooming, bathing, personal hygiene (hair care, nail care, mouth care, positioning, shaving, skin care), mobility (ambulation, positioning, transfer), elimination (using the toilet) and respiratory care.b. Chapter VII regulations governing assisted living residences, part 2.34, defines "Personal services" as those services that an assisted living residence and its staff provide for each resident including, but not limited to:(D) Assistance with activities of daily living.c. Chapter VII regulations governing assisted living residences, part 14.10, requires that unless otherwise allowed by statute, the assisted living residence shall not permit a qualified medication administration person to perform any of the following tasks: (G) Assessment of residents or use of judgment including, but not limited to, medication effect.d. Chapter VII regulations governing assisted living residences, part 14.20, requires that the assisted living residence contact the authorized practitioner for clarification of any orders which are incomplete or unclear and obtain new orders in writing.e. "Hypoxemia is a below-normal level of oxygen in your blood, specifically in the arteries. Hypoxemia is a sign of a problem related to breathing or circulation, and may result in various symptoms, such as shortness of breath. Hypoxemia is determined by measuring the oxygen level in a blood sample taken from an artery (arterial blood gas). It can also be estimated by measuring the oxygen saturation of your blood using a pulse oximeter - a small device that clips to your finger." Mayo Clinic (2023) Hypoxemia, retrieved from: https://www.mayoclinic.org/symptoms/hypoxemia/basics/definition/sym-200509302. Resident #6 was admitted to the residence on 1/17/22 with diagnoses including primary pulmonary hypertension. Resident #6 had a current practitioner order to receive 2 liters per minute (LPM) of oxygen continuously. However, on 2/21/23, Resident #6's oxygen was set at 3 LPM. Additionally, on 2/19/23, Resident #6's family member discovered the oxygen tank was empty, and Resident #6 seemed more tired than usual. Additionally, qualified medication administration persons (QMAPs) obtained verbal and telephone text message orders from the resident's practitioner, rather than obtained signed practitioner orders for changes to oxygen liters per minute. a. ObservationOn 2/21/23 at 11:33 a.m., Resident #6's portable oxygen tank was set to three liters per minute. Resident #6 was in the common area of the residence with the portable oxygen tank and a nasal cannula, so as to receive the oxygen. b. Record ReviewsA written practitioner order, dated 1/5/22, directed the residence to ensure Resident #6 received 6 LPM of oxygen, daily. A subsequent written practitioner order, dated 4/13/22, directed the residence to ensure Resident #6 received 2 LPM of oxygen, continuously. The February 2023 electronic medication administration record (eMAR) for Resident #6 read: "Oxygen 6 LPM Check that resident has oxygen on and at 2 (two) liters." There were staff initials for the oxygen at "Early AM," "Afternoon," and "Bedtime" from 2/1-2/21/23 in the afternoon. A document titled Service Agreement had a section titled "Oxygen Use," dated 1/17/22, that read: "Please assist (Resident #6) with oxygen and make sure she has on Nasal Cannula at 6 liters continuously." A document titled "Problem Driven Service Plan," had a section titled "Oxygen," dated 2/2/23, that read, in part: "6 (six) L (liters) nasal cannula continuously" and, "Staff will assist resident in wearing nasal cannula to receive O2 (oxygen) at all times." On 1/18/23 at 8:16 p.m., Staff #3 wrote a progress note that read Resident #6's oxygen saturation was low, and so Resident #6's practitioner was contacted. The note read the practitioner ordered 4 LPM of oxygen. The note identified that Staff #3 was a QMAP.On 1/23/23 at 10:10 p.m., Staff #5 wrote a progress note that read Former Staff #6 had called Staff #5 to inform her that Resident #6's practitioner had sent a telephone text message to Former Staff #6 instructing that Resident #6 receive 3 LPM of oxygen. The note read that Staff #5 was a QMAP.On 2/22/23 at 1:31 p.m., the clinical operations specialist (COS) provided a written practitioner order, dated 2/22/23 the date of the onsite investigation, that read: "Order clarification on 1/18/23 increase O2 to 4 (four) on 1/23/23 ok (okay) to decrease O2 back down to 3 LPM." c. InterviewsOn 2/22/23 at 11:29 a.m., Former Staff #6 confirmed she was a QMAP. Former Staff #6 also confirmed she had received a text message on 1/23/23 from Resident #6's external practitioner (EP) that directed staff to provide 3 LPM of oxygen to Resident #6. Former Staff #6 said that, because the residence had not had a nurse at that time, she and the EP had decided that texting the order was the best way to communicate Resident #6's changing needs for oxygen. On 2/22/23 at approximately 11:35 a.m., Resident #6's family member stated that on 2/19/22 she had visited Resident #6 and found the resident's portable oxygen tank, which the resident had been using, was empty. The family member said Resident #6 seemed tired and lethargic. The family member added that this had occurred a couple of times in the past, though she was not sure of the dates. On 2/22/23 at 11:59 a.m., the COS stated QMAPs were not permitted to take verbal or telephone text message orders from practitioners. The COS said she did not know why QMAPs had taken orders from a practitioner via text message and then changed Resident #6's oxygen settings. On 2/22/23 at 12:10 a.m., the clinical support coordinator #1 said, "I thought (Resident #6's) oxygen was six liters. That's what the family says."On 2/22/23 at 12:20 p.m., COS stated she did not know why the eMAR for Resident #6 read the resident was to receive 6 LPM of oxygen and 2 LMP. She said, "I think it came out on the MAR (eMAR) wrong." The COS could not explain why Residents #6's portable oxygen tank was set to 3 LPM of oxygen during the onsite investigation. She said, "I have a call into the (external practitioner), but there's no signed orders." The COS reiterated that there were no signed orders for oxygen at 3 LPM. On 2/22/23 at 2:40 p.m., the administrator confirmed Resident #6's family member had called her on 2/19/23 to tell her the resident's portable oxygen tank had been empty. The administrator said she did not know why the eMAR for Resident #6 read that both 6 and 2 liters of oxygen were to be provided. The administrator said she did not know why the resident's oxygen was at 3 LPM on the day of the onsite investigation. The administrator also stated QMAPs were not permitted to obtain orders from practitioners via telephone text or any other means. She added, "That's not okay." On 2/22/23 at 3:02 p.m., Staff #3 confirmed she was a QMAP. Staff #3 also confirmed that on 1/18/23 another QMAP, Former Staff #6, had called the resident's practitioner because Resident #6's oxygen was low. Staff #3 said, "Normal (oxygen saturation) is 90 percent. Maybe it (Resident #6's) was 70." Staff #3 said Former Staff #6 was told to change Resident #6's oxygen to 4 LPM. Staff #3 added, "It was two before, so we changed it to four." 2. Resident #5 was admitted to the residence on 2/16/23 with diagnoses including hypoxia.a. ObservationOn 2/22/23 at 1:05 p.m., Resident #5 had a portable oxygen tank with an installed battery and three other batteries sitting on a nightstand in the resident's room. All four batteries had light indicators that blinked depending on the batteries' charge level. All four batteries were blinking at the lowest charge level. b. Record ReviewA written practitioner order, dated 2/15/23, directed the residence to ensure Resident #5 received 4 LPM of oxygen continuously per nasal cannula. The order also ready "Document every shift for Hypoxia." A care plan for Resident #5 had a section titled "oxygen," dated 2/16/23 that read: "will allow staff to manage continuous oxygen use." There was no information on the care plan about charging the portable oxygen tank's batteries. c. InterviewsOn 2/22/23 at 12:01 p.m., a staff who wished to remain anonymous stated that twice in the week prior to the onsite complaint investigation, s/he had seen that all of Resident #5's batteries were on the lowest charge level. The staff said that to charge the batteries, staff had to plug in the portable tank with the battery inserted into the tank. S/he said it was important to charge the batteries overnight, when Resident #5 was sleeping. The staff explained that Resident #5 preferred to be out of his room and in the common areas during daytime hours, which meant the batteries could not be charged at that time, since Resident #5 would then be using the oxygen and it could not be plugged in. On 2/22/23 at 1:33 p.m., the COS stated the order to "Document every shift for Hypoxia," should not have been accepted. She said, "It's a bad order. The order should read that staff should obtain O2 (oxygen) stats every shift." The COS added that QMAPs would not know how to monitor for hypoxia. The COS said she thought the failure was that residence staff had not noticed and had not asked the practitioner to modify the order. On 2/22/23 at 1:38 p.m., Resident #2's family member stated the first time she had come to visit Resident #5, the week prior to the onsite investigation, the battery in the portable oxygen tank alarm sounded because it was out of oxygen. The family member said staff did not know how to charge the battery, and so she had had to teach them how to do so. The family member said one battery lasted approximately four hours. On 2/22/23 at 2:40 p.m., the administrator said she had no knowledge of Resident #5's oxygen tank, how to charge the batteries nor that staff had no system for doing so.

Based on record review and interview, the residence failed to ensure resident records contained progress notes that included information on resident status, as well as documentation regarding any out of the ordinary events or issues that affected residents' condition, and that staff documented progress notes before the end of their shifts, affecting four of five sample residents (#3-#5, #7). Findings include: 1. Residence PolicyThe residence's Narrative Charting Entries policy, dated 5/20/22, read in part: "Enter all essential facts related to resident status ... State the actions/interventions made in response to the data ... Follow up and document the resident's response to the action taken. A narrative entry is made upon admission, noting the date and time of admission ... A narrative entry addressing current resident status is made every shift (or more often if necessary) for 48 hours after a fall or sentinel event." 2. Resident #7 was admitted to the residence on 7/1/22. a. No Progress NotesAn incident report (IR) provided by the administrator, dated 9/22/22, read Resident #7 was "screaming for help in her room, found on floor." The IR also read the resident was sent to the hospital. However, there was no progress note regarding this event in the resident's record. On 8/12/22, Resident #7 was readmitted to the residence after a three day hospital stay. However, the record for Resident #7 contained no progress note regarding the resident's readmission. On 2/21/23 at 3:55 p.m., the clinical operations specialist (COS) stated, "There are issues with the progress notes. They (staff) were sending (Resident #7) out to the hospital, but there were no (progress) notes about the readmission." The COS stated she had noticed there was no progress note about Resident #7's readmission on 8/12/22 and had contacted the residence's vice president of operations (VPO). The COS said, "The (VPO) said he forgot to put in a progress note."b. Late EntriesProgress notes were not completed before the end of staffs' shift, as follows: A progress note, dated 7/3/22, read: "Late Entry for 7/1/2022 ... New admission." A progress note, dated 7/3/22, read: "Late Entry for 7/2/2022 ... Alert charting for new admission." A progress note, dated 7/13/22, read: "Late Entry for 7/8/22 ... Resident had an NP (nurse practitioner) visit for new resident evaluation." A progress note, dated 7/20/22, read: "Late Entry for 7/15/22 ... The resident had a NP visit for evaluation and management of cares." A progress note dated 7/27/22, read: "Late Entry for 7/22/22 ... Resident had an NP visit for labs and her behavior." A progress note, dated 8/4/22, read: "Late entry for 8/3/22 ... Resident had an NP visit for increased confusion." A progress note, dated 8/9/22, read: "Late Entry for 7/22/22 ... Resident had an NP visit for her behaviors and labs."A progress note, dated 8/17/22, read: "Late Entry for 8/12/2022 ... Resident had an NP visit for increased confusion." A progress note, dated 8/25/22, read: "Late Entry for 8/19/2022 ... Resident had a follow up visit for confusion and pain." A progress note, dated 9/22/22, read: "Late Entry for 9/19/22 ... has returned to (residence) from rehab." 3. Resident #3 was admitted to the residence on 3/29/22. a. No Progress NoteAn IR provided by the administrator, dated 2/1/23, read in part: "Unwitnessed Fall ... he roll (sic) out of bed ... the resident is on the floor." However, the record for Resident #3 did not contain a progress note about this event. On 2/22/23 at 2:40 p.m., the administrator stated there should have been a progress note about Resident #3's fall on 2/1/23.4. Resident #4Progress notes were not completed before the end of staffs' shift, as follows: A progress note, dated 12/7/22, read: "Late entry for 12/2/2022 ... Resident had an NP visit for (hypertension)" A progress note, dated 12/13/22, read: "Late Entry for 12/9/2022 ... Resident had an NP visit for dementia and labs and a fall." A progress note, dated 1/1/23, read: "Late Entry for 12/23/22 ... Resident had an NP visit for cough and gait and was assessed." A progress note, dated 1/3/23, read: "Late entry for 12/20/22 ... Resident had an NP visit for (hypertension), skin." A progress note, dated 1/23/23, read: "Late entry for 1/20/23 ... Resident had an NP visit" for follow up regarding discomfort when urinating. 5. Resident #5 was admitted to the residence on 2/16/23. A progress note was not completed before the end of staffs' shift, as follows: A progress note, dated 2/17/23, read: "Late Entry for 2/16/2023 ... admitted to (residence)." 6. InterviewsOn 2/21/23 at 1:44 p.m., the administrator stated IRs are not part of residents' records. On 2/22/23 at 10:38 a.m., the COS stated it was residence policy that IRs were internal documents and not considered part of residents' records. The COS said, "We are fully aware progress notes are messed up." On 2/2223 at 2:10 p.m., the clinical coordinator said, "Progress notes should be done on every shift. They should do it during their shift."On 2/22/23 at 2:16 p.m., the COS stated she was aware staff continued to not document progress notes before the end of their shifts. On 2/22/23 at 2:40 p.m., the administrator stated progress notes should be written for admissions, readmissions, falls and general observations about residents' status and wellbeing. The administrator said she expected staff to complete progress notes before the end of their shifts and that late entries should not occur.

Based on observation, record review and interview, the residence failed to ensure residents in a secure environment had an enhanced care plan that contained the required information, affecting six of six sample residents (#1-#6). (Cross-reference Q3030) Findings include: 1. ReferenceChapter VII regulations governing assisted living residences, part 12.10, requires that each resident care plan shall:(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. 2. Resident #1 was admitted to the residence's secure environment on 1/20/22. Resident #1's record contained an undated document titled, "Problem Driven Service Plan." The document had a section, titled "Enhance Care Plan: Privacy," dated 1/21/23, that only read: "will have independent access to their individual room." However, there was no information about who the resident would have continuous independent access to her room nor how Resident #1 would be protected from unwanted visitation by other residents. The document also had a section titled "Safety Risk," dated 1/19/22, that only read: "Monitor resident's whereabouts in the community as needed." There was no additional information about the type and level of oversight/monitoring and/or accompaniment that was deemed necessary to meet Resident #1's needs within the secure environment and secure outdoor area. The document additionally did not contain any information regarding the description of the resident's wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they had contact nor documentation describing the personal grooming and hygiene items that were determined safe for the resident to have in their own possession for self-care, and how those items were stored to prevent unauthorized access by other residents. 3. Resident #2 was admitted to the residence's secure environment on 4/18/19. Resident #2's record contained an undated document titled, "Problem Driven Service Plan." The document had a section titled "Psychotropic Medication," dated 8/16/19, that read: "on psychotropic medication for Dementia with behaviors. Staff to monitor for ... continued behaviors." However, there was no additional information about Resident #2's known behavioral expressions with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact. The document had a section titled "Safety Risk," dated 6/22/22, that read: "Staff will monitor for safety to minimize risk for falls or injury ... Staff will provide hourly eyes (sic) while up and about and provide every two HR (hour) checks while in bed." However, there was no other information regarding the oversight, monitoring, and/or accompaniment that was necessary to meet Resident #2's within the secure environment's outdoor area. The document additionally did not contain any information regarding how the resident had continuous independent access to her room, along with the plan to protect the resident from unwanted visitation by other residents nor documentation describing the personal grooming and hygiene items that were determined safe for the resident to have in their own possession for self-care, and how those items were stored to prevent unauthorized access by other residents. 4. Resident #3 was admitted to the residence's secure environment on 3/29/22. Resident #3's record contained an undated document titled, "Problem Driven Service Plan." A section titled "Enhance Care Plan: Privacy," dated 1/8/23, read: "will have independent access to their individual room." However, there was no information about how Resident #3 would have continuous independent access to his individual room nor the plan to protect the resident from unwanted visitation by other residents. A section titled "Safety Risk," dated 3/29/22, read: "Night Safety Checks: Check resident for safety every 2 (two) hours." The section also read: "Monitor resident's whereabouts in the community as needed." However, there was no additional information regarding the type and level of staff oversight, monitoring, and/or accompaniment that was necessary to meet Resident #3's needs within the secure environment and secure outdoor areaAdditionally, the document did not contain documentation describing the personal grooming and hygiene items that were determined safe for the resident to have in their own possession for self-care, and how those items were stored to prevent unauthorized access by other residents. 5. Resident #4 was admitted to the residence's secure environment on 6/22/20. Resident #4's record contained an undated document titled "Problem Driven Service Plan." The document did not contain any information regarding Resident #4's wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact; description of how Resident #4 would have continuous independent access to her individual room, along with the plan to protect her from unwanted visitation by other residents; identification of the type and level of staff oversight, monitoring, and/or accompaniment that was necessary to meet Resident #4's needs within the secure environment and secure outdoor area; nor documentation describing the personal grooming and hygiene items that were determined safe for the resident to have in their own possession for self-care, and how those items were stored to prevent unauthorized access by other residents. 6. Resident #5 was admitted to the residence's secure environment on 2/16/23. The document did not contain any information regarding Resident #5's wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect the resident and other residents with whom they have contact; description of how Resident #4 would have continuous independent access to her individual room, along with the plan to protect her from unwanted visitation by other residents; identification of the type and level of staff oversight, monitoring, and/or accompaniment that was necessary to meet Resident #4's needs within the secure environment and secure outdoor area; nor documentation describing the personal grooming and hygiene items that were determined safe for the resident to have in their own possession for self-care, and how those items were stored to prevent unauthorized access by other residents. On 2/22/23 at 2:16 p.m., the clinical operations specialist (COS) said the Resident #5's care plan was the first care plan the clinical services director had written, which was why it was missing required information. 7. Resident #6 was admitted to the residence's secure environment on 1/17/22. A section titled "Enhance Care Plan: Privacy," dated 1/4/23, read: "will have independent access to their individual room, and door will lock." However, there was no information about how Resident #6 would have continuous independent access to her individual room nor the plan to protect the resident from unwanted visitation by other residents. The document did not contain any information regarding Resident #6's wandering patterns and known behavioral expressions, along with individualized approaches to be implemented by staff to protect Resident #6 and other residents with whom they had contact; nor documentation describing the personal grooming and hygiene items that were determined safe for the resident to have in their own possession for self-care, and how those items were stored to prevent unauthorized access by other residents. On 2/21/23 at 12:11 p.m., the clinical support coordinator #1 (CSC #1) said Resident #6 habitually walked the residence's common area and required prompts to sit periodically. The CSC #1 said she had peppermint candies, which she used to encourage Resident #6 to take breaks from walking. The CSC #1 also said Resident #6 was sometimes resistant to care, and at those times, staff needed to explain what they were doing and patiently ask Resident #6 to assist with care. On 2/22/23 at 10:30 a.m., Staff #1 stated, "(Resident #6) likes to walk too much. She won't sleep. We encourage her to not walk too much." On 2/22/23 at 12:01 p.m., Staff #2 confirmed Resident #6 was at times resistant to care, and staff needed to explain what they were doing. Staff #2 also confirmed Resident #6 needed prompts not to walk too much and fluids to ensure she stayed hydrated when she was continuously walking. 8. InterviewsOn 2/22/23 at 1:00 p.m., the COS said the former clinical services director had walked off the job with no notice in the recent past. The COS said there had been issues with quality care plans since that time. On 2/22/23 at 2:16 p.m., the COS said she was not aware of the specific information that must be included in enhanced care plans for residents in the secure environment. On 2/22/23 at 2:40 p.m., the administrator, who had been the administrator since 1/23/23, stated she was aware of the requirements for an enhanced care plan and what should be included. She also said she knew residents' care plans did not contain the required information. She said, "We've not yet corrected that."

Based on observation, record review and interview, the residence failed to ensure residents had freedom of movement to their personal spaces, affecting three of three residents (#1, #2, #6) whose personal bedrooms were locked, though they did not have a key to the room. (Cross-reference Q2960)Findings include: 1. ObservationsOn 2/21 and 2/22/23 throughout the day, the doors to Residents #1, #2 and #6's rooms were locked when the residents were not in the rooms. 2. Resident #1 was admitted to the residence on 1/20/22 with diagnoses including Alzheimer's disease and cognitive communication deficit. The record for Resident #1 contained a document titled "Service Agreement" that had a section titled 'Privacy Plan," dated 1/21/23, that read: "Will have access to apartment at all times." The record also contained a document titled "Problem Driven Service Plan" that had a section titled "Enhance Care Plan: Privacy," dated 1/21/23, that read: "Will have independent access to their individual room ... will have access to apartment at al times." On 2/22/23 1:49 p.m., Resident #1's family member stated Resident #1's room was kept locked when the resident was not in the room. She said, "I think some of the residents wander and they go into what room they can." The family member said Resident #1 did not have a key to her room, would lose a key if she were given one, and would not know how to use a key to her room. The family member also said she and Resident #1 had to ask staff to unlock the door anytime they wanted to enter Resident #1's room. 3. Resident #2 was admitted to the residence on 4/18/19 with diagnoses including dementia. The record for Resident #2 contained an undated document titled "Service Agreement," but there was no information about how the resident would access their personal space. The record also contained an undated document titled "Problem Driven Service Plan" that likewise had no information about how the resident would access their personal space. 4. Resident #6 was admitted to the residence on 1/17/22 with diagnoses including dementia. The record for Resident #6 contained a document titled "Service Agreement" that had a section titled 'Privacy Plan," dated 1/4/23, that read: "Resident will have access to apartment at all times, and door will lock." The record also contained a document titled "Problem Driven Service Plan" that had a section titled "Enhance Care Plan: Privacy," dated 11/4/23, that read "Will have independent access to their individual room ... will have access to apartment at al times, and door will lock." On 2/21/23 at approximately 11:30 a.m., Resident #6's family member stated the residents room was always kept locked so other residents could not enter Resident #6's room. She said, "(Resident #6) has to ask (staff) to unlock the door." The family member said Resident #6 did not have a key to access her room. The family member said she did not believe Resident #6 would be able to use a key, if one were provided. 5. InterviewsOn 2/22/23 at 10:30 a.m., Staff #1 stated some residents' rooms were locked so other residents did not wander into rooms that were not their own. She added, "They don't have a key. We have to let them in." On 2/22/23 at 11:29 a.m., Staff #6 confirmed Residents #1, #2 and #6's rooms were kept locked. Staff #6 added, "I know for (Resident # 6), we had other residents that would go into her room." Staff #6 added staff had to let Resident #6 into her room when needed. On 2/22/23 at approximately 11:35, Staff #4 confirmed Resident #1 and #6's rooms were kept locked so other residents did not enter her room, though the residents did not have a key. On 2/22/23 at 12:01 p.m., Staff #2 said staff had to let Resident #2 back into her room when it was locked. Staff #2 added, "We do have residents who go into others' rooms." Staff #2 said she believed some residents' rooms were locked to keep other residents from wandering into their rooms. On 2/21/23 at 12:11 p.m., the clinical support coordinator #1 stated, contrary to observations and interviews above: "We don't have to keep resident rooms locked. We only lock (the rooms) if they have key and can go in and out."On 2/22/23 at 2:16 p.m., the clinical operations specialist (COS) stated that providing residents access to their rooms was challenging in a secure environment. The COS said, "If you leave the room open, others will go in." The COS added that some residents would not be able to use a key, if one were provided. The COS confirmed Residents #1, #2 and #6 were unable to manage a key, if one were provided. On 2/22/23 at 2:40 p.m., the administrator stated residents should have continuous access to their individual rooms. The administrator, who had only been the administrator since 1/23/23, said she did not know why Residents #1, #2 and #6's rooms were locked, though they did not have a key. On 2/21/23 at 3:02 p.m., the clinical support coordinator #2 (CSC #2) said, contrary to observations and interviews above: "Rooms are not locked." The CSC2 said only those residents who had a key had doors that were locked. However, the CSC2 added, "(Resident #6) doesn't have a key."

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 7.12.1 The assisted living residence shall make available, either directly or indirectly through a resident agreement, the following services, sufficient to meet the needs of the residents:(A) A physically safe and sanitary environment including, but not limited to, measures to reduce the risk of potential hazards in the physical environment related to the unique characteristics of the population. 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. 12.15 The assisted living residence shall develop policies and procedures to establish a fall management program. The program shall include the following:(A) Providing fall management education and materials to residents and family members;(C) Providing resident engagement activities to improve strength and balance as specified in Part 12.22(C);(D) Routinely inspecting and maintaining a safe exterior and interior environment as specified in Parts 21 and 22; and(E) Providing staff training related to fall prevention as specified in Part 7.8(B)(6).